From the Director
Glad we have our new fleeces – it’s freezing! Looks like we have a chance of snow on Friday, so be on the lookout for the many weather related emails that will come from Duke in the next few days. We are looking forward to having the SARs over on Friday night (thanks for waiting for your 2015 auction prize until we had a house to have a party in!). SARs, check with Andrea Sitlinger if you need more info.
We had a fantastic “2nd Look” weekend this weekend, and many thanks to Dr. Cathy Kuhn, Dr. Kim Evans, LaVerne Johnson-Pruden, Madi Smith, Dr. David Butterly and Dr. Betty Staples for planning and to all the residents and fellows who came out to support our recruitment efforts. Two more recruitment days left, so be sure to get to dinners, lunches, etc to meet our ‘future Duke residents’.
Fellowship planning information nights (general info) to be held in the Med Res Library on Feb 2 and Feb 9 from 6-8:30. The nights are the same, so plan on attending one of them if you are a rising SAR applying to fellowship next year or a current SAR applying to fellowship next year, or an intern planning CIP. Dani Zipkin and Sharon Rubin will be planning a hospital medicine and primary care career information night as well, details to follow.
If you are planning on applying in GI, the GI fellowship will be hosting their information night on Monday, March 7th at 5:00pm in the Tyor Conference Room located in the GI Administrative Suite. (Go to the end of the hallway in front of Clinic 1H and take the Purple elevator down the basement (not sub-basement). Walk straight off the Purple elevator. The Gastroenterology Suite 03107 will be just ahead on your right. Once in the suite, walk straight and my GI Office and the Malcolm P. Tyor, M.D. Conference Room will be on your left.) Please take the time to RSVP to Jill Rimmer if you are planning to attend.
We have a new member of the Duke Family! Lindsay Boole and Oussama Saleh welcomed Romel Steven Saleh, born 1/16 at 2:55pm. Mom, Dad and Romel are all doing great. Congratulations!! We can’t wait to meet him!
Kudos this week also to Lauren Collins for an amazing Chair’s Conference (and Sam Lindner for recognizing a medial longitudinal fasiculus lesion as our culprit), and to Christine Bates for her fantastic resident report on Monday. Additional kudos to Pascale Khairallah for being our first Lincoln Community Health Center volunteer doctor, with help from Dinushika Mohottige and Joel Boggan.
If you are interested, there is an opportunity to join the The White Coat marchers at the Moral March on Raleigh/HKonJ (Historic Thousands on Jones Street) People’s Assembly on Saturday morning, Feb 13, in Raleigh between 8:30 and 9. Please see the attached flyer for more details.
Pubmed from the program this week goes to Taylor Bazemore and Kahli Zeitlow for their recently accepted article! Zietlow KE; T Bazemore; and K Parikh. 2016. Diagnosing Pulmonic Valve Infective Endocarditis With Positron Emission Tomography-Computed Tomography. BMJ Case Reports.
Have a great week!
What Did I Read This Week?
Submitted by David Butterly, MD
Trends in Survival and Renal Recovery in Patients with Multiple Myeloma or Light Chain Amyloidosis on Chronic Dialysis
Alexendre DeCour, Bertrand Gondouin, et al Clinical Journal of the American Society of Nephrology 1/2016
This article evaluating dialysis treatment outcomes in patients with multiple myeloma was published in the January 2016 issue of CJASN. I recently had a patient with newly diagnosed Myeloma commence dialysis at one of our Durham HD units. He is being followed by our Oncology group and has started chemotherapy and appears to be responding well. This article examines outcomes and renal recovery with newer treatment options therefore caught my eye.
Kidney injury is a common complication of Myeloma and other plasma cell dyscrasias and is associated with increased mortality. The three most common types of monoclonal Ig-mediated kidney disease are 1) Myeloma Cast Nephropathy (MCN), 2) Light Chain Deposition Disease (LCDD), and 3) Amyloidosis (ALA). The term “Myeloma Kidney” refers to Myeloma Cast Nephropathy and should not be used to refer to the entire spectrum of myeloma associated kidney disease. Renal involvement is a common complication and some degree of CKD is observed at some point in the natural history of patients with Myeloma.
Renal involvement can progress to ESRD where survival has generally been poor. Newer available chemotherapy such as Bortezomib has positively impacted disease progression im MM. This paper looks at outcomes in patients with ESRD with the advent of these newer available agents.
All incident patients with ESRD due to MCN, LCDD, or ALA were included. Patients were reported to REIN which is similar to our USRDS. Data was collected for those initiating dialysis 1/1/2002-12/31/2011. The main objective was to evaluate survival of patients with MCN, LCDD, and ALA and identify risk factors for death.
Among 63,349 patients registered in REIN during the study period, 1,462 (2.3%) had ESRD due to MG. Of this study cohort: 861 (59% of the 1,462) had MCN. LCDD made up 23% and ALA was seen in 18%. Outcomes of this group were then compared to a control group without myeloma (5036) included in REIN database during the same time.
Patient Characteristics are detailed in Table 1. Dialysis was initiated as an emergency in roughly one-half and 72% initiated with a catheter. Of those with Myeloma, patients with ALA tended to be younger, had lower albumin levels, and more frequently had CHF.
Kaplan-Meier survival for those with Monoclonal Gammopathies along with outcomes for ALA, MCN, and LCDD are shown in Figure 1. Outcomes compared to the control subjects are shown on the next page in Figure 2. The outcomes of all groups with MGs was poor (roughly 2 fold the mortality compared to the control group at 2 years) but did not differ appreciably between the 3 subtypes.
Renal Recovery rates are shown in Figure 3. These rates did differ between the groups. This was highest in MCN at about 15% and lowest in ALA at 5%. LCDD had a rate of recovery between these two.
Finally, the rate of recovery before and after 2006 is shown in Figure 3 B. This demonstrated an improvement in renal recovery in the cohort treated more recently. Renal recovery was seen in roughly 15% of the group treated in the modern era compared to 5% of those treated prior to 2006.
This national cohort study demonstrated that outcomes of patients with MGs are poor but improving over time. Progressive malignancy was the leading cause of death and not surprisingly age, frailty, CHF, and initiation of dialysis via a catheter were all independent risk factors for mortality. Renal recovery was not rare and appeared to be highest in patients with Myeloma Cast Nephropathy. The rate of renal recovery has also improved over time.
Congratulations to Lindsay Boole and welcome Romel Steven Saleh to our Duke family!
Have you heard about the new paging template to improve RN-MD communication? A pilot has started on 4300 and you will be hearing more about it on Duke Gen Med. Please let us know if you want to get involved in this interdisciplinary QI work!
Congratulations to our HVC proposal team winners who are now getting started on their high value projects.
Please join us on Thursday for QI noon conference to discuss EM-IM patient flow.
This feature will return next week!
From the Chief Residents
Friday, January 22 - Dr. Harvey Marshall, Pulmonary
|1/19/16||PEAC Q&A Review||12:00||Dominos|
QI Patient Safety Noon Conference
Chair's 11:30 a.m., Recruitment lunch with Applicants
|12:15||Pipers in the Park|
From the Residency Office
General Medicine Health Services Research Fellowship at Duke (Attention SARS!)
Health services research (HSR) is multi-disciplinary and focuses on the impact of systems of care, access, cost, quality, behavior and other factors on health care outcomes. We have a very robust network of support and outstanding faculty in HSR at Duke. Here is an introduction to our fellowship, courtesy of David Edelman. The application cycle begins in January!
The Division of General Internal Medicine collaborates with the Center for Health Services Research in Primary Care in the Durham VA Medical Center to offer fellowships for MD and PhD scholars with an interest in training in clinical or health services research. The fellowship is ordinarily a two year program, though three year fellowships may be available to certain candidates. Training grants are funded by the VA Office of Academic Affairs (OAA). We have trained more than 100 fellows in our 30-year history, including many leaders in Health Services Research and many of our core faculty in General Internal Medicine.
The primary goal of the post-doctoral fellowships is for fellows to perform high-quality, mentored clinical or health services research working closely with a mentor from the Division of General Internal Medicine. MD fellows ordinarily obtain a Masters in Clinical Research from Duke’s CRTP program, with tuition paid by the fellowship. All fellows also participate in a Faculty/Fellow Development Seminar Series, a set of weekly, one-hour discussions addressing a variety of career development topics. Stipend is at the appropriate PGY level.
Senior Residents wishing to apply for July 2016 should contact Dr. David Edelman, Fellowship Director (David.Edelman@duke.edu) no later than Friday, January 9 to express interest. Written application will be due February 1 with interviews competed by the 3rd week in February and applicants notified of their status by March 1.
Click the link for more info:
Or, contact David Edelman, MD, Fellowship Director (email@example.com).
Book Club Event
Please join us for a special book club event on February 3rd from 5:30 - 7:30 pm in the Faculty Lounge. We'll be reading Black Man in a White Coat by our own Duke author, Dr. Damon Tweedy, who has graciously agreed to join us for the event. If you only make it to one book club event this year, make this the one!
If you would like to attend, please email firstname.lastname@example.org. As always, a limited number of FREE COPIES of the book are available so RSVP early to reserve your copy. We look forward to seeing you there!
Laura M. Caputo, MD
Hospital Medicine, Durham VA Medical Center
Fellowship Program Info Sessions
Gastroenterology Fellowship Program
Monday, March 7th at 5:00pm in the Tyor Conference Room located in the GI Administrative Suite.
Teaching and Leading EBM: A Workshop for Educators and Champions of Evidence-Based-Medicine
Registration is now open!
Teaching and Leading EBM: A Workshop for Educators and Champions of Evidence-Based-Medicine
Duke Medicine, Durham NC
April 12-15, 2016
This workshop focuses not only on learning EBM skills, but also on teaching EBM. Previous participants have included rising chief residents, faculty charged with developing an EBM curriculum, librarians, and other clinicians and faculty passionate about applying the best evidence to patient care. The program includes large group sessions in the morning, then supportive, small group, learner-driven sessions for the rest of the day.
The workshop will take place on the Duke Medicine campus in the new Trent Semans Center for Health Education and the Duke Medicine Pavilion.
Train leaders in medicine to facilitate evidence-based clinical practice in their teaching and practice settings.
Practice the skills involved in evidence-based medicine including clinical question formation and acquisition of medical evidence from the literature.
Review and develop critical appraisal skills and application of available evidence to patient care and medical education.
Develop skills in teaching EBM in both large and small group settings.
Provide interactive experience with a variety of evidence-based resources guided by faculty with expertise in evidence-based practice.
Opportunities for Wellness
Feeling down? Need to talk to someone?
All trainees at Duke have FREE access to Personal Assistance Services (PAS), which is the faculty/employee assistance program of Duke University. The staff of licensed professionals offer confidential assessment, short-term counseling, and referrals to help resolve a range of personal, work, and family problems. PAS services are available free of charge to Duke faculty and staff, and their immediate family members. An appointment to meet with a PAS counselor may be arranged by calling the PAS office at 919-416-1PAS (919-416-1727), Monday through Friday between 8:00 A.M. and 5:00 P.M. For assistance after hours, residents and fellows can call the Blood and Body Fluid Hotline (115 inside DUH, 919-684-1115 outside) for referral to behavioral health resources. Another resource is Duke Outpatient Psychiatry Referrals at (919) 684-0100 or 1-888-ASK-DUKE.
Upcoming Dates and Events
February 17 - Duke vs UNC
March 2 - JAR Networking Event
March 5 - UNC vs Duke
March 18 - Match Day Celebration
April 29 -Charity Auction
Main Internal Medicine Residency website
Main Curriculum website
Department of Medicine
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