Internal Medicine Residency News, August 22, 2016

What did I read this week?

Contributed by Alyson McGhan, MD

Chan FK, Leung Ki EL, Wong GL, et al. Risks of Bleeding Recurrence and Cardiovascular Events With Continued Aspirin Use After Lower Gastrointestinal Hemorrhage. Gastroenterology, Volume 151, Issue 2, August 2016, Pages 271-277. PMID: 27130815

Over the last year as a GI fellow, the pages about lower GI bleeding to the 9701858 pager were in abundance. With the recent USTPF recommendations for the use of aspirin for the prevention of cardiovascular disease and colorectal cancer, we will see increased use of aspirin therapy. Although the upper GI toxicity of aspirin is well known and studied, there is limited data on lower GI bleeding with aspirin.

This was a single center retrospective cohort study which included 295 patients with diagnosis of lower GI bleeding. Primary outcomes were recurrent lower GI bleeding, serious cardiovascular events, and death from other causes. Outcomes were compared between patients identified as aspirin users versus non users.

Results: Within 5 years, lower GI bleeding recurred in 18.9% of aspirin users (95% confidence interval [CI], 13.3%−25.3%) vs 6.9% of nonusers (95% CI, 3.2%−12.5%; P = .007). However, serious cardiovascular events occurred in 22.8% of aspirin users (95% CI, 16.6%−29.6%) vs 36.5% of nonusers (95% CI, 27.4%−45.6%; P = .017). Multivariable analysis showed that aspirin use was an independent predictor of rebleeding, but protected against cardiovascular events and death.

Conclusion: Among aspirin users with a history of lower GI bleeding, continuation of aspirin is associated with an increased risk of recurrent lower GI bleeding, but reduced risk of serious cardiovascular events and death.

Take home point: We recognize the importance of aspirin therapy for cardiovascular event prevention even in the presence of recent lower GI bleeding. Unlike upper GI bleeding, where we have PPIs to decrease the risk of upper GI tract bleeding in patients on aspirin, there is no medical therapies that mitigate the risk of recurrent lower GI tract bleeding. We will need to continue to prepare ourselves and accept the risk of recurrent lower GI tract bleeding in this population.

Clinic Corner: PRIME Clinic

Contributed by Sonal Patel, MD

Welcome to new interns and family practice residents! Please let us know how we in PRIME can be of assistance as you figure out your way in PRIME, in the VA, and in Durham. We have newly printed business cards for you to hand out to your patients so they can know all the members of your team.

Welcome also to Todd Marquez, DPT, who is our new in-house physical therapist in PRIME on Wednesday and Friday afternoons. Todd is available to see your patients with you for an evaluation, to see patients for routine scheduled PT followups, or to discuss/review physical exam tips with you. Please meet him and utilize his skills!

The VA at the national level is doing another round of PIV card enforcement which went into effect Friday 8/18. The Durham VA has been actively trying to arrange exemptions for trainees. If you are having trouble and have a Windows computer at home, you can pick up a PIV card reader in C8016a (Adam Banks’s office). We know this is vital to your taking care of your patients and we will work with you to help troubleshoot any issues that we can help with. 

Matt Atkins has crunched our continuity numbers for us and we will post them for you to review if you like. 51% of our visits were scheduled with the patient’s PCP (range: 36%-85%) and 83% were with the primary team. We are actively working to increase those numbers as we know continuity is important to patients and to you. Some of the low continuity numbers were with residents with smaller panel sizes, which will change as we take on more new patients which enroll at the VA every day.

We have had a couple of didactic sessions with our interdisciplinary pain management group. If you have complicated pain patients, this team is available to you to discuss management strategies including how best to have these challenging conversations with patients. 

As always, feel free to come anytime to me or Leigh with any questions or concerns you have.

From the Chief Residents

From the Residency Office

Have You Logged Your Duty Hours??

With the start of the 2016-17 academic year, the residency program is asking all house staff to log their duty hours on a daily basis.  This will allow us even closer oversight of duty hour compliance across the program.  In order to use the MedHub mobile Duty Hour app, you will need to know your actual MedHub log in as it will not accept your NetID/password log in.  If you have forgotten you main log in, please go to the main MedHub site, and select "Forgot my password."  You will then be able to re-set it via email.  Lynsey Michnowicz will be sending reminders each Wednesday to those who have not yet logged their duty hours for the week.  Thank you in advance for your attention to this task!

Office hours for program leaders

Please feel free to stop by during these times and of course always feel free to reach out to program leaders to set up a meeting outside of these times if needed.

• Aimee Zaas: Every Monday from 3:00 p.m. to 4:00 p.m. and Thursday from 10:00 a.m. to 11:00 a.m.
• Dani Zipkin: Wed., Aug. 31 from 2:00 p.m. to 3 p.m. in VA Prime clinic; Wed., Sept. 7 from 11 a.m. to 12 p.m. in Pickett Rd.

Global Health-Internal Medicine Residency Program recruiting eligible candidates

Internal Medicine Residents who have successfully completed PGY1 are eligible to apply for the Duke Global Health Pathway for Residents and Fellows, an extended residency that leads to a Master of Science in Global Health and a total of nine months providing clinical care and conducting mentored research at a Duke University international partner site. Visit www.dukeglobalhealth.org for an in-depth description of the core curriculum including sites, global health competencies, and program requirements as well as application instructions. Watch past global health internal medicine resident John Stanifer discuss his decision to pursue global health training at Duke in this video. Applications will be accepted on a rolling basis until Sept. 1, 2016. 

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/

Upcoming Dates and Events

• August 31 - Stead Trivia Night (Warren Society)
• September 1 - deadline for applications to the Global Health Pathway
• September 7 - Special lecture by Duke Nobel winner Paul Modrich. Registration is required.

• September 7 - Chief Happy Hour w/ Interns - Hope Valley Brewing

• October 8 - Stead Tread 5K Fun Run (Kempner Society)

Useful links

• GME Mistreatment Reporting Site
• Duke Health Influenza Policy
• http://duke.exitcareoncall.com/
• Main Internal Medicine Residency website
• Main Curriculum website
• Department of Medicine
• Confidential Comment Line Note (All submissions are strictly confidential unless you chose to complete the optional section requesting a response.)

Opportunities

• https://www.phs.wakehealth.edu/public/edu.cfm
• www.FloridayPhysicianWork.com
• www.bidmc.org/CentersandDepartments/Departments/BIDHC
• http://www.careermd.com/employers/latestbulletins.aspx