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 and Safety of Gastric Peroral Endoscopic Myotomy Across Different Etiologies of Gastroparesis: A Systematic Review and Meta-Analysis.

BACKGROUND AND AIMS: Gastric Peroral Endoscopic Myotomy (G-POEM) is an emerging treatment for refractory gastroparesis. While its efficacy and safety have been analyzed in previous systematic reviews and meta-analyses, no studies have compared its effectiveness based on etiology. Our study aims to evaluate the efficacy and safety of G-POEM by etiologies of gastroparesis. METHODS: We conducted a comprehensive search in major databases until October 2023, focusing on the efficacy and safety of G-POEM by etiology. Our primary outcome was clinical success based on etiology, with additional subgroup analysis on pre-and post-GCSI scores based on etiology using standard meta-analysis methods and the random-effects model. Heterogeneity was assessed using I2% statistics. RESULTS: In our analysis of 15 studies (7 retrospective, 8 prospective) involving 982 patients (mean age 50.81 years, mean follow-up 21 months), post-surgical conditions were the most common etiology in G-POEM (290 cases), followed by idiopathic factors (287 cases) and diabetes (286 cases). Subgroup analysis revealed pooled clinical success rates of 65% (CI: 51-77; I2 = 46%) for diabetes, 70% (CI: 46-86; I2 = 73%) for post-surgical, and 60% (CI: 41-77; I2 = 68%) for idiopathic etiologies. Our research also indicated that G-POEM significantly improved GCSI scores: 1.7 (95% CI: -0.01 to 3.5, p = 0.052) for diabetes, 1.34 (95% CI: -0.07 to 2.62, p = 0.038) for post-surgical, and 1.5 (95% CI: 0.36 to 2.75, p = 0.01) for idiopathic patients. CONCLUSION: Based on this meta-analysis, G-POEM is effective and safe for treating refractory gastroparesis irrespective of the etiology, with significant improvements in clinical success rates and GCSI scores.

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.

Systematic review of machine learning models in predicting the risk of bleed/grade of esophageal varices in patients with liver cirrhosis: A comprehensive methodological analysis.

Esophageal varices (EV) in liver cirrhosis carry high mortality risks. Traditional endoscopy, which is costly and subjective, prompts a shift towards machine learning (ML). This review critically evaluates ML applications in predicting bleeding risks and grading EV in patients with liver cirrhosis. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we conducted a systematic review of studies using ML to predict the risk of variceal bleeding and/or grade EV in liver disease patients. Data extraction and bias assessment followed the CHARMS (CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modeling Studies) checklist and PROBAST (Prediction model Risk Of Bias Assessment Tool) tool, respectively. Due to the heterogeneity of the study, a meta-analysis was not feasible; instead, descriptive statistics summarized the findings. Twelve studies were included, highlighting the use of various ML models such as extreme gradient boosting, artificial neural networks, and convolutional neural networks. These studies demonstrated high predictive accuracy, with some models achieving area under the curve values above 99%. However, significant heterogeneity was noted in input variables, methodologies, and outcome measures. Moreover, a substantial portion of the studies exhibited unclear or high risk of bias, mainly due to insufficient participant numbers, unclear handling of missing data, and a lack of detailed reporting on endoscopic procedures. ML models show significant promise in predicting the risk of variceal bleeding and grading EV in patients with cirrhosis, potentially reducing the need for invasive procedures. Nonetheless, the current literature reveals considerable heterogeneity and methodological limitations, including high or unclear risks of bias. Future research should focus on larger, prospective trials and the standardization of ML assessment criteria to confirm these models' practical utility in clinical settings.

Analysis of patients with Crohn's disease and intestinal obstruction: a National Inpatient Sample study.

Background: Crohn's disease (CD) predisposes patients to intestinal obstruction (IO), a severe complication. This study examined the outcomes and healthcare utilization of patients with CD and IO using data from the National Inpatient Sample (NIS). Methods: This retrospective analysis of NIS data from 2016-2020 compared hospitalized adult CD patients with and without IO. Outcomes studied include in-hospital mortality, length of stay (LOS), hospitalization charges, and the requirement for intervention, using regression models for adjustment. Results: Among the 304,149 CD patients, 27,024 had IO. These patients experienced higher in-hospital mortality (3.9% vs. 1.8% for non-IO, adjusted odds ratio [aOR] 1.78, 95% confidence interval [CI] 1.09-2.89; P=0.02), longer mean LOS (7.23 vs. 4.53 days for non-IO, P<0.001), and higher average hospitalization charges ($71,775 vs. $43,717 for non-IO, P<0.001). Additionally, they had higher odds of requiring admission to the intensive care unit (aOR 1.99, 95%CI 1.45-2.73; P<0.001), intubation (aOR 2.53, 95%CI 1.74-3.68; P<0.001), balloon dilation (aOR 1.50, 95%CI 1.132-1.98; P=0.005), or intestinal resection (aOR 2.29, 95%CI 2.11-2.49; P<0.001). Conclusions: CD patients with IO face considerable challenges, including greater mortality, longer hospital stays, and higher hospitalization costs. The need for intensive care and surgical interventions highlights the urgent need for improved management and treatment strategies to enhance outcomes for these patients.

Machine Learning-Based Prediction Models for Clostridioides difficile Infection: A Systematic Review.

INTRODUCTION: Despite research efforts, predicting Clostridioides difficile incidence and its outcomes remains challenging. The aim of this systematic review was to evaluate the performance of machine learning (ML) models in predicting C. difficile infection (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. RESULTS: Twelve retrospective studies that evaluated CDI incidence and/or outcomes were included. The most commonly used ML models were random forest and gradient boosting. The area under the receiver operating characteristic curve 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. DISCUSSION: 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.

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.

Cold snare polypectomy versus cold endoscopic mucosal resection for small colorectal polyps: a meta-analysis of randomized controlled trials.

Background/Aims: Cold snare polypectomy (CSP) is routinely performed for small colorectal polyps (≤10 mm). However, challenges include insufficient resection depth and immediate bleeding, hindering precise pathological evaluation. We aimed to compare the outcomes of cold endoscopic mucosal resection (CEMR) with that of CSP for colorectal polyps ≤10 mm, using data from randomized controlled trials (RCTs). Methods: Multiple databases were searched in December 2023 for RCTs reporting outcomes of CSP versus CEMR for colorectal polyps ≤10 mm in size. Our primary outcomes were rates of complete and en-bloc resections, while our secondary outcomes were total resection time (seconds) and adverse events, including immediate bleeding, delayed bleeding, and perforation. Results: The complete resection rates did not significantly differ (CSP, 91.8% vs. CEMR 94.6%), nor did the rates of en-bloc resection (CSP, 98.9% vs. CEMR, 98.3%) or incomplete resection (CSP, 6.7% vs. CEMR, 4.8%). Adverse event rates were similarly insignificant in variance. However, CEMR had a notably longer mean resection time (133.51 vs. 91.30 seconds). Conclusions: Our meta-analysis of seven RCTs showed that while both CSP and CEMR are equally safe and effective for resecting small (≤10 mm) colorectal polyps, the latter is associated with a longer resection time.

Assessing ChatGPT4 with and without retrieval-augmented generation in anticoagulation management for gastrointestinal procedures.

Background: In view of the growing complexity of managing anticoagulation for patients undergoing gastrointestinal (GI) procedures, this study evaluated ChatGPT-4's ability to provide accurate medical guidance, comparing it with its prior artificial intelligence (AI) models (ChatGPT-3.5) and the retrieval-augmented generation (RAG)-supported model (ChatGPT4-RAG). Methods: Thirty-six anticoagulation-related questions, based on professional guidelines, were answered by ChatGPT-4. Nine gastroenterologists assessed these responses for accuracy and relevance. ChatGPT-4's performance was also compared to that of ChatGPT-3.5 and ChatGPT4-RAG. Additionally, a survey was conducted to understand gastroenterologists' perceptions of ChatGPT-4. Results: ChatGPT-4's responses showed significantly better accuracy and coherence compared to ChatGPT-3.5, with 30.5% of responses fully accurate and 47.2% generally accurate. ChatGPT4-RAG demonstrated a higher ability to integrate current information, achieving 75% full accuracy. Notably, for diagnostic and therapeutic esophagogastroduodenoscopy, 51.8% of responses were fully accurate; for endoscopic retrograde cholangiopancreatography with and without stent placement, 42.8% were fully accurate; and for diagnostic and therapeutic colonoscopy, 50% were fully accurate. Conclusions: ChatGPT4-RAG significantly advances anticoagulation management in endoscopic procedures, offering reliable and precise medical guidance. However, medicolegal considerations mean that a 75% full accuracy rate remains inadequate for independent clinical decision-making. AI may be more appropriately utilized to support and confirm clinicians' decisions, rather than replace them. Further evaluation is essential to maintain patient confidentiality and the integrity of the physician-patient relationship.

Beyond the Diagnosis: A Deep Dive Into the End Stage Liver Disease Experience From the Patient Perspective.

INTRODUCTION: End-stage liver disease (ESLD) presents a multifaceted challenge that encompasses not only physical but also emotional, psychological, and social dimensions. This study aims to explore the experiences of ESLD patients within the United States healthcare system. METHODS: Utilizing a convenience sampling methodology, 15 ESLD patients from a tertiary care hospital in the USA participated in semi-structured interviews between April 2023 and January 2024. Data analysis was conducted using MAXQDA 2023, employing a phenomenological approach to identify common themes. RESULTS: The study identified six primary themes: the significance of communication style in diagnosis delivery, the crucial role of family and social support, varied understanding and preferences for palliative care, diverse attitudes towards advanced care planning, preferences for coordinated healthcare experiences, and the emotional and psychological impact of ESLD. CONCLUSION: Our study underscores the complexity of ESLD patient care beyond medical treatment, highlighting the importance of clear communication, empathetic care, and the integration of family and palliative care services.

Advancements in Early Detection and Screening Strategies for Pancreatic Cancer: From Genetic Susceptibility to Novel Biomarkers.

Pancreatic cancer is a rare but lethal cancer due to its biologically aggressive nature, advanced stage at the time of diagnosis, and poor response to oncologic therapies. The risk of pancreatic cancer is significantly higher to 5% in certain high-risk individuals with inherited genetic susceptibility. Screening for pancreatic cancer in these individuals from high-risk groups can help with the early detection of pancreatic cancer as well as the detection of precursor lesions leading to early surgical resection and improved overall outcomes. The advancements in radiological imaging as well as advanced endoscopic procedures has made a significant impact on the early diagnosis, surveillance, and staging of pancreatic cancer. There is also a significant advancement in the development of biomarkers for the early detection of pancreatic cancer, which has also led to the development of liquid biopsy, allowing for microRNA detection in serum and circulating tumor cells. Various societies and organizations have provided guidelines for pancreatic cancer screening and surveillance in high-risk individuals. In this review, we aim to discuss the hereditary risk factors for developing pancreatic cancer, summarize the screening recommendations by different societies, and discuss the development of novel biomarkers and areas for future research in pancreatic cancer screening for high-risk individuals.

Remimazolam for sedation in gastrointestinal endoscopy: A comprehensive review.

Worldwide, a majority of routine endoscopic procedures are performed under some form of sedation to maximize patient comfort. Propofol, benzodiazepines and opioids continue to be widely used. However, in recent years, Remimazolam is gaining immense popularity for procedural sedation in gastrointestinal (GI) endoscopy. It is an ultra-short-acting benzodiazepine sedative which was approved by the Food and Drug Administration in July 2020 for use in procedural sedation. Remimazolam has shown a favorable pharmacokinetic and pharmacodynamic profile in terms of its non-specific metabolism by tissue esterase, volume of distribution, total body clearance, and negligible drug-drug interactions. It also has satisfactory efficacy and has achieved high rates of successful sedation in GI endoscopy. Furthermore, studies have demonstrated that the efficacy of Remimazolam is non-inferior to Propofol, which is currently a gold standard for procedural sedation in most parts of the world. However, the use of Propofol is associated with hemodynamic instability and respiratory depression. In contrast, Remimazolam has lower incidence of these adverse effects intra-procedurally and hence, may provide a safer alternative to Propofol in procedural sedation. In this comprehensive narrative review, highlight the pharmacologic characteristics, efficacy, and safety of Remimazolam for procedural sedation. We also discuss the potential of Remimazolam as a suitable alternative and how it can shape the future of procedural sedation in gastroenterology.

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.

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.

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.

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.

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.