From the Director
It’s official! The first Med Res News of 2015-16. Congratulations again to our graduating SARs and outgoing chiefs, as well as to our new JARs and SARs! Welcome to our new interns – orientation week went really smoothly (THANK YOU to Lynsey Michnowicz, Jen Averitt, Tia Williams, Madi Smith and Lauren Dincher for keeping us on track) as did shadow day, and now we can finally begin. We are ready for a fantastic year.
Many many kudos this week … to Bonike Oloruntoba for a fabulous Grand Rounds (watch it on the webcast if you missed it!), to Marc Samsky for the Tom Holland Lecture, to John Paul Shoup and MS IV Yamini Krishnamurthy from Mike Mindner for outstanding work on CAD, to Azalea Kim from Rebecca Sadun for above and beyond patient follow up, to Steph Giattino from Chris Hostler for her work on ID consults, to Matt Turissini for an outstanding CAT-VA report, to Gena Foster, Eric Pollack, Vedran Oruc, Rachel Hu, Zach Wegermann and Sarah Goldstein for covering various services in the last week of the year, and to Kara Johnson, Christine Bates, Zach Wegermann, Rachel Hu, Lauren Collins and Vedran Oruc for running Intern ‘Boot Camp’.
This week kicks off our SAR-led intern emergency lecture series, so please be sure to make it to noon conference! Please also see announcements in your email from Murat Arcasoy regarding the 2015-16 Stead Research Grants, open to all residents.
This week’s pubmed from the program goes to Brian Sullivan for his article that was just accepted for publication ...check out all the faculty on his article as well! Sullivan, B, Ming, D, Boggan, J, Schulteis, R, Thomas, S, Choi, J, Bae, JG. “An Evaluation of Physician Predictions of Discharge on a General Medicine Service.” Journal of Hospital Medicine, accepted for publication, Summer 2015.
Be on the lookout for opportunities to GET INVOLVED here at Duke and with the program. We will be sending an update of various opportunities to you via email this week..examples include the PSQC, the Social Action Committee and more!
Have a great week,
What did I read this week?
(Submitted by: Aimee K. Zaas, MD, MHS)
What I read this week 6/16/15.
“PD-1 Blockade in Tumors with Mismatch Repair Deficiency”
Le, et al. NEJM May 30, 2015DOI: 10.1056/NEJMoa1500596
Why did I read this? This would generally be the type of article where I read the title and maybe the abstract when I got the NEJM table of contents. But, the first author was a year behind me in residency and the last author was in my residency class, so this caught my eye and I read the whole article. Their whole lab is pretty amazing, with work featured in the New York Times every few years or so.
What did the authors do? They took advantage of an observation they made about prior clinical trial data, and coupled it with their extensive knowledge of cancer biology and immunobiology.
First, the PD-1 is a negative immune regulator, turning off Th1 responses before the immune system can damage the host. This is a good thing, unless you are trying to use your immune system to fight off cancer. Prior studies have shown that blocking the PD-1 pathway with antibodies leads to a great response in many types of cancers, such as melanoma and lung cancer. Here’s where it gets really cool … they noticed that only one patient (out of 33) with colorectal cancer responded to PD-1 blockade in the clinical trials. They hypothesized that this patient’s tumor was different in a very specific way from the other 32 patients – that it had mismatch repair deficiency, leading to many more than average mutations in the cancer, and thus more immune targets for the patient’s immune system. So, allowing the immune system to work through PD-1 blockade meant tumor response. They tested the tumor and found that it did have mismatch repair deficiency, and the study was born.
They then did a phase 2 study with three groups of patients: metastatic colorectal cancer with mismatch repair deficiency (both Lynch syndrome and sporadic), metastatic colorectal cancer without mismatch repair deficiency, and patients with mismatch repair deficient tumors other than colon cancer.
Patients received pembrolizumab as the study agent. Pembrolizumab is a humanized monoclonal anti–PD-1 antibody of the IgG4 kappa isotype that blocks the interaction between PD-1 and its ligands, PD-L1 and PD-L2.
Patients were followed by tumor markers, radiographic tumor burden as well as survival over a 20 week period. They also sampled a subset of patients for sequencing of the tumors and determined how many “neoantigens” were created in the tumors because of lack of DNA mismatch repair.
What did they find? 32 patients with colorectal cancer were recruited (11 with mismatch repair deficiency – cohort A- and 21 with intact mismatch repair – cohort B), and 9 with other cancers that had mismatch repair defects – cohort C. The mismatch repair deficient patients were younger (46 vs 61) but otherwise similar to the other group.
The primary end points for cohorts A and B were the immune-related objective response rate and the 20-week immune-related progression-free survival rate, assessed with the use of immune-related response criteria.33 The primary end point for cohort C was the immune-related progression-free survival rate at 20 weeks.
Did it work? Yes, on a number of endpoints. The immune-related objective response rate in cohort A was 40% (4 of 10 patients; 95% confidence interval [CI], 12 to 74), and the immune-related progression-free survival rate at 20 weeks was 78% (7 of 9 patients; 95% CI, 40 to 97); the corresponding rates in cohort C were 71% (5 of 7 patients; 95% CI, 29 to 96) and 67% (4 of 6 patients; 95% CI, 22 to 96). In cohort B, which included patients with mismatch repair–proficient colorectal cancers, the immune-related objective response rate was 0% (95% CI, 0 to 20), and the immune-related progression-free survival rate at 20 weeks was 11% (2 of 18 patients; 95% CI, 1 to 35). Radiographic responses and fall of associated tumor markers were better in cohorts A and C as compared to B, as was survival.
Adverse events were few, but did include thyroid test abnormalities, particularly in cohorts A and C.
Genomic analysis showed 100x the number of mutations in the tumors from cohorts A and C as compared to B, and histologic analysis showed greater inflammatory infiltrate into tumors from cohorts A and C as compared to B.
What does this mean? This certainly confirms the immune system role in fighting cancer, and highlights the need for ‘personalized’ treatment of malignancies based on tumor characteristics. While further studies need to be done, this is a step towards improving therapies for subtypes of patients with cancer. This article is a great example of using one’s background knowledge to critically analyze the results of a trial (or to question a clinical phenomenon) and carry out studies to better understand why. Plus, always scan the table of contents for your friends and colleagues!
Clinic Corner 6/29/15
Jointly offered by Alex Cho and Dani Zipkin
Ambulatory Year in Review!
First, a big shout out to Bonike Oloruntoba for an outstanding year as Chief Resident for ambulatory. Her leadership and diligence and hard work were truly critical. Thanks also to the ACR’s who supported all the clinics throughout the year. Deep gratitude also goes to Lauren Dincher who manages incredibly complex scheduling with grace. Welcome to Armando Bedoya, who has already jumped in feet first and brings a lot of enthusiasm to the Chief role! It’s going to be a great year!
It’s been a wonderful year for ambulatory medicine in the program. Here are some highlights!
- Hopkins curriculum: Initiated by Katie Broderick as part of her GME concentration project in education, the PEAC curriculum has been implemented as a means of “gelling” the ambulatory months together. Each month, clinical topics are assigned for the didactic modules we are all working through (attendings too!), and Bonike was matching the morning report and noon conference content to the same topics. This has improved the delivery of core ambulatory content tremendously! We look forward to continuing with Armando’s leadership!
- Ambulatory Care Leadership Track completes its third year! This year, the ACLT residents learned about issues in health policy at the state level and participated in an advocacy visit to the North Carolina legislative offices in Raleigh. They met with several key legislators, and their one-page take away on the Homebase program at the DOC as an example of team based care for patients with multiple comorbidities and social barriers to care became a heavily-photocopied and talked about item in meetings at the Capitol after they left. Amazing impact! In other ACLT news, Claire Kappa, Adrienne Klement, and Brice Lefler completed the program, and each of them gave an engaging and informative teaching session to their peers during Academic Half Day. This prompted the obvious hashtag, #learnersmakethebestteachers. They really do!!
- Academic Half Day, the Friday morning didactic curriculum, continues to be highly regarded for its diversity and emphasis on interactive teaching. We are grateful for the expertise of our colleagues across multiple disciplines and departments who bring us their energy and enthusiasm. Departments represented include Otolaryngology, Ophthalmology, Gynecology, Urology, Orthopedics, Physical Therapy, Dermatology, Psychiatry, Neurology, and of course many Internal Medicine specialties.
- Leadership transition: Alex Cho is moving on from the Associate Program Director for Ambulatory role, to take on a leadership position with the Primary Care Consortium. Alex will keep teaching time at the DOC and will continue to work with DOC redesign and ACLT programs. Dani Zipkin will be taking over as APD and hopes to be able to half-way fill his shoes J
- Things to come!! The 4+1 schedule for the interns will allow each clinic to designate one half-day per week to administrative and didactic time. Stay tuned for longitudinal curricula in all things outpatient. Ask your medical director for more information: Lynn Bowlby at the DOC, Sonal Patel at Prime, and Sharon Rubin at Pickett.
- Last but not least, a huge thank-you to the many attendings who supervise residents in clinic and enrich the learning environment every day:
Welcome to David Halpern, Claire Kappa, and Michael Meredith!
Thank you to the continuing attendings for your commitment to teaching:
Farewell and thank you to Brian Wolf and Jacqueline Rookwood!
Welcome back to Gene Oddone!
Thank you to our continuing attendings for your commitment to teaching:
Farewell and thank you to Karen Goldstein and Will Yancy
Duke Outpatient Clinic:
Welcome to Patrick Hemming, who will join us in August, from Hopkins!
Welcome to Armando Bedoya, our fearless chief!
Thank you to our continuing attendings for your commitment to teaching:
From the Chief Residents
Friday, June 3rd - No Grand Rounds (July 4th Holiday)
|6/30/15||SAR Emergency Series: Chest Pain/ACS||Sarah Goldstein||12:00||Domino's|
|7/1/15||SAR Emergency Series: Tachyarrhythmias||Marc Samsky||12:00||China King|
|7/2/15||SAR Emergency Series: Acute Renal Failure||Matt Atkins||12:00||Chick-Fil-A|
|7/3/15||HOLIDAY - No Conference|
From the Residency Office
Get Involved 2015!
As we start another academic year, we remind you of all of the opportunities the program and Duke Medicine offer for you to get involved and give back to to our community. Please see the brochure linked at the end of this post for more information!
Duke Partners Club
We are a group of significant others (spouses/fiancés/partners, etc) of residents and fellows in the many different specialties at Duke. Our group offers several monthly activities such as book club, dinners, movies, playgroup, and most simply, a community for those sharing similar experiences during this exciting time in our partners' careers.
This year, GME invited us to participate in orientation with a info-table allowing us to share details about our group. Knowing that information received at orientation doesn't always make it home, please see the information available for download at the end of this post!
Certification in Language Translation Services
If you speak a language other than English fluently and would like to be certified as a medical translator in order to inform/consent patients, please contact The Duke International Patient Center (919) 681-3007
Housestaff Gym Closed on July 2
The Housestaff Gym (Alumni Fitness Center) will be closed on July 2 for equipment replacement.
First Annual Summerfest
The Duke Medical Alumni Association is delighted to host this year’s First Annual Summerfest, an event for all Duke residents and their families. We want to welcome Duke’s newest house staff and celebrate with all residents that they are part of the Duke medical alumni family.
Please know there is an excellent opportunity to hone your interviewing skills. Dr. Kathryn Pollak who is a communication coach and faculty member in the SoM will provide 4 1-hour sessions from which you can choose. In the session, Dr. Pollak will cover tips to finesse interviewing skills as well and give some a chance to role play. She also will be available for practice for their interviews in September and October.
The four sessions will be held the following dates and times:
Monday, August 17th: 12:00 noon to 1:00pm
Tuesday, August 18th: 4:00 to 5:00pm
Wednesday, August 26th: 12:00 to 12:00pm
Thursday, August 27th: 4:00 to 5:00pm
Each session will be 10 people or less, that way it’s more personalized. Please let me know as soon as possible which session you would like to sign up for. This is a very valuable tool being offered!
Upcoming Dates and Events
August 21 - Housestaff Welcome Event
Main Internal Medicine Residency website
Main Curriculum website
Ambulatory curriculum wiki
Department of Medicine
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