Internal Medicine Residency News, December 15, 2014

Monday, December 15, 2014

From the Director

DUKE.RESEARCH.NIGHT.03 (1)#Bestpartyever! Thank you to Dr. Klotman and the DOM for a fantastic holiday party.  Reported to have over 500 people in attendance, this year’s holiday party was outstanding.  It was great to see everyone all dressed up, and, of course, the highlight was the amazing chiefs video lip synch masterpiece…outstanding work Nilesh, Coral, Bonike and Aaron.  #setthebar.  If you haven’t seen the video and the bootleg videos of the lip synch, take a few minutes to be entertained.  Jenn, Armando, Chris and Lindsay … start planning.

Thanks to all who brought toys for our Toys for Tots collection.  If you forgot, details on how to donate follow.

It’s countdown to holiday schedule with just a couple more interview days until next year.  Thank you to Azalea Kim, Maggie Infeld, Rajiv Agarwal, John Yeatts as well as Juan Sanchez, Brittany Dixon, Joy Bhosai and Aparna Swaminathan for “resident share” with the applicants (or, perhaps, it’s new name of “My Take”?).  Also kudos to Jim Lefler for an amazing chair’s conference, complete with YouTube education. Amazing job.  Also kudos to Brian Sullivan from Jon Bae for outstanding night JAR work, and also to from Jon Bae to Pavle for an epic H&P and discharge summary, for Anubha Agarwal for being our constant cheerleader, and for Deng as our team leader powering us to a personal 2 week record of 51 discharges and 65 patients cared for.


Rumor has it that the 2nd annual latke cook off is to take place on Thursday.  Will Dr. Kussin beat Dr. Klotman? Will my sweet potato latkes stick together? Do you not know what a latke is?  Stop by the med res library Thursday afternoon to find out (details to follow).

We also celebrated a wonderful retirement party for Randy Heffelfinger on Tuesday.  Much thanks to Lauren Dincher for organizing!

We will have one more MED RES NEWS of 2014, so send in your kudos, and get ready for 2015!

Pubmed from the program goes to Carli Lehr for her article in Chest written with Ira Chiefetz, David Turner and David Zaas..""Ambulatory Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplantation: Walking While Waiting"

Have a great week


chief holiday party

Also congrats to the Atkins family on the birth of Abigail!




What Did I Read This Week?


Submitted by: Aimee Zaas, MD

Chronic Lymphocytic Leukemia: A Review” by Nabhan and Rosen in the Dec 3 issue of JAMA.

Why did I read this? We were talking about a patient with small B lymphocytic lymphoma in resident report and I wanted to review CLL and better understand the classification and therapies available. Fortunately, this article came out several days after report and fit what I was looking for.

What did the authors do? This is a structured review, looking at biology and therapy of CLL. They did a comprehensive search of appropriate databases (Pubmed, Google scholar, Cochrane and Scopus) and found 277 articles. Ultimately 24 articles met their preset criteria for inclusion.

What information did they learn from the literature?

Demographics: CLL is the most common blood malignancy in the Western World, with 15000 new cases a year and 5000 deaths. It is defined as a malignant proliferation of mature B cells. Molecular diagnostics is revolutionizing phenotyping and therapies.

Clinical presentation: Most diagnoses are made on routine CBC’s of asymptomatic adults. Lymphadenopathy is common but B symptoms are present in only 10%. Hepatosplenomegaly can be found 20-50% of time.

Lab findings include absolute lymphocyte count > 5000, with 10% of people having Autoimmune hemolytic anemia, ITP or hypogammaglobulinemia. On peripheral smear, you see lots of small cells with large dense nuclei. Smudge cells on a smear are characteristic.

Diagnosis is made by flow cytometry showing B cells with CD19, CD5 and CD23. CD 20 may weakly expressed and the cells should be kappa or lambda restricted (another sign of clonality). Imaging is not needed and BmBx or lymph node biopsy are sometimes done, but not a necessary part of the diagnostic algorithm.

What is small lymphocytic lymphoma: When CLL is restricted to nodes and marrow. A premalignant condition to CLL (kind of like MGUS is to MM) is monoclonal B lymphocytosis where there are monoclonal B cells but an ALC of < 5000. 1-2% of these patients progress to CLL per year.

How do we prognosticate for a patient with CLL? Historically, the Rai and Binet classifications are used.

To refresh, Rai prognosticates on the basis of lymphocytosis alone (survival > 10 years), LAD or HSM (7 years) or anemia/thrombocytopenia (< 4 years) and Binet prognosticates on how much LAD is present and if cytopenias are present.

More sophisticated prognostic indicators are shown here: Adverse Clinical/Laboratory Prognostic Factors

  1. Advanced agea
  2. Advanced stage (Rai III/IV or Binet C)
  3. Poor performance status
  4. Short lymphocyte doubling time (<12 mo)
  5. Diffuse bone marrow infiltration pattern
  6. Increased percentage of prolymphocytes
  7. Male sex
  8. High lactate dehydrogenase levelb
  9. High β2-microglobulin levelc
  10. Increased levels of soluble CD23
  11. Advanced stage (Rai III/IV or Binet C)

Novel/Molecular Adverse Prognostic Factors

  1. 17p and 11q deletions by fluorescence in situ hybridization
  2. CD38 overexpression (>30%)
  3. Zap-70 greater than 20%
  4. Unmutated IgVH
  5. NOTCH-1 mutations
  6. High lipoprotein lipase expression
  7. Variance expressions of specific micro-RNAs (ie, down-regulation of miR-15a and miR-16-1 is associated with good prognosis, whereas down-regulation of miR-29 family is associated with poor prognosis)

What about therapy?

First principle is not to treat until the patient is symptomatic, including anemia/thrombocytopenia, massive splenomegaly or adenopathy, rapid doubling time of lymphocyte count, debilitating constitutional symptoms.

The major agents classically are either alkylating agents (chlorambucil, bendamustine or cyclophosphamide) or purine analogs (fludarabine). Fludarabine is less toxic and has better response and is first line over chlorambucil.   Additional trials showed the combination of fludarabine and cyclophosphamide provide the best response rates and progression free survival so this is considered the gold standard for new therapies to compare to. Alkylating agents damage DNA and purine analogs interfere with DNA repair, so one can see why they might be synergistic.

Currently, chemoimmunotherapy is the new gold standard. Why is that the case?

Chemoimmunotherapy involves using ‘traditional’ chemotherapy agents plus a biologic agent (e.g. monoclonal antibody).

A landmark study compared rituximab (anti CD 20) plus cyclo plus fludarabine to the gold standard cyclo + fludarabine and showed significantly better overall and progression free survival at 86 months for the 3 drug arm (70% vs 62%). This study brought biologics to the forefront of CLL treatment.

Ongoing studies have shown that perhaps bendamustine + rituximab is better than the 3 drug combination but have not been fully published.

Overall, a retrospective surveillance study showed that survival in CLL is improved in the cohort of patients treated from 2001-09 than 1992-2000 (66% vs 60%).

Emerging possible therapies are the TKI ibrutinib and the PI3K inhibitor idelalisib.

Guidelines now recommend chemoimmunotherapy with stratification of choices based on performance status and renal function, as the 3 drug regimen listed above is not advised in individuals with GFR less than 70.

What is on the horizon? What remains controversial or needs further study?

Physicians and investigators are still debating the optimal treatment for Richter’s transformation (CLL progressing to an aggressive B cell lymphoma). It also remains unclear the best way to treat CLL associated AIHA or ITP.

Finally, in older patients or those with poor renal function or comorbidities may do best with chlorambucil plus  obinutuzumab.




Clinic Corner


Hello from Pickett! We had a great November and Thanksgiving gathering. Allan, Pascale and Jason were lucky to be in clinic during our Thanksgiving Feast. We will be having a clinic Christmas party as well on this week Thursday at the clinic at lunch and all Pickett Road Residents are welcome to come. Enjoy good food and a celebration for the holidays.


2014-11-25 12.19.53_resized

Welcome to Kelly Sullivan our new Nurse Manager! Her office is closest to the residency work room, across from the water fountain. Any nursing concerns or SRS can be now directed to Kelly.

2014-11-21 12.45.23_resized

Congratulations to our SARS who matched for fellowship! We are very proud of you!

Dr. Wolf is leaving at the end of the month. Make sure to say good bye and thank him for all his teaching. He will be starting at Signature Care in January and then precepting at the DOC. We will miss Dr. Wolf!

Lunch time topics start 12:45-12:50 pm if you are there all day. Please come back so we can go over the topics. We can try to go over the material if there is a break during the session but we are always so busy.

Remember mini cex's: the new schedule is in the work room. Sharee sends out the email, I send Maestro Epic message. Remind your attending to perform one that day. Interns you need 3 mini cex's to start seeing patients on your own in January. JAR and SAR you need 3 to sign out 2 patients (if one of them is a simple Aunt Minie).  Make sure you mark down when you had done a cex and remind your attending to put this into med hub (get credit!).

Make sure if you are on call, you are reviewing Sharee's email, and that your pager is correct.

We take care of a lot of Duke Employees. There is not much of preferred medications for Express Scripts but I will be posting the lists in all the patients rooms and the resident areas. We are enrolling the whole clinic to help with prior authorization for Express Scripts. if you get an email asking if Sharee Southern can be proxy to the account, log in and allow her to help expedite the Prior authorization process for Express Scripts.

Let me know ASAP if there are PECOS issues: prescribing for medications, test strips, durable medical equiptment.

Have a safe and happy holiday and new year!


Sharon Rubin, MD, FACP



What? The Ambulatory Care Leadership Track:

An elective clinical track for people interested in ambulatory medicine – either general medicine OR subspecialties with an outpatient focus.

  • Eligible to start as a JAR, for a two year track
  • 8 total residents, generally 4 JARs and 4 SARs
  • 3 blocks of ambulatory together, each year
  • Expanded offerings in clinics outside of medicine, per your preference: sports medicine, gynecology, dermatology, ENT, ophthalmology, and more
  • Focused curriculum in teaching skills, advanced evidence synthesisand presenting scholarship, and leadership/health policy.
  • Advocacy trips to Washington, DC and Raleigh, NC – alternating every other year

Interns are encouraged to apply now! Deadline for applications extended to January 15

ACLT application form - 2014-15


QI Corner

Aaron Mitchell, MD


Hey everyone! This week I have an update on the GME incentive program (that's where you guys can earn extra $$$ in your paycheck for meeting certain quality measures at the end of the year), and I have news that is even more epic than Nilesh lip-synching to Iggy Azalea. Ok, not quite. But pretty close. For the first time ever, medicine has passed pediatrics to become the fastest-responding program in the hospital to ED consults. Way to go guys! All of you on the 1010 pager are totally killing our target time, and are putting everyone well on their way to getting an extra $200 in June.




In terms of SRS reporting - November was the highest month yet, with 92 reports filed by trainees, but we will still need to pick up the pace quite a bit in order to get 1698 more by the end of the year.



From the Chief Residents

Grand Rounds

Fri., Dec. 19: Rheumatology, Dr. Irene Whitt

Noon Conference

Date Topic Lecturer Time Vendor
12/15/14 Interview Day  Lunch with applicants 12:00/MedRes  Nosh
12/16/14  MED PEDS INTERVIEW/ G Briefing Session  Lunch w/applicants 12:00/MedRes  Saladelia
12/17/14 Resident Jeopardy QI Team 12:00/Room 2002  China King
12/18/14 QI Patient Safety Noon Conference 12:15/2001  Chick Fil A
 12/19/14  Interview Day  Lunch w/ applicants  12:00/MedRes  Pipers in the Park

From the Residency Office

2014 Internal Medicine Residency Council Holiday Toy Drive

All toys will be donated to the 2014 Marine Corps Reserve Toys for Tots  Campaign! A donation to Toys for Tots would give toys to needy families in the local area just in time for Christmas!   If you were unable to attend the holiday party, we will also be collecting toys in the Medical Resident’s office through the end of the day on Wednesday, December 17th.


- Unwrapped

- New/Unused

- No guns

- Accepting toys for all ages including stuffed animals (really need toys for ages 0-2 and 11-13)

ABIM Summer 2015 Examination Dates

 Please see the attached flyer for information on dates and registration!

Stead Research Grant RFA

On behalf of the Stead Scholarship Committee, we would like to announce a Request for Applications for a clinical or translational research project involving a team of Internal Medicine, Med-Peds, and/or Med-Psych residents under the leadership of a faculty mentor in the Department of Medicine. The RFA is attached.

We are grateful to the leadership of the Stead Scholarship Committee (Chris Woods, Karen Alexander and Ravi Karra) for this generous initiative to promote and support team-research by our residents.

Best regards to all,

Murat and Aimee


Annual GME Holiday Celebration

Please join the Office of Graduate Medical Education and the Medical Alumni Office for the Annual GME Holiday Celebration.

Wednesday, December 17
7:30-9:30 am
T-401 Duke North (Bunker)

Thursday, December 18
4:30-6:30 pm
DMP 2W91 (conference room over the DMP gift shop)

Please make plans to join us for good food and giveaways!


Uniforms Ordering Closes December 31

All continuing trainees will be able to order uniforms one time,online through the Medical Center Bookstore. Orders must be placed by December 31, 2013.

Each individual department and/or program selects the style and quantities available to you and is provided to you at no cost by the GME Office.

Go to to place your order.

You will need to use the email address that is in MedHub to be able to log into the dukestores web site.

Do No Harm Project

The Lown Institute, in collaboration with the Do No Harm Project, is calling for applications to the first Do No Harm Project Vignette Competition.

The top two vignettes will be eligible for up to two scholarships ($1200/person in reimbursements in accordance with the Scholarship Policy). They will participate in the third annual Lown Institute Conference, March 8-11, 2015 in San Diego, CA AND will give an oral presentation during the Do No Harm Project workshop session on March 10, 2015 at the conference. To learn more about the eligibility and selection criteria, click here.

We are seeking clinical vignettes written by trainees describing harm or near harm caused by medical overuse. We want to hear about tests and treatments that are commonly performed and seen acceptable rather than errors or obvious malpractice.

We hope you will apply, or encourage your colleagues to apply, for this award to help improve clinicians’ awareness of the harms patients may experience because of overuse and to share ideas about how the delivery of care may be improved in the future.

Applications are due by January 7, 2015, and grant recipients will be announced in late January. Apply here today. This program is made possible through the generous support of the Robert Wood Johnson Foundation.

We look forward to receiving the many applications and we expect launching the creative projects will take us a step closer to restoring effective, compassionate and thoughtful medical care. Should you have questions, please do not hesitate to let us know at

Thank you,

Vikas Saini, MD                        Shannon Brownlee, MSc
President                                  Senior Vice President
Lown Institute                            Lown Institute


Evidence-Based Medicine: A Cross-GME Course

Open to all Duke residents and fellows

January 7 – February 11

Wednesdays 5:30 – 7:00 PM

(Duke Medicine Pavilion Conference Rooms)

Dinner Served

Evidence-based medicine provides the necessary foundation for clinical practice in this new era of accountable care and is recognized by the ACGME as an important educational outcome. However, many programs lack the time and resources to provide a solid EBM curriculum to their trainees. EBM training remains an unmet need at this institution: in a 2012 survey of trainees, we found that 78% highly value EBM, but only 28% are extremely confident in the ability to find the evidence and only 16% are extremely confident in appraising the evidence they find.  We have a way for you to fill this gap!

This interactive six session course will be presented by expert EBM faculty from across Duke Medicine and will provide the opportunity for residents to interact with others outside their programs.

We invite you to identify and send residents from your program or forward this notice to individual residents who may wish to participate.

Registration available at the following link:

For questions, please contact Megan von Isenburg (



Sign up to receive a complimentary e-subscription to The American Journal of Medicine in 2015! All you have to do is to complete the online form by December 8, 2014.  The subscription starts in January.

Hospitalist Opportunity

Internal Medicine Opportunities

Physician Recruiting Services - Beck & Field

Upcoming Dates and Events

February 18, 2015 - Duke vs UNC @ Tyler's Tap Room

February 27, 2015 - Charity Auction

March 3, 2015 - Duke vs UNC

Useful links