Mortality, morbidity & clinical outcome with different types of vasopressors in out of hospital cardiac arrest patients- a systematic review and meta-analysis.

BACKGROUND & OBJECTIVE: Despite their continued use, the effectiveness and safety of vasopressors in post-cardiac arrest patients remain controversial. This study examined the efficacy of various vasopressors in cardiac arrest patients in terms of clinical, morbidity, and mortality outcomes. METHODS: A comprehensive literature search was performed using online databases (MeSH terms: MEDLINE (Ovid), CENTRAL (Cochrane Library), Embase (Ovid), CINAHL, Scopus, and Google Scholar) from 1997 to 2023 for relevant English language studies. The primary outcomes of interest for this study included short-term survival leading to death, return of spontaneous circulation (ROSC), survival to hospital discharge, neurological outcomes, survival to hospital admission, myocardial infarction, and incidence of arrhythmias. RESULTS: In this meta-analysis, 26 studies, including 16 RCTs and ten non-RCTs, were evaluated. The focus was on the efficacy of epinephrine, vasopressin, methylprednisolone, dopamine, and their combinations in medical emergencies. Epinephrine treatment was associated with better odds of survival to hospital discharge (OR = 1.52, 95%CI [1.20, 1.94]; p < 0.001) and achieving ROSC (OR = 3.60, 95% CI [3.45, 3.76], P < 0.00001)) over placebo but not in other outcomes of interest such as short-term survival/ death at 28-30 days, survival to hospital admission, or neurological function. In addition, our analysis indicates non-superiority of vasopressin or epinephrine vasopressin-plus-epinephrine therapy over epinephrine monotherapy except for survival to hospital admission where the combinatorial therapy was associated with better outcome (0.76, 95%CI [0.64, 0.92]; p = 0.004). Similarly, we noted the non-superiority of vasopressin-plus-methylprednisolone versus placebo. Finally, while higher odds of survival to hospital discharge (OR = 3.35, 95%CI [1.81, 6.2]; p < 0.001) and ROSC (OR = 2.87, 95%CI [1.97, 4.19]; p < 0.001) favoring placebo over VSE therapy were observed, the risk of lethal arrhythmia was not statistically significant. There was insufficient literature to assess the effects of dopamine versus other treatment modalities meta-analytically. CONCLUSION: This meta-analysis indicated that only epinephrine yielded superior outcomes among vasopressors than placebo, albeit limited to survival to hospital discharge and ROSC. Additionally, we demonstrate the non-superiority of vasopressin over epinephrine, although vasopressin could not be compared to placebo due to the paucity of data. The addition of vasopressin to epinephrine treatment only improved survival to hospital admission.

The Impact of Gender Diversity on Excellence in Pathology Research and Education.

In this editorial, we inspect the critical role of gender diversity within the domain of pathology and its consequential impact on research innovation and clinical outcomes. The editorial commences with a historical overview of gender disparities in pathology, acknowledging advancements toward gender parity while highlighting persistent impediments to full inclusivity. The discourse emphasizes the intrinsic value of integrating diverse gender perspectives in research, illustrating how such inclusivity catalyzes innovation, mitigates research biases, and elevates the standard of patient care through a more comprehensive understanding of the field of pathology. Key barriers to gender diversity in pathology are systematically analysed, including disproportionate clinical burdens, time allocation conflicts due to societal roles, restricted access to specialized training, financial limitations, inadequate support networks, workplace discrimination, and the challenge of balancing family responsibilities with professional aspirations. We propose strategic interventions to address these barriers, advocating for increased awareness, diversity-focused training programs, and mechanisms for recognizing and rewarding the contributions of underrepresented genders in the field. Furthermore, we highlight exemplary initiatives that have successfully promoted gender diversity, such as the Johns Hopkins Pathology Department's outreach program, and the role of professional organizations, notably the American Society for Investigative Pathology and its "Women in Pathology" community, is discussed as pivotal in celebrating and advancing women's contributions to the field of pathology. In conclusion, we suggest that dismantling gender bias is imperative for realizing the full potential of pathology as a discipline. The editorial argues for a systemic embrace of gender diversity and inclusivity as fundamental to fostering research innovation, enhancing clinical practice, and ultimately improving patient outcomes. This scholarly examination calls for a concerted effort within the pathology community to integrate diverse perspectives, thereby enriching the field and contributing to the advancement of medical science.

Pathology in the Age of Artificial Intelligence (AI): Redefining Roles and Responsibilities for Tomorrow's Practitioners.

The evolution of pathology from its rudimentary beginnings around 1700 BC to the present day has been marked by profound advancement in understanding and diagnosing diseases. This journey, from the earliest dissections to the modern era of histochemical analysis, sets the stage for the next transformative leap to the integration of artificial intelligence (AI) in pathology. Recent research highlights AI's significant potential to revolutionize healthcare within the next decade, with a particular impact on diagnostic processes. A majority of pathologists foresee AI becoming a cornerstone in diagnostic workflow, driven by the advent of image-based algorithms and computational pathology. These innovations promise to enhance the precision of disease diagnosis, particularly in complex cases, such as cancers, by offering detailed insights into the molecular and cellular mechanisms. Moreover, AI-assisted tools are improving the efficiency and accuracy of histological analysis by automating the evaluation of immunohistochemical biomarkers and tissue architecture. This shift not only accelerates diagnostic processes but also facilitates early disease management, crucial for improving patient outcomes. Furthermore, AI is reshaping educational paradigms in pathology, offering interactive learning environments that promise to enrich the training of future pathologists. Despite these advancements, the integration of AI in pathology raises ethical considerations regarding patient consent and data privacy. As pathology embarks on this AI-augmented era, it is imperative to navigate these challenges thoughtfully, ensuring that AI enhances rather than replaces the pathologist's role. This editorial discussed the historical progression of pathology, the current impact of AI on diagnostic practices, and the ethical implications of its adoption, underscoring the need for a symbiotic relationship between pathologists and AI to unlock the full potential of healthcare.

Association of Collagenous Gastritis With Helicobacter pylori Infection.

Helicobacter pylori is the most common infection and is mostly asymptomatic in infected individuals. Only a few cases of collagenous gastritis associated with H. pylori infection have been reported in the previous literature. We report a case of a 54-year-old female presenting with heartburn and epigastric pain associated with bloating, gas, and sometimes constipation. The physical examination was unremarkable with a soft, non-tender, and non-distended abdomen. Upper endoscopy showed erythema in the stomach with non-erosive gastritis. Our patient was diagnosed with H. pylori-associated chronic active gastritis with collagenous gastritis on histologic evaluation of the gastric biopsy specimen. After treatment with H. pylori eradication therapy, patients with collagenous gastritis associated with H. pylori infections showed a significant improvement in collagenous gastritis on endoscopy.

Littoral Cell Angioma of the Spleen: A Case Report.

Littoral cell angioma (LCA) is a rare, primary vascular tumor of the spleen that originates from the cells lining the venous sinuses of the spleen. Around 150 cases have been reported worldwide, with most reported cases of LCA being non-malignant but with unspecified malignant potential. As of 2022, three cases of malignant LCA have been reported. A 75-year-old male with a history of monoclonal gammopathy of uncertain significance presented with left upper outer quadrant abdominal pain. Ultrasound (US) scan showed a 10.5 cm round, circumscribed mass lesion, with hyperechoic foci, occupying the posterolateral aspect of the spleen. US-guided core needle biopsy of the mass revealed a diagnosis of "atypical cells present, suggestive of vascular neoplasm of the spleen," which was based on histologic and immunohistochemistry characteristics. Due to the size of the lesion, a malignant neoplasm was suspected, and a splenectomy was performed. Histological and immunohistochemical features of the splenic lesion returned a final diagnosis of benign LCA.

Angiomyolipoma of Uterine Cervix: Report of a Rare Case.

Angiomyolipoma (AML) is classified as perivascular epithelioid cell neoplasm (PEComas) and is commonly seen in the kidney. AML is a solid mesenchymal neoplasm rarely encountered at the extrarenal site. Extrarenal AML is infrequently seen in the female genital tract. Four cases of AML of the cervix have been reported in the literature to our knowledge. We report a case of a 44-year-old female patient who presented with complaints of "lower abdominal pressure" and a history of post-coital bleeding and human papillomavirus (HPV) infection. A cyst in the uterine cervix was found incidentally on computerized tomography (CT) scan of the abdomen and pelvis. The patient underwent a loop electrosurgical excision procedure. The histologic and immunohistochemical features of the cervical biopsy favored the diagnosis of AML. The patient underwent a laparoscopic hysterectomy with bilateral salpingectomy. Grossly, a 4 cm white soft-to-firm mass was identified within the anterior lip of the cervix. Microscopy of the mass showed smooth muscle proliferation with prominent blood vessels, and scant mature adipose tissue trapped in between the smooth muscle bundles. Immunohistochemical stains showed smooth muscle actin (SMA) and desmin highlighting the smooth muscle component of AML. The histology and immunohistochemistry of the cervical mass in the surgical specimen were identical to the biopsy specimen and a diagnosis of AML was made.

Merkel Cell Carcinoma in an Elderly Male With Extensive Local Disease.

Merkel cell carcinoma (MCC) is a rare, highly aggressive neuroendocrine carcinoma of the skin. It is often found in the sun-exposed skin areas of elderly individuals of Caucasian descent. MCC has a tendency for local recurrence and the potential to invade nearby lymph nodes and spread to distant sites in the body. Here, we present the case of an 83-year-old male with a history of multiple comorbidities, including congestive heart failure, obesity, hypertension, benign prostatic hyperplasia, and sarcoidosis, who presented with a slow-growing, fungating lesion on his left lower leg. Histopathological examination revealed MCC with extensive necrosis and involved resection margins. Additional skin lesions on the left knee were confirmed to be MCC. Follow-up CT scans showed lymphadenopathy and a femoral lesion. The patient was deemed a poor candidate for resection and placed on immunotherapy treatment. The low incidence rate and indistinct clinical manifestations of MCC make a conclusive diagnosis dependent on examining histological features and immunohistochemical markers through a lesioned biopsy or resection. Due to the aggressive nature of MCC and the tendency for asymptomatic and painless lesions to escape notice, it is important to raise awareness about this condition. This will lead to earlier detection and intervention, potentially enhancing patient survival rates.

A Rare Case of Collecting Duct Carcinoma With Extensive Coagulative Necrosis.

Collecting duct carcinoma (CDC) is an aggressive renal malignancy with limited diagnostic and therapeutic consensus. We report a case of a 69-year-old male with CDC and extensive coagulative necrosis who presented with lower extremity swelling, abdominal distention, and an enlarged left kidney causing grade IV hydronephrosis. Initial treatment with a left percutaneous nephrostomy was followed by clinical deterioration and a diagnosis of emphysematous pyelonephritis. Pathological examination of drainage material revealed extensive coagulative necrosis and was suggestive of a necrotic neoplasm. Subsequent left nephrectomy confirmed CDC with high-grade features, stromal desmoplasia, and extensive coagulative necrosis. Immunohistochemistry studies supported the diagnosis. This study highlights the diagnostic complexity of CDC and emphasizes the need for accurate reporting of atypical presentations. CDC remains a formidable clinical entity with limited treatment options and poor outcomes. Further research is essential to enhance our understanding and management of this rare and aggressive renal malignancy.

A Narrative Review on the Monkeypox Virus: An Ongoing Global Outbreak Hitting the Non-Endemic Countries.

Monkeypox is a rare zoonotic DNA with lineage from the Poxviridae family, Chordopoxvirinae subfamily, and Orthopoxvirus genus. With a previous history of controlled and contained occasional outbreaks of the virus, currently, a widely erupted outbreak of monkeypox with progressively rising numbers has been reported since May 2022 in multiple countries of the western hemisphere that are not historically endemic for this infection, particularly the United Kingdom and European Union countries. We have written a comprehensive review article to help clinicians better understand the disease. The global cessation of smallpox vaccination has been hypothesized to cause the rise in monkeypox infections in recent years. Monkeypox, like any other viral infection, commences with prodromal symptoms; a maculopapular rash with centrifugal distribution usually follows. Polymerase chain reaction (PCR) confirms the diagnosis. Transmission in humans is possible through infected animals or humans. In the ongoing 2022 outbreak, the monkeypox virus has been undergoing novel mutations at an alarming rate. Treatment options for monkeypox are an area that still requires extensive research, and the utility of certain antiviral medications in treating monkeypox infection is currently being explored but is still controversial and debatable.

Digital Pathology: Transforming Diagnosis in the Digital Age.

In the context of rapid technological advancements, the narrative review titled "Digital Pathology: Transforming Diagnosis in the Digital Age" explores the significant impact of digital pathology in reshaping diagnostic approaches. This review delves into the various effects of the field, including remote consultations and artificial intelligence (AI)-assisted analysis, revealing the ongoing transformation taking place. The investigation explores the process of digitizing traditional glass slides, which aims to improve accessibility and facilitate sharing. Additionally, it addresses the complexities associated with data security and standardization challenges. Incorporating AI enhances pathologists' diagnostic capabilities and accelerates analytical procedures. Furthermore, the review highlights the growing importance of collaborative networks facilitating global knowledge sharing. It also emphasizes the significant impact of this technology on medical education and patient care. This narrative review aims to provide an overview of digital pathology's transformative and innovative potential, highlighting its disruptive nature in reshaping diagnostic practices.

The Changing Global Epidemiology of Re-emerging Human Monkeypox Virus Infection: A Systematic Review.

Human monkeypox virus (MPVX) infection represents an emerging zoonotic disease caused by an orthopoxvirus, resulting in a condition reminiscent of smallpox. More recent developments have witnessed a notable surge in global MPVX outbreaks, eliciting significant concerns. We aimed to investigate the epidemiological factors of the emerging human monkeypox virus infection, including the number of suspected, confirmed, and fatal cases, as well as the risk factors for contracting monkeypox infection. We performed a systematic review of peer-reviewed literature by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An electronic database search (PubMed, Wiley Online Library, and Science Direct) was undertaken. For monkeypox-related studies, we included 25 peer-reviewed articles from 2018 and 2022, and data were extracted on the current evidence on the cases and the risk factors for MPVX infection, to develop public health advisories. Our reports show a rapid rise of MPVX cases in the highly endemic African regions after the 1970s, spread to other countries, and an increase in the median age from young children to young adults. The cessation of smallpox vaccination might have been one of the factors responsible for these findings. As of 2022, the genomic sequences of ten MPVX strains associated with the recent countrywide outbreak have been determined. While the West African Clade has been primarily implicated in the recent viral surge, data were insufficient to determine which mutation contributed to increased transmissibility. In the Democratic Republic of the Congo (DRC), sleeping on the floor was significantly associated with contracting MPVX, while eating or processing of animal foods was not a significant risk factor. In the United States, cleaning the cages and bedding of sick animals, touching infected animals, and daily exposure to sick animals were associated with an increased probability of contracting the MPVX infection. Recent global outbreaks and the rising incidence of MPVX infections among young adults in the endemic zones might be a result of the cessation of the smallpox vaccine. The increased risk associated with exposure to sick animals or sleeping on the floor suggests high infectivity from animal excretions. Increasing awareness, strict surveillance, and contact tracing can help contain global outbreaks. The ring vaccination approach for exposed individuals is another potential disease containment strategy. Future studies should investigate measures for rapid laboratory diagnosis, maintaining lab safety, and transmissibility.

Sucrose Intakes and Incident Colorectal Cancer Risk among Women.

BACKGROUND: High sucrose intakes are hypothesized to increase colorectal cancer (CRC) risk by several mechanisms, and sucrose intakes have been consistently positively associated with CRC risk in case-control studies. However, all but one prospective study reported a null sucrose-CRC association. The only prospective study to report a positive association was the Iowa Women's Health Study (IWHS) of 35,221 cancer-free Iowa women, aged 55 - 69 years old at baseline in 1986, after four years of follow up. MATERIALS AND METHODS: To address the discrepant findings in the literature, after 26 years of follow up in the IWHS, we updated and expanded on our earlier reported analyses. During follow up through 2012, 1,731 women were diagnosed with CRC. Baseline dietary intakes were assessed with a Willett semiquantitative food frequency questionnaire. We used multivariable Cox proportional hazards regression models to estimate adjusted hazards ratios (HRs) and their 95% confidence intervals (CI). RESULTS: For those in the highest relative to the lowest intake quintiles, the adjusted HRs (95% CI) for CRC were 1.04 (0.87-1.23; Ptrend = 0.59) for sucrose, 1.00 (0.82-1.21; Ptrend = 0.67) for sucrose-containing foods, and 1.01, (0.83-1.22; Ptrend = 0.56) for nondairy sucrose-containing foods, respectively. These findings did not differ substantially by colorectal site or according to categories of selected participant characteristics. CONCLUSIONS: Our findings do not support that intakes of sucrose or sucrose-containing foods are substantially associated with CRC risk among older women.

Temporal Trends in the Prevalence of Diabetes Decompensation (Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State) Among Adult Patients Hospitalized with Diabetes Mellitus: A Nationwide Analysis Stratified by Age, Gender, and Race.

Background Disproportionate change in the burden of diabetes mellitus across various subgroups has been reported in the United States. However, changing landscape of the prevalence and mortality of decompensated diabetes (diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS)) remains indistinct across various age, gender, and racial groups of hospitalized diabetics. Methods The National Inpatient Sample (NIS) datasets (2007-2014) were sought to assess the prevalence and temporal trends in decompensated diabetes stratified by age, gender, and race and related in-hospital outcomes among the adult patients hospitalized with diabetes using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Discharge weights were used to obtain national estimates. Results Of 56.7 million hospitalizations with diabetes, 0.5 (0.9%) million patients revealed decompensated diabetes from 2007 to 2014. The decompensated diabetics consisted of younger (~52 vs. 66 yrs), more often black (24.2% vs. 17.3%) and Hispanic (12.9% vs. 10.9%) patients as compared to those without decompensation (p<0.001). Younger diabetes patients demonstrated the highest prevalence of in-hospital decompensation (18-44 yrs; 3.7%) with a relative increase of 32.4% (from 3.4% to 4.5%) from 2007 to 2014 (ptrend<0.001). Older diabetics (≥65 years) with decompensation suffered the highest in-hospital mortality (12.8%). The overall rate of decompensation was similar (0.9%) among male and female diabetes patients. However, over a period of 8 years, the rates of decompensation rose to 1.1% (ptrend<0.001) in males and 1.2% (ptrend<0.001) in females, respectively. All-cause in-hospital mortality among females with decompensated diabetes declined from 6.6% in 2007 to 5.9% in 2014 (ptrend=0.019). However, there was no significant drop in in-hospital mortality among male diabetics with acute decompensation (6.7% in 2007 to 6.8% in 2014, ptrend=0.811). We observed significantly increasing trends in decompensated diabetes among all race groups between 2007 and 2014 (ptrend<0.001). The in-hospital mortality was highest among Asian or Pacific Islander (0.9%) diabetes patients with decompensation from 2007 to 2014. There was a declining trend in the inpatient mortality among Asian or Pacific Islander (ptrend=0.029) and Hispanic (ptrend<0.001) patients with decompensated diabetes, whereas other race groups did not observe any significant decline in mortality over the study period. Diabetes hospitalizations with decompensation demonstrated significantly higher in-hospital mortality (6.3% vs. 2.6%; p<0.001), average length of stay (7.7 vs. 5.4 days; p<0.001), hospital charges ($65,904 vs. $42,889, p<0.001), and more frequent transfers to short-term hospitals (3.9% vs. 2.9%; p<0.001) in comparison to those without decompensation. The rates of acute myocardial infarction (AMI) (10.4% vs. 4.8%; p<0.001), stroke (4.0% vs. 3.3%; p<0.001) and venous thromboembolism (3.5% vs. 2.6%; p<0.001) were substantially higher among diabetics with decompensation compared to those without. Conclusions There was an increasing trend in the prevalence of decompensated diabetes from 2007 to 2014, most remarkable among younger black male diabetics. The patients with decompensated diabetes suffered higher in-hospital mortality and rates of AMI, stroke and venous thromboembolism, there was no significant decline in the mortality between 2007 and 2014.