Haris Muhammad

The notion of a “July effect,” suggesting that the influx of new residents in teaching hospitals every July (JU) may adversely affect patient care and outcomes, remains debatable. This study evaluated the impact of resident turnover in JU on patients admitted for congestive heart failure (CHF) and concomitant sepsis. This retrospective cohort study utilized data from the 2016 to 2020 National Inpatient Sample. Patients with CHF and concomitant sepsis hospitalized at teaching hospitals, as determined by International Classification of Diseases, 10th Revision (ICD-10) codes, were included. Univariate and multivariate logistic regression analyses were performed to estimate in-hospital mortality and secondary outcomes after adjustment for confounders, including cardiac arrest (CA), cardiogenic shock, non-ST segment elevation myocardial infarction, respiratory failure (RF), use of cardiac and respiratory devices, and healthcare resource utilization metrics such as length of stay (LOS) and total hospitalization charges (TOTCHG). Patients were classified according to the month of admission as JU or other months (OM) to investigate the potential impact of the “July effect” on patient outcomes. The study included 281,874 patients, of which 8% were in the JU group and 92% in the OM group. The mean age was 71 ± 13 years, with a slight male predominance (52% vs 48%), and most patients were White (70%). A total of 34,974 in-hospital deaths occurred, with no significant difference between the JU and OM groups (odds ratio [OR] = 0.95; 95% confidence interval [CI] = 0.85–1.06; p=0.329). Similarly, no significant differences were observed in CA (OR = 0.88; 95% CI = 0.70–1.11; p=0.282), RF (OR = 0.98; 95% CI = 0.90–1.06; p=0.597), ventilator use (OR = 0.99; 95% CI = 0.77–1.25; p=0.879), LOS (11.3 vs. 11.3), and TOTCHG (USD 136,377 vs. USD 136,181). However, lower rates of acute kidney injury were observed in the JU group compared with the OM group (OR 0.90; 95% CI, 0.84–0.98, p=0.011). This study demonstrates that the “July effect” does not significantly influence in-hospital outcomes in patients with CHF and concomitant sepsis. While mortality and major clinical outcomes were comparable across groups, lower rates of acute kidney injury were observed in patients admitted in JU. Further research is needed to understand the complex interplay between healthcare resident turnover and patient outcomes.

Takotsubo syndrome (TTS), also known as broken heart syndrome, is an acute cardiac condition with a poorly understood pathophysiology due to its relative rarity. Once considered benign, it is now recognized as a serious disorder with severe complications and a mortality rate comparable to or exceeding that of acute coronary syndrome. This narrative review aims to summarize current knowledge on the prognostic factors associated with TTS, with a particular focus on its relationship with diabetes mellitus (DM). A thorough analysis of 57 relevant studies, selected from over 98,000 articles retrieved from PubMed and Google Scholar, was conducted based on strict inclusion criteria. The findings indicate that advanced age, female sex, pre-existing cardiovascular diseases, and systemic disorders significantly influence the prognosis and mortality of patients with the syndrome. DM plays a paradoxical role, being associated with increased long-term mortality risk while potentially providing a protective effect during the acute phase of the syndrome, possibly by modulating stress responses involved in its onset. Therefore, a deeper understanding of the prognostic implications of TTS and its interaction with diabetes is crucial for developing appropriate risk stratification tools and improving clinical management of patients.

Takotsubo syndrome (TTS), also known as the “broken heart syndrome” or “stress cardiomyopathy,” is characterized by transient left ventricular systolic dysfunction, usually in the absence of significant obstructive coronary artery disease. The pathophysiology of TTS remains incompletely understood, though commonly proposed mechanisms include catecholamine surge, estrogen deficiency, and coronary circulation dysfunction. TTS was initially regarded as benign and reversible; however, studies indicate that it may have severe short- and long-term complications. There are several prognostic factors associated with TTS that may influence patient outcomes. In this review, we aim to explore these prognostic factors in relation to various clinical variables, including age, gender, trigger type, atrial arrhythmias, rate-corrected QT interval, baseline left ventricular systolic function, and comorbidities. While many factors are thought to influence TTS, current research findings remain inconsistent. To improve prognosis, there is an urgent need to develop better risk-assessment tools. This can be achieved through large-scale, multicenter studies and analysis of existing research. By understanding these prognostic factors, better prevention and intervention strategies can be developed for TTS, reinforcing its recognition as a serious cardiovascular condition.

Myocardial infarction with non-obstructive coronary arteries (MINOCAs) affects about 15% of patients diagnosed with myocardial infarction (MI). Patients with MINOCA often lack significant cardiac risk factors such as diabetes mellitus, cigarette smoking, and hypertension. Notable, MINOCA is common among female individuals, often occurring in younger women. This highlights the importance of considering MINOCA in women presenting with symptoms suggestive of MI, even in the absence of conventional risk factors. Precisely, MINOCA is not a distinct disease entity but rather a working diagnosis which necessitates further evaluation. MINOCA results from a heterogeneous group of conditions that ultimately result in ischemic injury to the myocardium and causes can be cardiac (e.g., coronary embolism) or non-cardiac (e.g., sepsis). Diagnosis involves coronary angiography to rule out obstructive coronary artery disease (CAD) and transesophageal echocardiography for the assessment of regional wall motion abnormalities. Cardiovascular magnetic resonance imaging can be performed to rule out acute myocarditis or takotsubo cardiomyopathy, which is non-ischemic cause of myocardial injury in MINOCA. Management of MINOCA is specific to the underlying cause and usually influenced by the degree of myocardial damage, and the prognosis is variable and depends largely on the underlying etiology. While some studies suggest that MINOCA patients may have a better short-term prognosis compared to those with MI and obstructive CAD, they still face a significant risk of long-term adverse cardiovascular events, including recurrent MI, heart failure, stroke, and death. Identifying the specific causes of MINOCA is crucial for accurate risk stratification and tailored management to improve patient outcomes.

Pregnancy-associated spontaneous coronary artery dissection (P-SCAD) is a rare but severe cause of acute coronary syndrome. The clinical presentation of P-SCAD can vary widely, ranging from asymptomatic cases to cardiac arrest and sudden cardiac death. Chest pain is the most common presenting symptom, though other symptoms, such as dyspnea, nausea, vomiting, and palpitations, may also occur. P-SCAD is often underdiagnosed because patients typically do not fit the profile of those with atherosclerosis and myocardial infarction. It predominantly occurs in younger individuals without traditional cardiovascular risk factors. The diagnosis of P-SCAD is commonly made during coronary angiography. Therefore, in pregnant and postpartum females presenting with chest pain or pressure, P-SCAD should be considered in the differential diagnosis, regardless of the presence of other risk factors such as age, hypertension, or diabetes.

We report three cases of coronary artery aneurysm (CAA) in adults who presented with acute coronary syndrome. Two of these patients did not have traditional coronary artery disease risk factors. Management of CAA poses a significant challenge to interventionalists. We discuss the etiologic mechanisms, risk factors, pathophysiology, and diagnosis using angiography, intravascular ultrasound, and coronary computed tomography. We also highlight management options, including medical therapy and catheter-based interventions such as stenting, coil embolization, stent-assisted coil embolization, and surgical exclusion.

Takotsubo Cardiomyopathy (TCM) is known as stress induced cardiomyopathy which may be triggered by emotional or physical stress. It contributes approximately 0.02% of all the hospitalizations in the US. It is acute and reversible cardiomyopathy with transient decrease in ventricular function and unremarkable angiogram. TCM was initially considered to be a benign condition however recent studies have shown that it may be associated with complications and mortality similar to acute coronary syndrome (ACS). Therefore, its early recognition is fundamental in the management of potentially reversible pathology.

With the increasing incidence and prevalence of end-stage liver disease, demand for donor grafts continues to increase. Approaches on maximizing the potential donor grafts vary depending on the region. This review aims to summarize the current practice of liver transplantation with an emphasis on challenges encountered in developing countries.

Exertional heat stroke is a medical emergency characterized by excessive heat production and inadequate heat dissipation usually after heavy exertion in hot and humid climates and can be associated with multiorgan failure. Treatment is largely supportive, but liver transplantation (LT) may be necessary in select patients. Here, we report the case of a 44-year-old runner who was found unconscious after a 5-mile run and developed acute liver failure. He underwent successful LT 1 week later when he developed encephalopathy. This case report illustrates the importance of early LT referral in patients with exertional heat stroke-induced acute liver failure.