Internal Medicine Residency News, April 18, 2016

April 14, 2016

From the Director

Hope everything is going well to start off the week. Jen, Lynsey, Saumil, Murat and I are learning a lot at the Program Director’s/Program Adminstrator’s meeting. We are looking forward to bringing back some good ideas from our colleagues around the country. Murat is also presenting our poster detailing the incredible rise in resident research output over the past 5 years…we look forward to publishing this in the coming year.

Kudos this week go to our own Dr. Daniella Zipkin who was selected for the SGIM Education Committee, to Peter Hu (and the rest of the NF crew – Rachel Hu, Mike Dorry, Anubha Agarwal and Ani Kumar) from Suchita Shah. Peter was instrumental in expediting care for a very sick transfer. Also kudos to Josh Lee from Armando Bedoya and Sue Woods for his answers in AM report, to Brian Andonian for his fantastic wellness talk and to Nick Turner and Winn Seay for an outstanding overview of 1010 talk.

Congratulations to Lauren Ring on her wedding to surgery resident Mohan Mallipeddi (can’t wait to post some pics!), a belated congratulations to Joanne Wyrembak on her engagement and also a congratulations to Maggie Infeld on her engagement!

This week’s pubmed from the program goes to Jessie Seidelman for her abstract "Are primary care providers in the Southeastern U.S. ready to prescribe PrEP?” to be presented at the 21th International AIDS Conference (AIDS 2016), to be held in Durban, South Africa.

Have a great week
Aimee

What Did I Read This Week?

Submitted by Christopher Hostler, MD

OK so the section header “What Did I Read This Week” is a lie this time. It should read “What Did I Read 2 Weeks Ago And Desperately Hope Nobody Else Would Use For Their WDIRTW So That I Could Shamelessly Talk About Chronic Lyme Disease.” I guess for brevity’s sake, the former is a much better title.

Chronic Lyme. Dr. Corey’s favorite diagnosis. The “diagnosis” that has caused Micah McClain to report more physicians to the medical board for malpractice than any other. Those who claim to have Chronic Lyme interestingly have the greatest likelihood ratio of Multiple Cat Ownership (MCO). Side note: did you know that Armando has multiple cats? I’m just saying…

For years, chronic lyme has been the bane of ID physicians’ existence; a diagnosis that doesn’t exist but is characterized by vague symptoms, perseverance on “that time I got bitten by a tick and now my left ring finger tastes like green olives,” and a strong desire to conduct protests outside of IDSA conferences. What’s worse, some “providers” prey on patients who identify as having chronic lyme by giving years of unnecessary and unfounded antibiotics, exposing patients to increased costs, increased adverse drug effects, and higher population resistance to antibiotics. Why, you may ask, don’t we just do a trial to show that long-term antibiotics don’t help these patients?

Ask and you shall receive! On March 31, the NEJM published an RCT of long-term therapy for patients who attribute symptoms (musculoskeletal pain, arthritis, arthralgia, neuralgia, sensory disturbances, dysesthesia, neuro-psychological disorders, or cognitive disorders, with or without persistent fatigue) to Lyme disease. Patients who claimed these symptoms and could show temporal relation to an erythema migrans rash (or otherwise proven symptomatic case of Lyme disease) or had positive B. burgdorferi IgG or IgM were eligible for this Dutch study. Upon enrollment, patients were randomized in a 1:1:1 fashion to three treatment arms. All patients received 2 weeks of IV ceftriaxone and then patients either received 12 weeks of doxycycline (100mg bid), clarithromycin-hydroxychloroquine (500-200mg bid). Adherence was monitored by pill-count, patient diaries, and the Medication Event Monitoring System, where microprocessors in the pill bottle cap record each time the bottle is opened. The primary outcome was health-related QOL as measured by the physical component summary score of the RAND SF-36, a well-validated measure of health status. Secondary outcomes included other components of the SF-36 and fatigue as measured by the fatigue-severity scale of the Checklist Individual Strength (another well-validated tool). A modified intention-to-treat protocol was used for statistical analysis of primary and secondary outcomes. In all, this was a very well designed trial that used appropriate statistical techniques and well-validated outcomes (as well as stringent adherence monitoring protocols). It’s almost like you can hear the study designers saying, “I’m not going to leave any doubt about the truth of the outcomes here…”

So what did it show? All treatment groups had an improvement in symptoms and fatigue both at the end of the 2 weeks of ceftriaxone as well as at the end of the 12 weeks of blinded therapy. Not surprisingly, the improvement in all groups was the same. Adverse events were also documented, and as you would expect, those with doxycycline had a greater amount of photosensitivity and those taking clarithromycin-hydroxychloroquine experienced a greater likelihood of developing a rash. Interestingly, patients who took placebo had a significantly greater likelihood of reporting visual impairment due to their treatment (p=0.02). Maybe next time we should pack those placebos with vitamin A (or vitamin H, as the case may be…)!

All in all, pretty convincing evidence that long-term antibiotic therapy does not improve symptoms for those who report persistent symptoms due to Lyme disease. This is not to say these patients don’t experience symptoms, and some may be attributable to the damage done by Lyme disease (if they had it), but hopefully this will help put to rest the notion that an active spirochete infection necessitating long-term antibiotics is causing these symptoms. Critics may argue that there was no true placebo group since everyone got 2 weeks of ceftriaxone, but given that the study coordinators couldn’t guarantee that patient’s had been appropriately treated for Lyme in the first place, it would have been unethical not to treat patients with standard of therapy. Not only that, but the purpose of this study was to show that long-term antibiotic therapy isn’t needed, not that treatment of potentially acute Lyme disease is unnecessary. Others my say that since this study was performed in the Netherlands and American Borrelia burgdorferi spirochetes are clearly much hardier (because ‘Merica!), the study conclusions are clearly not applicable on this side of the pond. To that, I refer to USA for Africa’s 1985 hit single “We Are the World”.

Let the madness end.

QI CORNER

The Patient Safety and Quality Council will be meeting THIS THURSDAY at 5:30PM in the med res library. Join us! We'll be looking at successes and challenges of the paging project (with data!) and planning next steps. We can always put new QI projects on the table as well, so if you have ideas I hope you'll come.

Also, please join us on Wednesday at noon conference for a great M&M presentation with Lish. Then Thursday, we have a special QI noon conference in which we'll discuss paging culture and practices in a multidisciplinary setting as we're joined by the nurse paging champions from 4300. Be there for this great opportunity for bidirectional feedback and improvement!

**The CRQS position for 2017-2018 will be opening to applications soon. We have just found out from the VA that both rising and current SARs will be eligible to apply. Please contact me or Joel Boggan if you think this job could be right for you!**

CLINIC CORNER

PRIME family,

We can’t believe the year is coming to an end. Please stay tuned we will be having a lunch in PRIME clinic to say good-bye to our SARs. We appreciate all that you do for our Veterans and making the clinic the best that it can be.

If you see Stephanie Li, please congratulate her on her WOW award for the month of March.

Please check-in on the daily board when you arrive for your clinic session and keep an eye out for any updates from the facility. We will have a list of formulary changes and medications that are taken off the restricted drug lists that will make our lives easier.

To improve continuity please hand out your team specific cards to your patients, emphasizing to patients to make appointments with you or your team whenever possible. Also please use provided team spreadsheet that lets you know when you will be in clinic when entering return to clinic orders for your patients.

Lastly, life events! While we in PRIME don’t want to be nosy, we do want to know about wonderful (or even not-so-wonderful so we can help during trying times as well) things going on in your lives! Weddings, babies, all that stuff – pass the news along, and bring/send pictures!

PRIME clinic

From the Chief Residents

Grand Rounds

Friday, April 22 - Heme/Cellular Therapy, Dorothy Sipkins

Noon Conference

Date	Topic	Lecturer	Time	Vendor
4/18/16	What a medicine resident needs to know about Lung Transplants	Jamie Todd	2002/12:00	Domino's
4/19/16	MED-PEDS Combined: Med-Peds SAR Talk		2002/12:00	Bullocks
4/20/16	Resident M&M		12:00	China King
4/21/16	QI Patient Safety Noon Conference		12:00	Hungry Leaf
4/22/16	Chair's Conference		12:00	Firehouse

From the Residency Office

MEDICAID EXPANSION AND REFORM: A LEGISLATIVE FORUM: Tuesday, April 26, 2016

On Tuesday April 26 from 6:30 - 8:30 at NCCU there will be a gathering of local legislators and leaders from the Durham health sector (DUHS, Health Department, Senior PharmAssist) discussing Medicaid expansion and reform. It's a great opportunity to learn more about proposed changes that could impact many of our patients.

Please see PDF file attached at the end of this post for more information.

Schwartz Center Rounds

Title: “Life After Death: A Donor Mom Shares her Son’s Legacy”

Panelists:

Ms Delores Benton Evans - Donor mom and kidney recipient

Nancy Knudsen, MD - Co-Director, SICU

Debra Bird - Organ Donation Coordinator with Carolina Donor Services

Lindsay Stietzel - Family Support Coordinator with Carolina Donor Services

Wednesday, April 20, 2016, Noon - 1 p.m., Duke North 2002 Lecture Hall

About Schwartz Center Rounds:

All members of the Duke Medicine community are invited to attend an ongoing series of discussions called the Schwartz Center Rounds about the human side of patient care. Schwartz Center Rounds is a monthly interdisciplinary conference that offers all of us from no matter which discipline as well as non-clinicians who work closely with our patients a regularly scheduled time.... We are excited to have brought this program here to Duke and hope many of you will be able to join us on a regular basis.

Please contact, Lynn Bowlby, MD (lynn.bowlby@duke.edu), or Nathan Gray, MD (nathan.gray@dm.duke.edu) with questions. There is no need to RSVP, but we do recommend that you arrive early as food and seats are at a premium!

Office Hours for Dr. Zaas

Dr. Zaas will have the following office hours. Please feel free to stop by during these times and of course always feel free to reach out to her office to set up a meeting outside of these times if needed!

Monday - 3:00 p.m. to 4:00 p.m.

Thursday 10:00 a.m. to 11:00 a.m.

General Internal Medicine Career Night

Interested in a career in General Internal Medicine?

Thinking about primary care medicine, Gen Med fellowship or hospitalist medicine?

Envision working in academics, research, Quality Improvement

or a combination?

Come to Gen Med Career Night

Tuesday May 3, 2016

6:30-8:30pm

Gen Med Resident Library

Dinner from Nosh

Come ask questions for our panelists about their path and journey:

Kevin Shah, Claire Kappa, Sharon Rubin, David Edelman, Sonal Patel, Lance Teagen, David Gallagher and Daniella Zipkin

Please RSVP to Sharon.rubin@dm.duke.edu by May 2, 2016

Please see flyer at the end of this post

Charity Auction 2016

The Internal Medicine Residency program Charity Auction, benefiting Senior PharmAssist will take place Friday, April 29th, 2016 @ 7:00 p.m. at Motorco in Durham! Tickets will go on sale in early April. We look forward to seeing you there. Please see the flyer at the end of this post!

LiveSafe Mobile App

Duke is introducing a new mobile app called LiveSafe to put a powerful safety tool in the hands of the Duke community.

The app, available as a free download from Apple and Android app stores, enables smartphone users to submit real-time tips to Duke Police, virtually “SafeWalk” friends and family while traveling, place emergency calls, and access important resources for support.

You can find more information, including instructions on how to download the free app, on the DukeALERT website: http://emergency.duke.edu/notified/livesafe.

Book Club Survey

If you haven't been to one of our events yet, please support the Dept of Medicine book club project by taking a quick moment to fill out the survey below! Your participation is totally voluntary and anonymous, and the questions only takes ~2 minutes. You may remember filling this out before -- if you have, try to use the same identifier you used last time (if you can't find it, just make up a new one).
Here's the link: https://duke.qualtrics.com/SE/?SID=SV_bfJqGFkA6HScRq5
Feel free to email Laura.Caputo@duke.edu if you have any questions. Thanks so much for your participation!

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.

https://www.hr.duke.edu/pas/