Internal Medicine Residency News: June 23, 2014

Sunday, June 22, 2014

From the Director

DUKE.RESEARCH.NIGHT.03 (1)

It's here! The new interns start orientation on Monday!

A tremendous thank you and kudos to our chiefs Krish, Vaishali, Stephen and Joel. Only at Duke would a post op day 1 chief come to his co chiefs grand rounds. Amazing grand rounds given by Stephen Bergin!  We all can't thank you enough for a fantastic year.

And we welcome Nilesh, Coral, Bonike and Aaron to the ranks. They completed their first task - the pull list- so we are well on our way to an amazing year.

Kudos also to Ryan Jessee for a great chairs conference and to Aparna Swaminathan and Rebecca Sadun for covering some colleagues on Friday so they could attend the VERY FUN SAR-b-q at our house. Also to Brice Lefler and Katie B-F for replying.

The SAR b-q was a great send off to a legendary class. Double benefit that they bought it at the charity auction. Looking  forward to hosting the interns (aka almost JARs) on Saturday.

Congrats also to the outgoing chiefs and Lauren Dincher on their 5 year service awards,and a special congratulations to the award recipients presented at grand rounds!

  • Bruce Dixon AwardLindsay Boole (nominees included  John Stanifer, Chris Hostler, Matt Summers, Lindsay Boole, Jim Gentry, Armando Bedoya, Meredith  Clement)
  • Fellow Teaching Award:  Zach Healy (nominee included -  Tony Tran, Jacob Doll, Megan Diehl, Ann Marie Navar Boggan) 
  • Haskel Schiff Award:  Matt Summers (nominees included  Chris Hostler, Matt Summers, Lindsay Boole, Brian Miller, Armando Bedoya, Tim Mercer)
  • Outstanding Service Award:  Randy Heffelfinger

This week's pubmed from the program goes to Myles Nickolich for his upcoming poster presentation: "WHAT BOTHERS LUNG CANCER PATIENTS THE MOST? A PROSPECTIVE, ELECTRONIC, PATIENT-REPORTED OUTCOMES STUDY IN ADVANCED NON-SMALL CELL LUNG CANCER"

Have a great week

Aimee

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What Did I Read This Week?

submitted by: Krish Patel, MD

Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014 Apr 10;370(15):1402-11

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1302097

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Why I read this:

This week’s JAMA had several articles about thrombolysis in acute PE.  Mostly a meta-analysis and an editorial.  Those articles were interesting, but mostly served to remind me to look for the publication of a trial I’d heard about earlier this year from Vic Tapson called the PIETHO trial.

We see a lot of patients with acute pulmonary emboli and the spectrum of presentation can vary quite widely.  We see patients with shock from PEs that require lytics and ICU admisssions to patients with no symptoms and incidental PEs on imaging of the chest intended for other purposes.  One area of uncertainty that we commonly face is what to do with “large PEs” with suggestions of RV dysfunction, but without overt hemodynamic compromise (so called intermediate risk patients).  There is little data to guide us in that regard.  The PIETHO trial was designed and undertaken to help provide more guidance in this area of clinical uncertainty….

Design: 

This study was a multicenter (Europe) double blinded, randomized, controlled trial.  The trial enrolled adult patients (n=1006) with acute PE (<15 days) and RV dysfunction (defined by specific ECHO or CT dimensional criteria) with myocardial injury (positive Troponin).  Patients with contraindication to thrombolytics, with overt hemodynamic instability, or recent IVC filter placement or thrombectomy were excluded from participation.  Patients were randomized to either single bolus dose of tenecteplase + intravenous unfractionated heparin vs. placebo + intravenous UFH.  The primary outcome was the composite of death from any cause and hemodynamic collapse within 7 days of randomization.  Secondary endpoints included 30 day all-cause mortality, recurrence of PE within 7 days of randomization, and various 7 day bleeding rates (major bleeding, intracranial hemorrhage, major extracranial bleeding).  Overall, the groups were fairly balanced in baseline characteristics and had similar proportions achieving therapeutic PTT on UFH within 24 hours of randomization. 

Results: 

So what did they find? The primary outcome occurred less often in the group receiving tenectaplase + UFH (2.6% vs 5.6%; p=0.02). However, this was primarily driven by a difference in hemodynamic decompensation (1.6% vs. 5.0%; p=0.002).  The study was not powered to detect a difference in death rate and the death rates in both groups was quite low (1.2% vs 1.8%; p=0.42).  Hemodynamic decompensation included some meaningful events (cardiac arrest, need for catecholamines for BP support) but also a perhaps less meaningful one (SBP <90mm Hg for >15mins).  Nevertheless, the occurrence of each type of hemodynamic decompensation was numerically different in both groups (statistical significance not published).

table 1

How about safety endpoints?  Well as might be expected there was notably more bleeding and hemorrhagic stroke in the tenectaplase group in comparison to the placebo group.

table 2

What does this mean for us:

Well, this trial demonstrates that patients with acute PE, RV dysfunction and myocardial injury have an increased risk of hemodynamic decompensation and that single dose tenectaplase may mitigate that risk.  However, the risk of significant bleeding, including a 2% incidence (10x relative risk) of hemorrhagic stroke ,may outweigh the benefit of the reduction in hemodynamic compromise.  Overall, this trial also tells us that the risk of death in patients with acute PE, RV dysfunction, and myocardial injury is relatively low and these patients can be managed well with careful monitoring and anticoagulation (the placebo arm) and that thrombolysis perhaps should be reserved for patient’s who fail this initial approach.

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From the Chief Residents

Grand Rounds

Presenter:  Dr. Mary Klotman

Chair, Department of Medicine

Topic:   State of the Department of Medicine

Noon Conference

Day Date Topic Lecturer Time Vendor
Monday 6/23 MKSAP Mondays - Thrombocytopenia Chiefs 12:00 Subway
Tuesday 6/24 Immunizations Review Anne Phelps 12:00 Sushi
Wednesday 6/25 How to Give a Talk Zaas 12:00 Cosmic Cantina
Thursday 6/26 Novel therapies for staph aureus infections Ralph Corey 12:15 Domino's
Friday 6/27 Tom Holland Lecture Chiefs 12:00 Chick-Fil-A
 
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From the Residency Office

GME Resident Council

The following are your peer selected representatives to the Resident Council for 2014-2015. The Resident Council has elected Dr. Michael Barfield, General Surgery, as Chair and Housestaff Representative and Dr. Nicholas Rohrhoff, Internal Medicine, as Vice-Chair.

  • Dr. Michael Barfield - General Surgery, Chair
  • Dr. Nicholas Rohrhoff - Internal Medicine, Vice-Chair
  • Dr. Eun Eoh Anesthesiology
  • Dr. Dinesh Kurian Anesthesiology
  • Dr. Jolene Jewell Dermatology
  • Dr. Manisha Bahl Diagnostic Radiology
  • Dr. Michael Malinzak Diagnostic Radiology
  • Dr. Lauren Siewny Emergency Medicine
  • Dr. Nikki Henry Family Medicine
  • Dr. Michael Barfield General Surgery
  • Dr. Brittany Dixon Internal Medicine
  • Dr. Nicholas Rohrhoff Internal Medicine
  • Dr. Kevin Trulock Internal Medicine
  • Dr. Jesse Tucker Internal Medicine
  • Dr. Colby Feeney Internal Medicine/Peds
  • Dr. Amy Newhouse Internal Medicine/Psych
  • Dr. Owoicho Adogwa Neurological Surgery
  • Dr. David Lerner Neurology
  • Dr. Joseph Dottino Obstetrics and Gynecology
  • Dr. Jaya Badhwar Ophthalmology
  • Dr. Norah Foster Orthopaedic Surgery
  • Dr. Robert Henderson Orthopaedic Surgery
  • Dr. Richard Rutherford, Jr. Orthopaedic Surgery
  • Dr. Russel Kahmke Otolaryngology
  • Dr. Alyssa Kraynie Pathology
  • Dr. Christopher Severyn Pediatrics
  • Dr. Robert Bahnsen, Jr. Psychiatry
  • Dr. Alexander Eksir Psychiatry
  • Dr. Christina Cramer Radiation Oncology
  • Dr. Brian Gulack Surgery Research Fellowship
  • Dr. Melissa Mendez Urology
  • Snyderman Award Winner

Snyderman Award

The Snyderman Award was presented to Dr. Lindsey Boole, MD by Dr. Catherine Kuhn at the June ICGME Meeting last week. The winning submission is titled “Residents finding their roots: Resident workshops to improve patient safety on the wards while teaching root cause analysis”. Dr. Boole will receive $1000 (after taxes) and her name on the Snyderman Plaque. Congratulations to Dr. Boole and all who submitted projects for Snyderman Award consideration. More information about the Snyderman Award can be found on the GME Web site.

Moonlighting

All Internal (TSMA) Moonlighting approvals will expire on June 30, 2014.
To record moonlighting activities within MedHub, the activity must be approved through the TSMA/Moonlighting Request Forms located in the Schedule Planning section of MedHub.

The following policies apply to the moonlighting opportunities that are available to trainees:

At no time may the hours allocated for TSMA activities negatively impact training or violate duty hour policies. Residents who would like to be considered for Temporary Special Medical Activity (TSMA) in Oncology, Emergency Medicine, Cardiology, or Student Health must meet the following:

  1. Program level – either JAR or SAR
  2. Successful completion of rotations on MICU and Gen Med
  3. Be in good standing and without any active corrective action
  4. Provide written support from their advisor supporting the trainee’s request. The advisor may send an email to the attention of the Program Director, copy to the Program Coordinator, confirming their approval (to be completed prior to initiating the online TSMA form).
  5. Initiate the online TSMA form found on MedHub.
  6. Meet any additional training requirements as specified by the sponsoring department.

On notification of approval by GME, the trainee may contact the service Director and request approval to participate in the TSMA service.

Please Note: TSMA is approved only for each academic year. If you are currently participating in TSMA and plan to continue after July 1, you will need to resubmit the required forms for approval.

Duke Ahead

Duke Ahead

Information/Opportunities

Albemarle Procurement

Upcoming Dates and Events

  • Intern Welcome Celebration:  June 27 @ the PIT

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