From the Director
Week two is in the books! Thank you to all of the interns, JARs, SARs, chiefs, fellows and attendings for making the transition to our new year such a smooth one. I have received so many compliments about the outstanding care and teaching you are all providing…kudos this week to Dinushika Mohottige from a patient's family for outstanding care overnight, to Sajal Tanna from Carter Davis for great supervision on 9100 nights, to Jess Tucker, Andrea Sitlinger and Lakshmi Krishnan from Susan Gurley for great work at the VA, to Sneha Vakamudi and Alyson McGhan for outstanding SAR talks, to our former prelim intern now radiologist Mike Malinzak for his noon conference as well (and to Brian Griffith for the EPIC noon conference), and to Kevin Shah for chair's conference. Chair's had really strong audience participation which was much appreciated as well. Kevin Trulock and Brittany Dixon represented us at the ICGME (that is all the house staff programs) meeting on Wednesday…they are your GME representatives, and can provide you with information about what is being talked about at the institution level regarding GME.
Fellowship applications are able to be downloaded by fellowship programs starting JULY 15th! If anyone applying has last minute questions, please let me know. Don't forget to also register for the NRMP once you have uploaded your application to ERAS. Mock interviews will be offered soon, so be on the lookout for information about this great opportunity as well. Starting next week, we will be bringing program information to you right before noon conference starts..look for information about how we address issues that arise in rotation evaluations, confidential comments, and other program admin related issues.
Please don't forget to do your RL Solutions (that's the new SRS system) training! It is due July 15th for ALL MEMBERS OF THE MEDICAL STAFF (that's you!).
This week's pubmed from the program goes to Ragnar Palsson for his review written with Dr. Uptal Patel…Palsson R, Patel UD. Cardiovascular Complications of Diabetic Kidney Disease. Advances in Chronic Kidney Disease, May 2014 (in press).
Have a great week! Looking forward to seeing you at the upcoming summer celebration at Dr. Klotman's on July 25th!
What Did I Read This Week?
submitted by: Aimee Zaas, MD
What I read this week is brought to you by some clinical questions we had on gen med 1. Here are some short answers to a few items that came up for our team.
Clinical questions from this week (with some answers)
Does my patient have iron deficiency anemia?
It can be difficult to tease out iron deficiency and anemia of chronic inflammation in hospitalized patients because they often have comorbidities making them "chronically inflammed", thus there is often overlap between the two. This is a nice paper from JGIM that studies a group of medically complex VA patients, comparing lab values with the gold standard of bone marrow biopsy for detecting iron deficiency. The money is in the ferritin. All the other parameters (MCV, TIBC, iron, % sat) are essentially equivocal. The cutoff they come up with is 100. If the serum ferritin is <100 then that gives a 65% sensitivity and 96% specificity for iron deficiency. (Thank you to VA ACR Tim Mercer for this information!)
What is cryptosporidiosis?
Cryptosporidium is a parasite that causes watery diarrhea, which is self limited in immunocompetent folks. Diarrhea can last longer in the immune compromised, but there are still no effective treatments except time. It is famous for an outbreak in the Milwaukee water supply in 1993, and has been detected in swimming pools, and other public water supplies. We test for it using a stool antigen test, and this PLUS giardia are what you get with a standard "O and P" at Duke. I misspoke and it was cyclospora that was associated with a strawberry and raspberry associated diarrhea.
What are the anticoagulation guidelines after atrial fibrillation?
As Kevin Shah mentioned in chairs, the American College of Cardiology has great guidelines for all things cardiac, including post atrial fib anticoagulation. We were asking about post-chemical cardioversion duration of anticoagulation. Here are the Class 1 and II a recommendations..
6.1.1. Thromboembolism Prevention: Recommendations
1. For patients with AF or atrial flutter of 48-hour duration or longer, or when the duration of AF is unknown, anticoagulation with warfarin (INR 2.0 to 3.0) is recommended for at least 3 weeks prior to and 4 weeks after cardioversion, regardless of the CHA2DS2-VASc score and the method (electrical or pharmacological) used to restore sinus rhythm (320-323).
(Level of Evidence: B)
2. For patients with AF or atrial flutter of more than 48 hours or unknown duration that requires immediate cardioversion for hemodynamic instability, anticoagulation should be initiated as soon as possible and continued for at least 4 weeks after cardioversion unless contraindicated.
(Level of Evidence: C)
3. For patients with AF or atrial flutter of less than 48-hour duration and with high risk of stroke, intravenous heparin or LMWH, or administration of a factor Xa or direct thrombin inhibitor, is recommended as soon as possible before or immediately after cardioversion, followed by longterm anticoagulation therapy.
(Level of Evidence: C)
4. Following cardioversion for AF of any duration, the decision regarding long-term anticoagulation therapy should be based on the thromboembolic risk profile (Section 4).
(Level of Evidence: C)
1. For patients with AF or atrial flutter of 48-hour duration or longer or of unknown duration who have not been anticoagulated for the preceding 3 weeks, it is reasonable to perform a TEE prior to cardioversion and proceed with cardioversion if no LA thrombus is identified, including in the LAA, provided that anticoagulation is achieved before TEE and maintained after cardioversion for at least 4 weeks (164). (Level of Evidence: B)
2. For patients with AF or atrial flutter of 48-hour duration or longer, or when the duration of AF is unknown, anticoagulation with dabigatran, rivaroxaban, or apixaban is reasonable for at least 3weeks prior to and 4 weeks after cardioversion (230, 324, 325).
(Level of Evidence: C)
What is the JAK-2 mutation and what does it signify?
We were discussing this in relation to polycythemia vera. PCV, Essential thrombocythemia and primary myelofibrosis are all part of the "myeloproliferative disorders" or "myeloproliferative neoplasms", and these three are the BCR-ABL mutation negative myeloproliferative neoplasms (CML is BCR-ABL positive). These are clonal marrow disorders, and all have a risk of transforming into acute myeloid leukemia. The JAK2-V617F mutation in exon 14 characterizes these disorders, and is present in 95% of PV, 50--70% of ET and 40-50% of MF. With this mutation, the JAK2 tyrosine kinase is activated constitutively, resulting in cellular proliferation. This is an oversimplification of the pathogenesis, as There are other activating mutations found in these disorders within the JAK-STAT signaling cascade as well. Lowering thrombosis risk is the major goal in PV treatment and Age and history of thrombosis are the prominent risk factors that predict future thrombosis risk. The efficacy and safety of low-dose aspirin (100mg daily) in PV has been assessed in the European Collaboration on Low-dose Aspirin in Polycythemia (ECLAP) double-blind, placebo-controlled, randomized clinical trial.
When do you treat candiduria?
The IDSA guidelines are a great place to look for how to manage various infections (www.idsociety.org). For asymptomatic candiduria, most individuals don't require treatment. Recommendations are shown below.
Recommendations: asymptomatic candiduria
1. Treatment is not recommended unless the patient belongs to a group at high risk of dissemination (A-III). Elimination of predisposing factors often results in resolution of candiduria (A-III).
2. High-risk patients include neutropenic patients, infants with low birth weight, and patients who will undergo urologic manipulations. Neutropenic patients and neonates should be managed as described for invasive candidiasis. For those patients undergoing urologic procedures, fluconazole administered at a dosage of 200- 400 mg (3-6 mg/kg) daily or AmB-d administered at a dosage of 0.3-0.6 mg/kg daily for several days before and after the procedure is recommended (B-III).
3. Imaging of the kidneys and collecting system to exclude abscess, fungus ball, or urologic abnormality is prudent when treating asymptomatic patients with predisposing factors (B-III).
Recommendations: symptomatic candiduria
1. For candiduria with suspected disseminated candidiasis, treatment as described for candidemia is recommended (A-III).
2. For cystitis due to a fluconazole-susceptible Candida species, oral fluconazole at a dosage of 200 mg (3 mg/kg) daily for 2 weeks is recommended (A-III). For fluconazole-resistant organisms, AmB-d at a dosage of 0.3-0.6 mg/kg daily for 1-7 days or oral flucytosine at a dosage of 25 mg/kg 4 times daily for 7-10 days are alternatives (B-III). AmB-d bladder irrigation is generally not recommended.
3. For pyelonephritis due to fluconazole-susceptible organisms, oral fluconazole at a dosage of 200-400 mg (3-6 mg/kg) daily for 2 weeks is recommended (B-III). For patients with fluconazole-resistant Candida strains, especially C. glabrata, alternatives include AmB-d at a dosage of 0.5-0.7 mg/kg daily with or without flucytosine at a dosage of 25 mg/kg 4 times daily (B-III), or flucytosine alone at a dosage of 25 mg/kg 4 times daily (B-III) for 2 weeks.
And from Carli Lehr…
In our patient with DIABETES and probably OSTEOMYELITIS...how is our physical exam? Here is an article helping us decide if our patient has osteo. Our patient had ulcer > 2 cm and an abnormal X-ray. ESR is close to the cut-off here too.
|Finding||Likelihood Ratio||Negative Likelihood Ratio|
|Ulcers >2 cm2||7.2 (CI 1.1-49)||0.48 (CI 0.31-.076)|
|Positive “probe to bone” test*||6.4 (CI 3.6-11)||0.39 (CI 0.20-0.76)|
|ESR >70||11 (CI 1.6-79)||0.34 (CI 0.06-1.9)|
|Abnormal plain X-ray**||2.3 (CI 1.6-3.3)||0.63 (CI 0.51-0.78)|
|Abnormal MRI||3.8 (CI 2.5-5.8)||0.14 (CI 0.08-0.26)|
*Probe to bone test: the examiner gently and in a sterile fashion, probes the ulcer with a steel probe to determine if the probe can advance to bone
**abnormal X-Ray findings include: focal loss of trabecular pattern, periosteal reaction, and frank bone destruction. 2 or 3 views can be selected
Renaming Pickett Road Resident Clinic: We are revamping the clinic here at Pickett and what better why to start out fresh but with a new name. Dr. Peyser is asking all the residents to nominate a NEW name for the Pickett Road Clinic. The top names will be selected and then voted on in August! Please send me an email with nomination for new clinic name. Jars and Sars will be paired with intern for their first day. Let the intern shadow you and give them pearls of advice to succeed in clinic.
Make sure to ADD the Interns: go to Inbasket, Attach, #2 Grant Access
Eric Black Maier EWB16
Dave Kopin DJK23
Tim Hinohara TTH10
John Musgrove JLM 138
Rachel La Voy/Hu REL 31
Pascale Khairallah PK110
Get ready for Mini CEX: for the interns our goal is to get one done in the first 4-5 visits you are here. Mini cex is observation of the history, PE or assessment part of the visit. I schedule these for when attendings: residents are 1:2. Congrats to Myles who completed the first CEX of the year! TBA is because you are not in clinic enough for CEX in July and August.
|Resident Mini Cex 2014-2015|
|Resident||Attending||1st CEX||Plan for CEX|
|Hu/La Voy||Rookwood 7/25/14|
For future lab orders:
It is the correct process to have all lab patients check in at the front desk in an effort to have their lab orders released prior to presenting to the lab. If you have not received your business cards please let Erin Payne know to order more. You can give out your cards to patients in the hospital and act as their Outpatient PCP.
This week the internal medicine Patient Safety and Quality Council will be having its first meeting of the new academic year. Come by the medicine library at 5:30 on Wednesday to learn about what the group has done in the past, get connected for any QI ideas that you might have, and eat some pizza.
Time: Wednesday, July 16, 5:30pm
Place: Med Res Library
Confusingly, I also want to let everyone know about a similarly-named but separate group, the GME Patient Safety and Quality Council. For anyone interested in quality improvement, health care systems, or patient safety issues, this forum is a great place to get to sit down with some of the top safety officers at Duke. Meetings are monthly. If you are interested and would like to be know when the first meetings this year will be, let me know!
Next week will also be the first of our monthly Morbidity and Mortality noon conferences. Dr. Alicia Clark and I will be preparing a case for discussion. This is a great opportunity to learn from our collective past "experiences" - because we doctors never make "mistakes," right? :-)
Time: Wednesday, July 16, 12pm
Place: Med Res Library
Have a good week everyone!
From the Chief Residents
Friday, July 18th - Palliative Care/Oncology, Dr. Amy Abernethy
|7/14/14||SAR Emergency Series: Delirium||Hal Boutte||12:15||Picnic Basket|
|7/15/14||SAR Emergency Series: Undifferentiated Shock - Initial Mgmt||Adam Banks||12:15||Rudinos|
|7/16/14||Resident M&M||QI Team||12:15||China King|
|7/17/14||SAR Emergency Series: Inpatient Diabetes Management||Allyson Pishko||12:15||Chick-Fil-A|
From the Residency Office
Survival Guides and End of Year Gifts
The 2014 Survival Guides are in and they are awesome. If you are a continuing Internal Medicine resident, please come by the MedRes office and pick up your copy during normal business hours. We can only provide one copy per resident. If you are interested in purchasing a copy, please contact Jen Averitt. An electronic version of the guide is currently in development and we should have more information on when that will be available soon!
For all continuing Internal Medicine residents, please also pick up your copy of “The Evidence – Classic and Influential Studies Every Medicine Resident Should Know” with the compliments of the program for a great year!
Stead Resident Research Grants- Request for Proposals
For All Internal Medicine, Med-Peds, and Med-Psych Residents
We are pleased to announce the Request for Proposals for the inaugural “Stead Resident Research Grant” applications. We are grateful to the leadership of the Stead Scholarship Society for their generosity to support resident research and our Stead Leaders for their mentorship and for promoting your scholarly activities !
The applications due on September 1, 2014 for a funding start date on October 1, 2014.
Please find attached the Stead Resident Research Grant Instructions-2014, Stead Resident Research Grant Application Forms-2014, Human Subjects example, and NIHSAMPLE Biosketch Form. Please include your mentor’s NIH Biosketch and support letter with your application.
Please see link below for Biostatistical Support resources available to you for your projects and discuss with your mentor.
Each proposal must have a Human subjects section that describes the protections of the patients and patient data, describe the consent procedure if applicable, status of IRB protocol (to be submitted, already submitted or already approved, as appropriate) etc. This section is required whether to not your project is a retrospective or prospective study, whether patient identifiers are exposed (or not) during data collection/analysis, whether consent is to be obtained or there is a waiver for consent. Please see attached example language that you can adapt to your own protocol after discussing with your research mentor who has already thought about the Human subjects issues.
Wishing you continued success with your research projects !
Murat Arcasoy and Aimee Zaas
Whether you are going to interview for hospitalist position, primary care or attending position after fellowship, there are some skills to learn for the interview and essential questions to ask. Come to this session for dinner, sponsored by the North Carolina American College of Physicians, and get the answers you need before your job interview. Welcome to all medical students, residents, interns and fellows.
Panelists: Dr. Jon Bae, Dr. Saumil Chudgar, Dr. David Simel, Dr. Pooh Setji, Dr. Poonam Sharma, Dr. Bruce Peyser, Dr. Sharon Rubin
Location: Duke Internal Medicine Library, Durham, NC
Date: Wednesday August 6, 2014
Time: 7:00 PM to 8:30 PM
Please RSVP to Dr. Sharon Rubin by August 4, 2014
Upcoming Dates and Events
July 25th- Summer Celebration at Dr. Klotman’s House
August 6th- Interview Skills Session
August 17th- Kerby Society Hosting Durham Bulls Game Gathering
- July 14 Resp Fit Testing-T-Dap-TB Skin Testing Flyer2
- Main Internal Medicine Residency website
- Main Curriculum website
- Ambulatory curriculum wiki
- Department of Medicine
- Confidential Comment Line Note: ALL submissions are strictly confidential unless you chose to complete the optional section requesting a response