Basic Principles and Role of Endoscopic Ultrasound in Diagnosis and Differentiation of Pancreatic Cancer from Other Pancreatic Lesions: A Comprehensive Review of Endoscopic Ultrasound for Pancreatic Cancer.

Pancreatic cancer is one of the leading causes of cancer-related deaths worldwide. Pancreatic lesions consist of both neoplastic and non-neoplastic lesions and often pose a diagnostic and therapeutic challenge due to similar clinical and radiological features. In recent years, pancreatic lesions have been discovered more frequently as incidental findings due to the increased utilization and widespread availability of abdominal cross-sectional imaging. Therefore, it becomes imperative to establish an early and appropriate diagnosis with meticulous differentiation in an attempt to balance unnecessary treatment of benign pancreatic lesions and missing the opportunity for early intervention in malignant lesions. Endoscopic ultrasound (EUS) has become an important diagnostic modality for the identification and risk stratification of pancreatic lesions due to its ability to provide detailed imaging and acquisition of tissue samples for analysis with the help of fine-needle aspiration/biopsy. The recent development of EUS-based technology, including contrast-enhanced endoscopic ultrasound, real-time elastography-endoscopic ultrasound, miniature probe ultrasound, confocal laser endomicroscopy, and the application of artificial intelligence has significantly augmented the diagnostic accuracy of EUS as it enables better evaluation of the number, location, dimension, wall thickness, and contents of these lesions. This article provides a comprehensive overview of the role of the different types of EUS available for the diagnosis and differentiation of pancreatic cancer from other pancreatic lesions while discussing their key strengths and important limitations.

Machine Learning-based Prediction Models for C difficile Infection: A Systematic Review.

BACKGROUND: Despite research efforts, predicting Clostridioides difficile incidence and its outcomes remains challenging. This systematic review aimed to evaluate the performance of machine-learning (ML) models in predicting CDI incidence and complications using clinical data from electronic health records. METHODS: We conducted a comprehensive search of databases (OVID, Embase, MEDLINE ALL, Web of Science, and Scopus) from inception up to September 2023. Studies employing ML techniques for predicting CDI or its complications were included. The primary outcome was the type and performance of ML models assessed using the area under the receiver operating characteristic curve (AUROC). RESULTS: Twelve retrospective studies that evaluated CDI incidence and/or outcomes were included. The most common used ML models were random forest and Gradient Boosting. The AUROC ranged from 0.60 to 0.81 for predicting CDI incidence, 0.59 to 0.80 for recurrence, and 0.64 to 0.88 for predicting complications. Advanced ML models demonstrated similar performance to traditional logistic regression. However, there was notable heterogeneity in defining CDI and the different outcomes, including incidence, recurrence, and complications, and a lack of external validation in most studies. CONCLUSION: ML models show promise in predicting CDI incidence and outcomes. However, the observed heterogeneity in CDI definitions and the lack of real-world validation highlight challenges in clinical implementation. Future research should focus on external validation and the use of standardized definitions across studies.

Incidence, implications and predictors of abdominal compartment syndrome in acute pancreatitis: A nationwide analysis.

BACKGROUND: Acute pancreatitis (AP) often presents with varying severity, with a small fraction evolving into severe AP, and is associated with high mortality. Complications such as intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are intricately associated with AP. OBJECTIVE: To assess the clinical implications and predictors of ACS in AP patients. METHODS: We conducted a retrospective study using the National Inpatient Sample (NIS) database on adult AP patients, further stratified by the presence of concurrent ACS. The data extraction included demographics, underlying comorbidities, and clinical outcomes. Multivariate linear and logistic regression analyses were performed using STATA (v.14.2). RESULTS: Of the 1,099,175 adult AP patients, only 1,090 (0.001%) exhibited ACS. AP patients with ACS had elevated inpatient mortality and all major complications, including septic shock, acute respiratory distress syndrome (ARDS), requirement for total parenteral nutrition (TPN), and intensive care unit (ICU) admission (P < 0.01). These patients also exhibited increased odds of requiring pancreatic drainage and necrosectomy (P < 0.01). Predictor analysis identified blood transfusion, obesity (BMI ≥30), and admission to large teaching hospitals as factors associated with the development of ACS in AP patients. Conversely, age, female gender, biliary etiology of AP, and smoking were found less frequently in patients with ACS. CONCLUSION: Our study highlights the significant morbidity, mortality, and healthcare resource utilization associated with the concurrence of ACS in AP patients. We identified potential factors associated with ACS in AP patients. Significantly worse outcomes in ACS necessitate the need for early diagnosis, meticulous monitoring, and targeted therapeutic interventions for AP patients at risk of developing ACS.

Efficacy of Endoscopic Therapy in Symptomatic Pancreatic Divisum: A Systematic Review and Meta-analysis.

BACKGROUND AND AIMS: Pancreas divisum (PD) is a congenital malformation of the pancreas and is implicated as a cause of pancreatitis. The role of endotherapy has been variable in symptomatic PD indicated by recurrent acute pancreatitis (RAP), chronic pancreatitis (CP), or chronic pancreatic-type abdominal pain (PP). The aim of this study was to analyze the pooled data to determine the success of endoscopic intervention for pancreas divisum. METHODS: We conducted a comprehensive search of several databases (inception to July 2023) to identify studies reporting on the use of endoscopic therapy in symptomatic pancreatic divisum. The random-effects model was used to calculate the pooled rates and I2% values were used to assess the heterogeneity. RESULTS: A total of 27 studies were retrieved that reported endoscopic intervention in pancreatic divisum. The calculated pooled rate of technical success was 92% (95% CI: 87-95; I2=63%). The calculated pooled rate of clinical success was 65% (95% CI: 60-70; I2=60%). The rate of clinical success by PD subtypes was highest in RAP at 71% (95% CI: 65-76; I2=24%). Available studies had significant heterogeneity in defining clinical success. The rate of adverse events was 71% (95% CI: 65-76; I2=24%). CONCLUSIONS: The role of endoscopic therapy in pancreatic divisum is variable with the highest success rate in recurrent acute pancreatitis. Endoscopic intervention is associated with a higher-than-usual rate of adverse events, including post-ERCP pancreatitis.

Diagnostic accuracy of bowel ultrasonography in patients with inflammatory bowel disease: a systematic review and meta-analysis.

Background: Bowel ultrasonography (BUS) is emerging as a promising noninvasive tool for assessing disease activity in inflammatory bowel disease (IBD) patients. We evaluated the diagnostic accuracy of BUS in IBD patients against the gold standard diagnostic method, standard colonoscopy. Methods: Major databases were searched from inception to May 2023 for studies on BUS diagnostic accuracy in IBD. Outcomes of interest were pooled sensitivity, specificity, positive (PPV), and negative (NPV) predictive values. Endoscopic confirmation served as ground truth. Standard meta-analysis methods with a random-effects model and I2 statistics were applied. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Results: Twenty studies (1094 patients) were included in the final analysis. The majority (75%) of studies considered bowel wall thickness >3 mm as abnormal. Endoscopic evaluation was performed between days 3 and 180. The pooled diagnostic accuracy of BUS in IBD was 66% (95% confidence interval [CI] 58-72%; I2=78%), sensitivity was 88.6% (95%CI 85-91%; I2=77%), and specificity 86% (95%CI 81-90%; I2=95%). PPV and NPV were 94% (95%CI 93-96%; I2=25%) and 74% (95%CI 66-80%; I2=95%), respectively. On subgroup analysis, small-intestine contrast-enhanced ultrasonography (SICUS) demonstrated high sensitivity (97%, 95%CI 91-99%; I2=83%), whereas BUS exhibited high specificity (94%, 95%CI 92-96%; I2=0%) and NPV (76%, 95%CI 68-83%; I2=80.9%). Meta-regression revealed a significant relation between side-to-side anastomosis and BUS specificity (P=0.02) and NPV (P=0.004). Conclusion: The high diagnostic accuracy of BUS in detecting bowel wall inflammation suggests utilizing regular BUS as the primary modality, with subsequent consideration of SICUS if clinically warranted.

Early palliative care referral may improve end-of-life care in end-stage liver disease patients: A retrospective analysis from a non-transplant center.

BACKGROUND: Patients with end-stage liver disease (ESLD) who are not transplant candidates often have a trajectory of rapid decline and death similar to patients with stage IV cancer. Palliative care (PC) services have been shown to be underutilized for such patients. Most studies examining the role of PC in ESLD have been done at transplant centers. Thus, determining the utilization and benefit of PC at a non-transplant tertiary center may help establish a standard of care in the management of patients with ESLD not eligible for transplant. METHODS: We conducted a retrospective analysis of adult (>18 years) patients with ESLD admitted to Rochester Regional Health (RRH) system hospitals from 2012 to 2021. Patients were divided into groups based on the presence or absence of PC involvement. Baseline characteristics were recorded. The impact of PC was assessed by comparing the number of hospitalizations before and after the involvement of PC, comparing code status changes, health care proxy (HCP) assignments, Aspira catheter placements, and frequency of repeated paracentesis. RESULTS: In our analysis of 576 patients, 41.1% (237 patients) received a PC consult (PC group), while 58.9% (339 patients) did not (no-PC group). Baseline characteristics were comparable. However, their mean number of admissions significantly decreased (15.66 vs. 3.49, p < 0.001) after PC involvement. Full code status was more prevalent in the no-PC group (67.8% vs. 18.6%, p < 0.001), while comfort care code status was more common in the PC group (59.9% vs. 20.6%, p < 0.001). Changes in code status were significantly higher in the PC group (77.6% vs. 29.2%, p < 0.001). The PC group had a significantly higher mortality rate (83.1% vs. 46.4%, p < 0.01). Patients in the PC group had a higher likelihood of having an assigned HCP (63.7% vs. 37.5%, p < 0.001). PC referral was associated with more frequent use of an Aspira catheter (5.9% vs. 0.9%, p < 0.001) and more frequent paracentesis (30.8% vs. 16.8%, p < 0.001). CONCLUSIONS: In conclusion, our study provides compelling evidence of the diverse advantages of palliative care for patients with end-stage liver disease, including reduced admissions, improved goals of care, code status modifications, enhanced healthcare proxy assignments, and targeted interventions. These findings highlight the potential significance of early integration of palliative care in the disease trajectory to provide comprehensive, patient-centered care that addresses the unique needs and preferences of individuals with advanced liver disease.

Unveiling the Hazards: A Case Report on Kayexalate-induced Colonic Necrosis.

Sodium polystyrene sulphonate (SPS), employed in the management of severe hyperkalemia, is typically combined with sodium sorbitol to avert potential intestinal obstruction. Nonetheless, the administration of Kayexalate, even in the presence of minimal sorbitol, can lead to the grave complication of colonic necrosis. We present a case of Kayexalate-mediated colonic necrosis, highlighting the vital necessity of acknowledging the inherent risks associated with its usage in spite of its efficacy in potassium reduction. In light of these potential risks, it is incumbent upon physicians to exercise caution, and contemplate the use of alternative pharmacological agents that effectively eliminate excess potassium, whilst minimizing associated adverse effects.

Dialysis Decision Making, Dialysis Experiences, and Illness Perceptions: A Qualitative Study of Pakistani Patients Receiving Maintenance Hemodialysis.

Rationale & Objective: The incidence and prevalence of patients with kidney failure requiring dialysis are increasing in Pakistan. However, in-depth perspectives on kidney care from Pakistani people requiring maintenance dialysis are lacking. Study Design: Qualitative interview study. Setting & Participants: Between September 2020 and January 2021, we interviewed 20 adults receiving maintenance hemodialysis in 2 outpatient dialysis units in Pakistan. We asked open-ended questions to explore their experiences with various aspects of kidney care. Analytical Approach: We recorded, transcribed, and then, using a phenomenological approach, thematically analyzed interviews. Results: We observed the following 6 main themes: (1) Patients perceived various supernatural phenomena as causes of their illness and chose traditional medicine for chronic kidney disease (CKD) treatment. (2) Patients expressed dissatisfaction with their physicians' communication. They felt poorly informed and resented their decision to initiate dialysis. (3) Family members tried to dissuade patients away from dialysis but also provided support once dialysis was initiated. (4) Patients and families found it challenging to afford dialysis and transplantation and also to arrange for transportation. (5) Women found it challenging to fulfill their obligations as wives and mothers while receiving maintenance dialysis. (6) Patients seemed reluctant to discuss end-of-life care. Limitations: We collected data from only 2 hospitals in neighboring cities. Additionally, patients on peritoneal dialysis were not included. Conclusions: Our findings shed light on patients' perspectives on kidney care in Pakistan and call for financially feasible solutions to raise kidney disease awareness and improve patients' experiences with dialysis. Physician training in communication and shared dialysis decision making along with the development of culturally adapted decision aids are needed to improve CKD knowledge and shared decision making. Although financial challenges preclude many from receiving long-term dialysis, cost-effective strategies to improve the availability of other options (eg, supportive kidney care, peritoneal dialysis, and transplantation) are still warranted.

Plasmablastic Lymphoma Mimicking Osteomyelitis of Femur in an Immunocompetent Individual: A Case Report.

Plasmablastic lymphoma (PBL) is an aggressive type of diffuse large B-cell lymphoma. It is most commonly seen in patients with human immunodeficiency virus (HIV) infection and other immunodeficiencies manifesting commonly in the form of oral lesions. Here, we report a case of an HIV-negative, immunocompetent elderly male who presented with a painful solitary tender lesion on the right anterior lateral thigh. A preliminary diagnosis of osteomyelitis (right femur) from a possibly infected dynamic compression plate was made following initial ultrasound and MRI of the right lower extremity. An attempt was made to incise and drain the lesion, which was abruptly stopped as it resulted in drainage of copious blood, leading to hemodynamic instability. Histopathology of the specimen revealed findings consistent with PBL. The diagnosis of PBL was further confirmed by immunohistochemical staining, which was positive for CD138, MUMI, and CD56 and negative for CD20 and ALK. Due to its rarity and heterogeneous presentations, PBL could be easily overlooked clinically in immunocompetent patients. Therefore, our case highlights the importance of considering the diagnosis of PBL even in lesions whose course is consistent with other infectious bone pathologies.

Uropathogens Antimicrobial Sensitivity and Resistance Pattern From Outpatients in Balochistan, Pakistan.

Objective To determine the pattern of microbes responsible for urinary tract infections and their susceptibility to different antibiotics. Method This is a cross-sectional study conducted at Quetta, Pakistan. The urine samples of 400 patients were collected and sent for culture and sensitivity analysis. The results were recorded on an excel datasheet. Descriptive statistics were used to describe the data. Results Out of 400 urine samples, 266 samples were culture positive for microorganisms. The most common organism on analysis was Escherichia coli 123/266 (46.24%) followed by Staphylococcus saprophyticus 59/266 (22.18%) and Klebsiella pneumonia 49/266 (18.42%). Gram-negative microorganisms were most susceptible to fosfomycin, cefoperazone/sulbactam, and meropenem. Gram-positive microorganisms were most susceptible to fosfomycin, cefoperazone/sulbactam, meropenem, and amoxicillin/clavulanate. High rates of resistance in E. coli were observed to most commonly prescribed broad-spectrum antibiotics; ceftriaxone (64.35%), cefotaxime (76.54%), ceftazidime (49.43%), cefepime (53.44%), levofloxacin (71.26%), and amoxicillin/clavulanate (70.31%). E. coli was the major multidrug-resistant organism. Conclusion High rates of antibiotic resistance and multi-drug resistance were revealed in this study due to the widespread and injudicious use of broad-spectrum antibiotics. Thus, it is highly recommended to regulate the pharmacies. Physicians should judiciously prescribe antibiotics and practice the culture and sensitivity of urine samples rather than blind prescription. Continued surveillance on uropathogens prevalence and resistance, new and next-generation antibiotics, and rapid diagnostic tests to differentiate viral from bacterial infections is the need of time.

Vitamin D Deficiency and Associated Risk Factors in Muslim Housewives of Quetta, Pakistan: A Cross-Sectional Study.

Background Vitamin D (Vit-D) plays a central role in calcium homeostasis and maintains skeletal integrity. Housewives in Quetta, Pakistan are at increased risk of vitamin D deficiency (VDD). They spend a greater part of their day in cleaning, washing, cooking, managing daily groceries, and other household chores. Thus, little time is left for self-care and outdoor activities. They wear hijab and have very little exposure to sunlight. In addition, their diet is deficient in Vit-D-rich food items, rendering them at high risk of VDD. Fear of getting tanned, melasma, and preference for a fair complexion further limit their sun exposure. This study evaluates the prevalence of VDD in housewives and determines its various risk factors to recommend screening guidelines for VDD. Methods A cross-sectional study was performed between November 2020 and April 2021 and recruited housewives aged >18 from the outpatient department of a tertiary care hospital in Quetta. Informed consent was obtained from all participants. VDD was defined as a serum 25(OH)-D level <20 ng/mL (50 nmol/L). Sociodemographic variables and information about the dietary habits, perception, attitudes towards sunlight, and daily duration of sunlight exposure were collected. Mean and standard deviation (SD) were calculated for continuous variables and counts, and proportions were calculated for categorical variables like education, age. Univariate and multivariate logistic regression analyses were performed to determine the risk factors and associations of VDD. Data were analyzed by SAS/STAT software (version 9.4). Results Among 151 housewives, 58.9% of housewives had VDD. VDD group had a higher proportion of females aged 18-30 years and a lower proportion of graduates. The reported use of Vit-D supplements was much lower in the VDD group compared with the non-deficient group, 38.2% versus 71.0 %, P-value <0.001. History of fragility fractures was reported by 10.1% of housewives in the VDD group compared to 4.8% in the non-deficient group, P-value: 0.03. Around 77.5% of housewives in the VDD group spent 15 minutes or less outdoors versus 51.6% in the non-deficient group; 55.1% of housewives in the VDD group reported that they never consumed milk versus 17.7 % in the non-deficient group, P-value <0.00001. In the univariate logistic regression model, housewives with an 11-12th grade of education had 4.80-fold higher odds of VDD compared to those who had undergraduate or graduate degrees (OR: 4.80, 95 % CI: 1.07-21.45). Housewives who never consumed milk had 9.72-fold (95 % CI: 3.69-25.58) higher odds of VDD compared to those who consumed milk on daily basis. Odds of VDD were 3.61-fold (95% CI: 1.06-12.31) higher in those who never consumed fish as compared to those who ate fish at least 1-2 days/week. In multivariate logistic regression, age group 18-30 (OR: 17.07, 95% CI: 1.18-246.86), and never consuming milk (OR: 7.33, 95 % CI: 1.99-26.89) were independently associated with VDD. Conclusion VDD is highly prevalent (58.9%) in housewives of Quetta. It is the need of time to increase awareness regarding the health benefits, sources, and deficiency symptoms of Vit-D. Our study revealed VDD in housewives irrespective of education and income. Dietary supplementations were greater predictors of VDD. Daily sun exposure should be encouraged, and food items should be fortified with Vit-D. Recommendations for Vitamin D screening would be a good step, especially in Muslim housewives.

Hereditary Chorea Associated With and Aggravated by Systemic Lupus Erythematosus.

Chorea is caused by a number of conditions, including genetic, metabolic derangements, infections, drugs, toxins, tumors, and disorders of the immune and inflammatory system of the body. Huntington's disease (HD) is the most common genetic cause of chorea. Systemic lupus erythematosus (SLE) is an autoimmune condition. Common symptoms include oral ulcers, joint pain, malar or discoid rashes, photosensitivity, and blood dyscrasias. It can involve the heart, lungs, kidneys, and brain. SLE can cause neuropsychiatric manifestations like psychosis, seizures, headache, confusion, and stroke. Chorea is a known symptom of SLE. HD is now recognized to involve more than one system and is associated with a number of comorbid conditions. We report the first case of hereditary choreiform disorder associated with and aggravated by SLE. This is also the first case report of probable Huntington disease from Balochistan, Pakistan. We report a 19-year-old girl with choreiform disorder and a family history of chorea. Choreiform disorder was present in her paternal grandmother and uncles. She presented with fever, cough, and aggravation of choreiform movements of upper and lower limbs for 10 days. She also complained of pain in the small joints of her hands and feet, oral ulcers, hair loss, and aggravation of choreiform movements for two and half months. Probable differential diagnoses of HD, Wilson's disease, and other types of hereditary chorea, aggravated by infections, SLE, or Covid-19, were made. Her initial lab results revealed pancytopenia, increased D-dimers and serum ferritin, positive antinuclear antibodies (ANA), and anti-double-stranded DNA (anti-dsDNA). Her C3 and C4 complement factors were low. The rest of the lab test results, including polymerase chain reaction (PCR) coronavirus disease (COVID-19), blood culture, and malaria, were negative. Thus, a diagnosis of hereditary chorea associated with and aggravated by SLE was made. Hereditary choreiform disorders can be associated with and aggravated by autoimmune conditions like SLE. Thus, it is recommended to be vigilant and have a low threshold for diagnosing co-existing autoimmune conditions like SLE in patients with hereditary choreiform disorder.