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Acute pancreatitis is most commonly attributed to gallstones, alcohol abuse, and metabolic disorders such as hyperlipidemia and hypercalcemia. Medications are an infrequent yet commonly overlooked etiology of pancreatitis. Although several drugs have been implicated, antidiabetic agents are a rare cause for drug-induced pancreatitis. Canagliflozin is a new drug in the class of SGLT-2 inhibitors used for the treatment of type 2 diabetes mellitus. Serious reported side effects include renal impairment, hyperkalemia, and hypotension. Pancreatitis as a result of canagliflozin, however, is exceedingly rare. Here we describe a case of a 33-year old female who presented with severe acute pancreatitis in the setting of recent initiation of canagliflozin. Given the timing of her presentation and after excluding all other possible etiologies, it was determined that canagliflozin was the likely source of her illness. This case highlights the importance of identifying drug-induced pancreatitis, especially in novel drugs, as it is commonly neglected in patients with multiple medical comorbidities and those taking numerous medications. Prompt identification of drug-induced pancreatitis can improve management as well as decrease morbidity and mortality in these individuals.

Metastatic melanoma is a rare form of skin cancer, but one that comes with a high mortality rate. Pulmonary involvement is frequently seen in metastatic melanoma with only 2% of malignant melanoma patients with thorax metastasis presenting with pleural effusions. Herein, we report an extremely rare case of black pleural effusion from thoracic metastasis of cutaneous malignant melanoma. A 74-year-old man with known metastatic melanoma presented with a 1-month history of worsening lower back and hip pain and was found to have extensive osseous metastatic disease and multiple compression fractures. The patient underwent an uneventful kyphoplasty; however, the following day, he became acutely hypoxic and tachypneic with increased oxygen requirements. Radiographic evaluation revealed new bilateral pleural effusions. Bedside thoracentesis revealed a densely exudative, lymphocyte-predominant black effusion. Cytological examination showed numerous neoplastic cells with melanin deposition. A diagnosis of thoracic metastasis of malignant melanoma was established based on the gross and microscopic appearance of the pleural fluid. To the best of our knowledge, this is the first reported case of black pleural effusions secondary to metastatic melanoma in the United States. Despite the rarity of this presentation, it is important to determine the etiology of the black pleural effusion and to keep metastatic melanoma as a differential diagnosis.

Participation in clinical research projects may allow an opportunity for early detection of covert diseases and subclinical disorders in asymptomatic volunteers from study-specific screening process. Exclusion of a potential participant due to failure to meet inclusion criteria eliminates any possibility of potential for research related benefit, as may exist for those that are deemed eligible and allowed to proceed with participation in the specific research study. Although the institutional bodies overseeing conduct of clinical research strive to ensure an ongoing scrutiny and prioritization of participants' wellbeing, we perceive that these mechanisms fall short as regards the interests of those volunteers who are subsequently excluded from participation in clinical research of relevance. While provision of ancillary care to address health concerns that are unmasked during the screening process may be an optimal strategy, the likelihood of successfully implementing this latter concept in current times of fiscal constraints is slim to nonexistent. Through this submission, we hope to initiate a dialogue within the research community regarding whether the current paradigm of conduct of clinical research be modified to include some degree of consideration for the screened out. We herein propose that for those volunteering for disease/disorder specific clinical research, some added degree of benefit can be assured to the screened out population through the provision of targeted health education or counseling.

Cannabinoid hyperemesis syndrome (CHS) is a rare constellation of clinical findings that includes a history of chronic heavy marijuana use, severe abdominal pain, unrelenting nausea, and intractable vomiting. A striking component of this history includes the use of hot showers or long baths that help to alleviate these symptoms. This is an underrecognized syndrome that can lead to expensive and unrevealing workups and can leave patients self-medicating their nausea and vomiting with the very substance that is causing their symptoms. Long-term treatment of CHS is abstinence from marijuana use—but the acute symptomatic treatment of CHS has been a struggle for many clinicians. Many standard medications used for the symptomatic treatment of CHS (including ondansetron, promethazine, and morphine) have repeatedly been shown to be ineffective. Here we present the use of lorazepam as an agent that successfully and safely treats the tenacious symptoms of CHS. Additionally, we build upon existing hypotheses for the pathogenesis of CHS to try to explain why a substance that has been used for thousands of years is only now beginning to cause this paradoxical hyperemesis syndrome.

e11522 Background: It has been observed that patients undergoing systemic therapy for metastatic breast cancer (MBC) may demonstrate a mixed metabolic treatment response on FDG PET (MMTR) while maintaining stable disease on CT (SDCT). The purpose of this study is to determine (1) the clinical outcome of MBC patients demonstrating MMTR+SDCT who were maintained on the same treatment regimen and (2) the behavior of oncologists when faced with a report of MMTR+SDCT. Methods: All FDG PET/CT scan reports performed at one institution between 2006-2011 were searched and studies describing a MMTR also containing the term “breast cancer” were identified. MBC patients without other active malignancies were extracted from the search and scans were re-analyzed. MMTR was defined as a PET/CT scan demonstrating a minimum of 2 lesions with a SUVmax change of +25% or more combined with at least 2 lesions demonstrating a SUVmax change of -25% or more. The subset of patients with MMTR+SDCT (by anatomical RECIST criteria) who were maintained on their current treatment regimen was further examined to identify time to progression (TTP). Results: Thirty-two cases were identified that demonstrated MMTR+SDCT in metastatic breast cancer patients. No change in therapy occurred within 3 months of the scan in 9/32 patients. Of the 9 patients who were maintained on their current treatment regimen, 5 patients demonstrated subsequent disease progression at 3 (n=2), 5 (n=2), and 11 (n=1) months (mean TTP = 5.4 months, range 3-11 months). One patient remains stable at 16 months and 3 patients have insufficient follow-up. Therapy was changed immediately after the scan in the remaining 22 patients for various reasons including preference of the treating oncologists, treatment toxicities, increase in tumor markers, or clinical progression. Conclusions: MMTR+SDCT in patients with MBC predicted subsequent disease progression within 6 months in the majority of individuals. Oncologists commonly alter treatment regimen when faced with a report of MMTR+SDCT. Based on the observation of outcomes in patients who did not change therapy, this practice seems justified.