A 49-year-old male with history of chronic alcohol-induced pancreatitis presented with one month of worsening left pleuritic chest pain and shortness of breath. Chest radiograph demonstrated bilateral pleural effusions. Thoracentesis revealed increased amylase in the pleural fluid. Computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) showed a fistula tract between the left pleural cavity and pancreas which was confirmed on endoscopic retrograde cholangiopancreatography (ERCP). Patient was treated with placement of a pancreatic stent with complete resolution of the fistula tract approximately in 9 weeks. A systematic literature search was performed on reported cases with pancreaticopleural fistula (PPF) who underwent early therapeutic endoscopy within the last 10 years. Imaging modalities, particularly CT and MRCP, play essential role in prompt preprocedural diagnosis of PPF. Early therapeutic ERCP is an effective and relatively safe treatment option for PPF, so invasive surgery may be avoided.

Introduction: Diabetes is one of the most common chronic diseases that is encountered in healthcare. While there have been trials about ideal glycemic targets over the years, there is still lack of guidelines pertaining to the appropriate context for de-intensifying diabetic medications. Our study aimed to assess the general perception amongst primary care physicians and endocrinologists on de-intensifying diabetic medications in patients with stable HbA1C for 1 year. Methods: In 2016, we mailed a national cross-sectional survey to 480 adult endocrinologists and 720 adult primary care physicians (PCPs) listed in the American Medical Association (AMA) Physician Masterfile. Physicians were asked this yes-no question: “ In general, if your patient with type 2 diabetes has a low, stable HbA1c level for 1 year, do you ever initiate conversations about discontinuing or reducing the dose of their diabetes medications”. Physicians who answered yes to the first question were then directed to a follow-up question: “At what HbA1c level do you initiate this conversation ?” Main outcomes were physician self-reported, with options including “HbA1C < 5.0%”, “HbA1C <5.7%”, “HbA1C< 6.0%”, “HbA1C <6.5%”, “HbA1C <7.0%”, “HbA1C < 8.0% “, “HbA1C level depends on the patients characteristics” and “other”. Summary statistics were calculated using means and proportions as appropriate. P-values less than 0.05 were considered statistically significant. Results: The adjusted survey response rate was 41% (N=357). For patients with type 2 diabetes, 81% of endocrinologists and 76% of primary care physicians marked “yes” to initiating conversations about de-intensifying medications (no statistically significant difference between the two specialties, p=0.14). For the second part of the survey, “ At what HbA1c level do you initiate this conversation? ”, most of the providers initiate the conversation at HbA1c<6.0% (30% of PCPs and 28.5% Endocrinologists, p=0.09). Endocrinologists were more likely than PCPs to report that they initiate conversations on de-intensifying at any “HbA1c level [depending] on the patient’s characteristics” (15% vs. 7%, p=0.09), but this result was not statistically significant. Conclusion: In our survey, there were no significant differences in practice patterns between PCPs and endocrinologists regarding de-intensifying medication. Currently, there is no established guideline in ADA for how to approach medication de-intensification in patients with type 2 diabetes, though ACP recommends to consider de-intensifying medications in patients with HbA1C <6.5%. Raising awareness of physicians about individualizing glycemic goals and reducing or discontinuing medications as appropriate can save the patients from taking unnecessary medications and achieve patient appropriate health goals.