Predicting In-Hospital Mortality After Acute Myeloid Leukemia Therapy: Through Supervised Machine Learning Algorithms.

PURPOSE: Despite careful patient selection, induction chemotherapy for acute myeloid leukemia (AML) is associated with a considerable risk for treatment-related mortality (5%-20%). We evaluated machine learning (ML) algorithms trained using factors available at the time of admission for AML therapy to predict death during the hospitalization. METHODS: We included AML discharges with age > 17 years who received inpatient chemotherapy from State Inpatient Database from Arizona, Florida, New York, Maryland, Washington, and New Jersey for years 2008-2014. The primary objective was to predict inpatient mortality in patients undergoing chemotherapy using covariates present before initiation of chemotherapy. ML algorithms logistic regression (LR), decision tree, and random forest were compared. RESULTS: 29,613 hospitalizations for patients with AML were included in the analysis each with 4,177 features. The median age was 58.9 (18-101) years, 13,689 (53.7%) were male, and 20,203 (69%) were White. The mean time from admission to chemotherapy was 3 days (95% CI, 2.9 to 3.1), and 2,682 (9.1%) died during the hospitalization. Both LR and random forest models achieved an area under the curve (AUC) score of 0.78, whereas decision tree achieved an AUC of 0.70. The baseline LR model with age yielded an AUC of 0.62. To clinically balance and minimize false positives, we selected a decision threshold of 0.7 and at this threshold, 51 of our test set of 5,923 could have potentially averted treatment-related mortality. CONCLUSION: Using readily accessible variables, inpatient mortality of patients on track for chemotherapy to treat AML can be predicted through ML algorithms. The model also predicted inpatient mortality when tested on different data representations and paves the way for future research.

Association between spinal stenosis and wild-type ATTR amyloidosis.

Age-related cardiac amyloidosis results from deposits of wild-type tranthyretin amyloid (ATTRwt) in cardiac tissue. ATTR may play a role in carpal tunnel syndrome (CTS) and in spinal stenosis (SS), indicating or presaging systemic amyloidosis. We investigated consecutive patients undergoing surgery for SS for ATTR deposition in the resected ligamentum flavum (LF) and concomitant risk of cardiac amyloidosis. Each surgical specimen (LF) was stained with Congo red, and if positive, the amyloid deposits were typed by mass spectrometry. Patients with positive specimens underwent standard of care evaluation with fat pad aspirates, serum and urine protein electrophoresis with immunofixation, free light-chain assay, TTR gene sequencing and technetium 99 m-pyrophosphate-scintigraphy. In 2018-2019, 324 patients underwent surgery for SS and 43 patients (13%) had ATTR in the LF with wild-type TTR gene sequences. Two cases of ATTRwt cardiac amyloidosis were diagnosed and received treatment. In this large series, ATTRwt was identified in 13% of the patients undergoing laminectomy for SS. Patients with amyloid in the ligamentum flavum were older and had a higher prevalence of CTS, suggesting a systemic form of ATTR amyloidosis involving connective tissue. Further prospective study of patients with SS at risk for systemic amyloidosis is warranted.

Alternative chemoradiotherapy in anal carcinoma patients with mutations in thymidylate synthase and dihydropyrimidine dehydrogenase genes.

BACKGROUND: 5-fluorouracil (5-FU) and mitomycin-C (MMC) with radiotherapy (RT) remain an established treatment for patients with anal cancer (AC). Genetic mutations in two major metabolizing enzymes for 5-FU; dihydropyrimidine dehydrogenase (DPYD and thymidylate synthetase (TYMS), have been associated with clinical response and toxicity. However, their place in the treatment of AC remains undetermined. METHODS: We retrospectively reviewed 21 patients with AC, including T2-4, N0-1, M0 or T1-4, N2-3, and M0 treated between 2012 and 2018. All patients were treated with 5-FU 1,000 mg/m2/day via continuous intravenous (IV) infusion 1-4 and 29-32, MMC 10 mg/m2 IV bolus days 1 and 29 plus RT. Patients who developed ⩾3 grade toxicities were tested for the DPYD and TYMS genes. Treatment was either modified with reduced doses or changed to MMC 10 mg/m2 day 1 and 29 with cisplatin 25 mg/m2/week plus RT. Toxicities and responses were collected. RESULTS: Six out of 21 patients who developed ⩾3 grade toxicities including pancytopenia, neutropenia, thrombocytopenia, mucositis, nausea, rash, and nephritis were found to have genetic mutations: TYMS 2RG/3RC (n = 2), 3RG/3RC (n = 1), 2R/2R (n = 2), TYMS 3'UTR del/Ins (n = 2), and DPYD c.2864A > T heterozygous (n = 1). Two patients received 5-FU at a 50% reduced dose on days 29-32; one patient refused to receive 5-FU (continued with MMC and RT); one patient received only radiation therapy due to persistent pancytopenia despite the use of growth factors; two patients received an alternative regimen consisting of MMC 10 mg/m2 on day 29 with cisplatin (CDDP) 25 mg/m2/week plus RT; and two patients received cisplatin/MMC with RT from the beginning as they were prospectively detected to have TYMS abnormalities prior to dosing the chemotherapy. These patients tolerated treatment very well with only grade 2 toxicities. All the patients (4/4) on cisplatin/MMC achieved clinical complete response (cCR), while four patients (4/15) on 5-FU/MMC reached cCR at the first assessment. Radiological response showed complete response at the end of 24 weeks assessment. CONCLUSIONS: Molecular testing for DPYD and TYMS genes can allow us to identify patients who are most likely to respond or face severe toxicity to 5-FU in a potentially curable cancer. Combining radiation with CDDP with MMC in patients with AC is feasible. A prospective study based on pharmacogenetic testing comparing MMC/cisplatin with MMC/5-FU is indicated in patients with AC.

Length of Stay and Hospital Costs for Patients Undergoing Allogeneic Stem-Cell Transplantation.

PURPOSE: Patients who undergo allogeneic hematopoietic stem-cell transplantation (allo-HSCT) usually require a prolonged hospital stay that varies greatly across patients. Limited information exists on the factors associated with hospital length of stay (LOS) after allo-HSCT and the impact on transplant-related costs. The objective of this study was to determine predictors for longer LOS for allo-HSCT and to assess their impact on the cost of transplant stay. METHODS: Using the National Inpatient Sample database, adult patients hospitalized for allo-HSCT were identified using International Classification of Diseases, Ninth Revision, primary and secondary procedure codes. RESULTS: Between 2002 and 2015, 68,296 hospitalizations for allo-HSCT were identified. Peripheral blood was the most common stem-cell source (80%) followed by bone marrow (15%) and cord blood (5%). Median LOS was 25.8 days (interquartile range [IQR], 21-34.0 days), and the overall inpatient mortality rate was 8%. Stem-cell source was a significant predictor for longer LOS, being significantly longer for cord blood (median, 36.9 days; IQR, 26.7-49.9 days) compared with bone marrow (median, 27.2 days; IQR, 21.5-35.2 days) and peripheral blood (median 25.4 days; IQR, 20.8-32.7 days). Other predictors for longer LOS were patient characteristics such as age and race, transplant/post-transplant characteristics, and complications such as total body irradiation use, acute graft-versus-host disease, and infections. Longer LOS was also found to be associated with higher hospital costs. CONCLUSION: In patients who undergo allo-HSCT, LOS can be predicted using patient- and transplant-related characteristics as well as post-transplant complications. LOS is also a driver for increased cost, and further efforts are needed to mitigate transplant complications and resource utilization.

Trends and outcomes of fungal infections in hospitalized patients of inflammatory bowel disease: a nationwide analysis.

BACKGROUND: Immunosuppressive therapy is being increasingly used in the management of inflammatory bowel disease (IBD) which comprises of ulcerative colitis (UC) and Crohn's disease (CD). Patients on immunosuppressive therapy are at increased risk of developing opportunistic fungal infections. We conducted this analysis to describe the epidemiology of opportunistic fungal infections in this cohort. METHODS: We analyzed the National Inpatient Sample (NIS) database for all subjects with discharge diagnosis of IBD (UC and Crohn's disease) & Fungal infections (Histoplasmosis, Pneumocystosis, Cryptococcosis, Aspergillosis, Blastomycosis, candidiasis, Coccidioidomycosis) as primary or secondary diagnosis via ICD 9 codes during the period from 2002-2014. RESULTS: In UC, the incidence of all fungal infections was more in age above 50 (except for pneumoconiosis) male gender (except Candidiasis) and in Caucasians. In CD, the incidence was more in age above 50 (except Pneumocystosis, Blastomycosis & Coccidioidomycosis), female gender (except Histoplasmosis, Pneumocystosis & Cryptococcosis) and in Caucasians. Histoplasmosis and Blastomycosis were more prevalent in Midwest, Cryptococcosis and Candidiasis in South, Coccidioidomycosis in west in both UC and CD. Age above 50, south region, HIV, Congestive heart failure, underlying malignancies, diabetes mellitus with complications, chronic pulmonary disease, anemia, rheumatoid arthritis, collagen vascular disease, pulmonary circulation disorders, weight loss were significant predictors of fungal infections in IBD. The yearly trend showed a consistent small rise in incidence, and the mortality dropped till 2006 to peak again in 2008 with a subsequent decline. CONCLUSIONS: Our study is the first one to describe the basic demographics features and characteristics of opportunistic fungal infections in hospitalized patients with IBD. The yearly incidence of fungal infections did not show a significant rise. The mortality increased between 2006-2008 and a significant difference remains between IBD patients with and without fungal infections. One explanation of rise in mortality but a consistent incidence could be due to the use of biologics that did not increase but compromised the ability of IBD patients to fight opportunistic fungal infections.

Prospective Evaluation of Effect of Metformin on Activation of AMP-activated Protein Kinase (AMPK) and Disease Control in a Sub-group Analysis of Patients with GI Malignancies.

BACKGROUND: Observational studies have demonstrated association of metformin with reduced cancer incidence and mortality in multiple cancer types, including gastrointestinal (GI) malignancies. Anti-neoplastic effects of metformin are believed through many mechanisms including activation of AMP-activated protein kinase, which controls mammalian target of rapamycin (mTOR) growth regulatory pathway. METHODS: In a pilot, delayed-start randomized study, non-diabetic patients with GI cancers were randomized to 2 arms, Stage 1: concurrent metformin (500mg twice daily) plus chemotherapy vs. chemotherapy alone followed by cross over to metformin plus chemotherapy arm in Stage 2, while adverse events (DLT) were assessed by CTCAE v.3.0. As a translational correlate, we used phosphorylation of AMPKα at Thr172 to measure AMPK activation by western blot technique in PBMCs isolated from patients before and after receiving M. These levels were correlated with radiological (RECIST 1.1) and tumor marker outcomes by descriptive analysis. In this study, we present the sub-group analysis of patients with GI cancers. RESULTS: 41 patients with GI cancers (colorectal: 22, pancreatic: 12, gastroesophageal: 4, biliary: 2, others: 1) were treated in this trial. Mean duration of metformin therapy was 85 days (range: 9-443). There was no significant difference in grade 3 or above DLT in metformin plus chemotherapy vs. chemotherapy arm (14% vs. 12% respectively). Gel band density analysis on 19 patients showed that 63% patients had increased phosphorylation of AMPKα after metformin (ratio of phospho-AMPKα after and before metformin > 1) with mean = 1.227 (± 0.134). RECIST 1.1 restaging showed disease control in 55% patients and 45% patients had decline in tumor markers. Of note, 60% of patients with disease control also showed increase in phosphorylation of AMKα. CONCLUSIONS: This group of patients treated with metformin prospectively demonstrates the impact of metformin on AMPKα phosphorylation, and correlates with clinical benefit in patients with GI cancers when metformin was added to systemic chemotherapy of varying types. We aim to perform a dose-escalation of metformin in our next study with additional metabolomics correlates.

COVID-19 pandemic and the risk of infection in multiple sclerosis patients on disease modifying therapies: "what the bleep do we know?"

The novel coronavirus which emerged in Wuhan province of China has taken world by surprise. Since been diagnosed in December 2019, it has been termed a "Pandemic" and there is a growing concern in physicians across the globe. As new evidence is emerging, there are various preventative strategies which are being deployed. Multiple sclerosis patients who are on disease modifying therapies (DMTs) might be at a higher risk of acquiring or a poorer outcome due to their immune status. This review looks at the available evidence in managing this global crisis.

Dual Monoclonal Antibody Therapy in Patients With Systemic AL Amyloidosis and Cardiac Involvement.

BACKGROUND: Systemic AL amyloidosis (AL) is a rare disease in which clonal immunoglobulin light chains produced by monoclonal plasma cells circulate and misfold, resulting in direct toxicity and fibrillar deposition of amyloid in numerous tissues. Early mortality from cardiac damage remains high. As depth of organ response carries a prognostic significance, combining anti-plasma cell and anti-amyloid therapies might hold the key to achieving long lasting responses. We report a series of patients who received 2 monoclonal antibodies, anti-CD38 and anti-amyloid, simultaneously. MATERIALS AND METHODS: We describe the characteristics and outcomes of 19 patients who received daratumumab (anti-CD38) on progression with front-line therapy for AL, 9 of whom were on concurrent dual monoclonal antibody treatment with daratumumab and NEOD001 (anti-amyloid), and also provide data on the schedule, safety, and tolerability of intravenous infusions of these monoclonal antibodies. RESULTS: The 9 patients who received treatment with dual monoclonal antibodies achieved a high rate (100%) of hematologic response in a median of 33 days. There was no significant toxicity to dual monoclonal antibody therapy. Seven of the 8 met criteria for cardiac response, achieved in less than 3 months of combined therapy. Ten patients who received daratumumab alone also had high rates of hematologic and organ responses. CONCLUSIONS: Monoclonal antibodies with distinctly different targets can be safely combined in patients with AL and cardiac involvement. Patients experienced high rates of hematologic and cardiac response with combined anti-CD38 and anti-amyloid monoclonal antibody therapies. Further study of this combined approach is warranted.

Recent Trends in Electively Treated Unruptured Intracranial Aneurysms.

BACKGROUND AND PURPOSE: To determine recent treatment and outcome trends in patients undergoing elective surgical clipping (SC) or endovascular therapy (EVT) for unruptured intracranial aneurysms (UIAs) in the United States. METHODS: Data were extracted and analyzed from the National Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality for all patients admitted for elective EVT or SC of UIAs between 2011 and 2014. Treatment trends, in-hospital mortality, complication rates, length of stay (LOS) and total hospital costs were evaluated and analyzed. RESULTS: A total of 31,070 patients with UIAs were included in our analysis, of which 14,411 and 16,659 underwent elective SC and EVT, respectively. There was no significant difference in in-hospital mortality rates between the 2 groups. EVT was associated with lower in-hospital complication rates, decreased median LOS (.8 days versus 3.3 days, P ≤ .0001), and an increased likelihood of discharge to home (92.9% versus 72.9%, P = .0001). Median total hospital charges were similar in both treatment cohorts. Independent predictors of mortality in the elective population were age over 40 years (P ≤ .0001), weekend treatment (P ≤ .0001), and high co-morbidity status (P ≤ .0001). CONCLUSIONS: In-hospital mortality rates were similar in elective EVT and SC UIA patients; however, EVT was associated with lower in-hospital complication rates and shorter LOS.

Capecitabine for the treatment of pancreatic cancer.

INTRODUCTION: Capecitabine is an oral prodrug of 5-fluorouracil (5-FU) which is converted to 5FU by a series of reactions catalyzed by different enzymes, the last of the enzymes being thymidine phosphorylase (TP). TP is found to be elevated in tumor cells in comparison to normal cells, which consequently tumor-localizes the production of 5-FU, thereby limiting its systemic toxicity. Today, capecitabine is extensively used for the treatment of many solid malignancies, with a particular focus in breast and gastrointestinal tumors, but also in pancreatic cancer. Areas covered: This review summarizes the pharmacology and the clinical evidence relevant to the use of capecitabine in the treatment of pancreas cancer. The authors provide, furthermore, provide their expert perspectives on its use. Expert opinion: Capecitabine has the advantage over other therapeutics in so much that it has both convenient oral administration and a favorable toxicity profile. Current data has promised the use of capecitabine in all stages of pancreatic cancer. However, predictive markers for outcome and toxicity remain to be validated.

Trends in Incidence and Outcomes of Clostridium difficile Colitis in Hospitalized Patients of Febrile Neutropenia: A Nationwide Analysis.

INTRODUCTION: Clostridium difficile infection (CDI) has been attracting attention lately as the most common hospital acquired infection. Patients with neutropenia because of malignancy seem to be at an increased risk for developing CDI. There is currently limited data that assesses the national burden and outcomes of CDI in Febrile Neutropenia (FN). METHODS: We analyzed the National Inpatient Sample (NIS) database for all subjects with discharge diagnosis of FN with or without CDI (ICD-9 codes 288.00, 288.03,780.60, and 008.45) as primary or secondary diagnosis during the period from 2008 to 2014. All analyses were performed with SAS, version 9.4 (SAS Institute). RESULTS: From 2008 to 2014 there were total 19422 discharges of FN patients with CDI. There was a rising incidence of CDI in patients with FN from 4.11% (in 2008) to 5.83% (in 2014). The In-hospital mortality showed a decreasing trend from 7.79% (in 2008) to 5.32% (in 2014), likely because of improvements in diagnostics and treatment. The overall mortality (6.37% vs. 4.61%), length of stay >5 days (76.45% vs. 50.98%), hospital charges >50,000 dollars (64.43% vs. 40.29%), colectomy and colostomy (0.35% vs. 0.15%), and discharge to skilled nursing facility (10.47% vs. 6.43%) was significantly more in FN patients with CDI versus without CDI over 7 years (2008 to 2014). Age above 65 years, Hispanic race, hematological malignancies, urban hospital settings, and sepsis were significant predictors of mortality in febrile neutropenia patients with CDI. DISCUSSION: Despite the significant decrease in mortality, the incidence of CDI is rising in hospitalized FN patients with underlying hematological malignancies. Risk factor modification, with the best possible empiric antibiotic regimen is imperative for reducing mortality and health care costs in this cohort.

Rising Events and Improved Outcomes of Gastrointestinal Bleed With Shock in USA: A 12-year National Analysis.

OBJECTIVE: Limited information is available based on single-center studies on trends of incidence and outcomes in gastrointestinal (GI) bleed with shock. METHODS: We analyzed data from 2002 to 2013 National Inpatient Sample. Using ICD-9 codes we identified 6.4 million hospital discharges of GI bleed from National Inpatient Sample database. Events were analyzed based on type of GI bleed, in-hospital mortality, hemodynamic status, and use of blood products. RESULTS: GI bleed with shock results in higher hospital mortality (20.77% with shock vs. 2.6% without shock). Between 2002 and 2013, there has been an increase in the percentage of upper and lower GI bleed with shock (1.35% to 4.92% and 1.49% to 3.06%) along with a reduction in mortality in both upper GI bleed with shock (26.9% to 13.8%) and lower GI bleed with shock (54.7% to 19.7%). Consistent with the rise in GI bleed with shock was an increase in blood product utilization. Packed red blood cell (pRBC) transfusion was associated with reduction in mortality in both nonvariceal upper GI bleed with shock (18.3% without pRBC vs. 13.9% receiving pRBC) and lower GI bleed with shock (36.05% without pRBC vs. 22.13% receiving pRBC), but did not affect mortality in variceal upper GI bleed with shock (31.79% vs. 32.22%). CONCLUSIONS: GI bleed with shock carries a higher mortality and have been steadily increasing from 2002 to 2013. pRBC transfusion was associated in improved mortality in GI bleed with shock except variceal bleed.

The safety of lanreotide for neuroendocrine tumor.

INTRODUCTION: Lanreotide autogel is a synthetic somatostatin analogue which has been FDA and EMA approved for unresectable, well to moderately differentiated, locally advanced or metastatic gastroenteropancreatic neuroendocrine tumor. Its action is mediated by its affinity to somatostatin receptors, especially sst2 and sst5 receptors. Its longer half-life offers the convenience of 4-week dosing over the need for frequent injections of short-acting somatostatin analogues. Areas covered: Lanreotide ATG offers progression-free survival benefit in locally advanced or metastatic neuroendocrine tumor (NET) compared to placebo, reflecting a strong antiproliferative signal. As lanreotide is commonly used for management of NET, it is imperative to recognize and appropriately manage any drug-related toxicities. In this review, we will provide an overview of the toxicity with lanreotide and its management. Expert opinion: Lanreotide is highly effective in managing carcinoid symptoms and has a robust anti-tumor effect in NET. Overall, it is well tolerated with low rates of treatment discontinuation due to toxicity. It's toxicity profile is mostly predictable, and patients should be informed of the transient nature of some of the upfront toxicities.

Enterococcus Faecalis Infective Endocarditis and Colorectal Carcinoma: Case of New Association Gaining Ground.

Mostly Streptococcus bovis (S. bovis) bacteremia and endocarditis (60%) has been found to be associated with underlying colorectal cancer (CRC). Enterococcus faecalis (E. faecalis) bacteremia and endocarditis has no identifiable source in most of the cases. E. faecalis is part of normal gut flora that can translocate through the intestine and cause the systemic infection. With any intestinal lesion or tumor, the barrier is breached and the gut flora like E. faecalis can translocate and cause infection. A 55-years-old male known to have non-ischemic cardiomyopathy with implantation of automated implantable cardioverter defibrillator (AICD) and atrial fibrillation presented with weight loss, fever and back pain. He was diagnosed to have E. faecalis bacteremia and subsequent endocarditis and osteomyelitis of T7 - T8 and L4 - L5 vertebrae. He underwent colonoscopy for screening of malignancy because of his age and presenting symptoms suggestive of one. The colonoscopy found pedunculated polyp in sigmoid colon, and after biopsy the histology revealed an invasive well differentiated mucinous adenocarcinoma, with focal squamous differentiation. He underwent removal of AICD and antibiotic treatment for infective endocarditis and osteomyelitis. He underwent sigmoid colectomy with pathology of removed specimen showing adenocarcinoma with negative margins and lymph nodes. In many of the patients with E. faecalis endocarditis, if identifiable the source is genitourinary tract. But in most of the cases the source of E. faecalis bacteremia is unidentified. There is some evidence to suggest that in patients with unidentified source, colonoscopy may reveal a hidden early stage CRC or adenoma. We conclude that in cases of E. faecalis bacteremia and endocarditis with unidentified source, colonoscopy should be considered if feasible to rule out the diagnosis of CRC.

Unstable angina: trends and characteristics associated with length of hospitalization in the face of diminishing frequency-an evidence of a paradigm shift.

BACKGROUND: Unstable angina (UA) has been one of the most common presentations of acute coronary syndrome. The numbers of admitted UA patients have been diminishing in the recent past. However, we are seeing higher costs and higher length of inpatient stay. We attempt to identify the trends and characteristics of length of hospitalization in patients admitted with UA using a nationally representative dataset. METHODS: We used the nationwide inpatient sample (NIS) from 2002-2014 to assess the factors associated with length of stay in patients admitted with unstable angina using ICD-9-CM primary diagnosis codes (411.1, 411.81, and 411.89). All variables pertaining to hospitalization were compared across the 3 groups based on varied length of hospital stay. RESULTS: A total of 131,601 patients were admitted with the diagnosis of UA. The length of inpatient stay was ≤1 day, 2-6 days, and ≥7 days in 60,309 (45.83%), 67,291 (51.13%), and 4,001 (3.05%) patients, respectively. In a multivariate adjusted model, the percentage increased odds of ≥2 days of inpatient stay was noted as follows: age ≥65 years (29%), female gender(24%), African-American race (28%), obesity (14%), diabetes mellitus (15%), chronic lung disease (33%), congestive heart failure (529%), renal failure (26%), coagulopathy (68%), alcohol abuse (21%), peripheral vascular disease (22%), myocardial infarction (17%), deep vein thrombosis (119%), sepsis (105%), pneumonia (171%), stroke (164%), urinary tract infection (112%), blood loss (95%), cardiac catheterization (86%), percutaneous transluminal coronary angioplasty (24%), and blood transfusion (206%). The percentage of UA patients with ≥2 days of hospital stay has decreased from 15% to 3.7%, whereas the average costs of managing a UA patient in the hospital have increased by 175%. CONCLUSIONS: More than half of patients admitted with UA stay in the hospital for ≥2 days, with the most important determinants being pre-existing medical comorbidities and inpatient complications.

Successful Endoscopic Treatment of Bouveret Syndrome in a Patient with Choledochoduodenal Fistula Complicating Duodenal Ulcer.

INTRODUCTION: Cholecystoduodenal fistulas represent the most common type of bilioenteric fistulas while choledochoduodenal fistulas account for only 1-25% of cases. Bilioenteric fistula cases are associated with cholelithiasis and are rarely associated with duodenal peptic ulcers. Here we present the first case of Bouveret syndrome secondary to choledochoduodenal fistula complicating peptic duodenal ulcer managed successfully via endoscopic mechanical lithotripsy. CASE: 86-year-old male with a medical history significant for coronary artery disease and stage 3 colorectal cancer status after resection and chemoradiation presented with intractable sharp abdominal pain worse postprandially for one week in duration, associated with early satiety, anorexia, and 5 lbs weight loss in one week. CT abdomen showed possible choledochoduodenal fistula and a distended stomach. An esophagogastroduodenoscopy (EGD) was performed revealing a large 2.5-3 cm stone lodged in the duodenal bulb at the base of duodenal ulcer with a fistula opening beneath it. The stone was extracted in 2 pieces via mechanical lithotripsy. Endoscopic ultrasound of the CBD revealed Rigler's triad. CONCLUSION: Bouveret syndrome is mostly associated with cholecystoduodenal fistula and has high mortality and morbidity due to underlying comorbid conditions and elderly age. Patients are not always fit for surgical management, and endoscopic management is not always successful.

Nephropleural Fistula Effectively Managed with Serial Thoracentesis: A Case Report.

Nephropleural fistulae are rare but serious thoracic complications of percutaneous nephrolithotomy (PCNL). Herein, we present the management of a 54-year-old female with a delayed presentation of nephropleural fistula. The role of serial thoracentesis as a safe, less invasive, less painful alternative to tube thoracostomy is highlighted. In select cases, this may represent an attractive management strategy for nephropleural fistula after PCNL.