From the Director
Hope everyone was able to enjoy a little bit of the last few days of summer this week. Hard to believe how quickly this year is going..I’m excited to hear about all the interviews our SARs are getting for fellowships, and am gearing up to open ERAS for intern applicants in a few short weeks. Pretty soon, we will be reminding you to get your flu shot – it’s mandatory for employment without an approved health exemption, so be on the lookout for reminders.
We had a fun JAR dinner this week, checking out the new recruitment dinner location Gonzo’s Tacos-n-Tequila at 604 W. Morgan – thanks Kara Johnson, Zach (Wegermann) Johnson, Vedran Oruc, Brian Andonian and Bill McManigle for joining me! Also kudos this week to our ongoing excellent SAR talks by Amy Newhouse, Andrea Sitlinger, Ryan Jessee and Paul St. Romain. Good thing Andrea gave her talk on Monday – pretty soon after we welcomed the newest member of the Duke family! Congrats to Andrea and Justin. Other kudos come from Jesse Tucker to the “bro-nation” VA CCU crew of Eric Yoder and Andy Mumm as well as to the NF crew of Peter and Rachel Hu, Lauren Ring and Stephanie Li from fellow night JAR Jenny Van Kirk for awesome teamwork and unselfishness in order to provide amazing patient care. Zach Wegermann also gave an outstanding Chair’s Conference with Haley Peterson getting the diagnosis. Additional kudos to Joanne Wyremnbak from Dr.Decastro for doing an amazing job on Night Float this past Saturday. Kudos also to Kristen Glisinski and Alana Lewis from psychiatry intern Ahmad Ali for their fantastic help on his night float rotation.
Many many thanks to our outstanding ACRs – Sarah Goldstein, Marc Samsky-Goldstein and Matt Atkins. Welcome to our new ACRs Rajiv Agarwal, Ben Peterson and Alan Erdmann.
ITE’s started last week – thanks to the entire staff for keeping this process running smoothly. Let us know if you have any questions about date or location!
This week’s pubmed from the program goes to Eric Black-Maier for his upcoming presentation at the AHA Scientific Sessions in Orlando - Indications and Outcomes Following Transvenous Extraction of ICD versus Pacemaker Leads
Have a great week
Aimee
What did I read this week?
Submitted by Dr. Daniella Zipkin
This week, I scrapped the article I initially planned to discuss because something interesting popped up in the NEJM – Screening for Occult Cancer in Unprovoked Venous Thromboembolism (Carrier et al., N Engl J Med 373;8. August 20, 2015). On Thursday, I saw a patient in clinic with Sarah Nouri – He is a 65 year old man with an unprovoked DVT 9 months prior. Duration of anticoagulation hadn’t really been decided. We debated risks and benefits of long-term anticoagulation (no PUD or other bleeding risks, normal renal function, great adherence) and decided to continue anticoagulation lifelong, transitioning to Rivaroxaban if Medicaid will allow it. Looking at cancer screening, PSA was 0.18 (tested because of the DVT), and colonoscopy up to date. In the back of my mind, as with all cases of unprovoked thromboembolism, I thought “how worried should we be about an occult malignancy?” and “how much more workup is needed?”. Boom, here’s a randomized controlled trial. Let’s look at it:
- Population: Unprovoked VTE patients referred to a thrombosis clinic in Canada within 21 days of Dx (not sure if that’s a major selection filter, altering typical patient characteristics in this group, or if that sort of referral is common in Canada?).
- Randomization: Done with random number tables, with permuted blocks of 2 or 4 with stratification according to center and age under or over 50. What does all that mumbo jumbo mean? Permuted blocks keep the numbers even at each clinical site, so that the site itself doesn’t become a confounder. Check. Stratification evens out the ages of patients in both groups because age itself is the biggest confounder when it comes to presence of cancer. Check. Nicely done.
- Intervention: Limited cancer screening PLUS enhanced CT of the abdomen and pelvis. Limited cancer screening included H&P, CBC, Chem 12, CXR, breast exam or mammo in women over 50, Pap in women under 70, prostate exam or PSA in men over 40. The CT was special: bowel prep, virtual colonoscopy, gastroscopy, enhanced liver and pancreas protocol, enhanced CT of distended bladder.
- Comparison: Limited cancer screening only.
- Follow-up: One year
- Primary Outcome: Newly diagnosed cancer in patients with a negative screening for occult cancer (i.e. cancer that was found by the CT or found otherwise).
- Results: 854 patients, 64-70% male, 92-94% white, with mean age 54, 67% with DVT, 33% PE, 12% both. 14 patients (3.2%) in limited screening and 19 patients (4.5%) in limited screening plus CT received a new cancer diagnosis (difference is not statistically significant). 4 of the 14 were missed by limited screening, and 5 of 19 were missed by expanded screening. Also, “patients with unprovoked VTE and a negative screening result for occult cancer with a limited screening strategy had an incidence of cancer diagnosis of 0.93% over one year, which is similar to the incidence reported in patients without VTE”.
- Conclusions: A limited cancer screening strategy may be adequate for patients with first unprovoked VTE.
- CAVEAT: This study might have been under-powered. They aimed for a sample size based on a projected incidence of new cancers of 6.1% at time of diagnosis and 10% by 12 months based on prior data, but they only reached 3.2% to 4.5% at 12 months. In other words, this study may have missed a true difference between screening strategies. When you make conclusions based on fewer outcome observations than planned, power is compromised – the risk of concluding there is no difference when a difference actually exists (Type II error) is higher.
Back to this patient – should we add other testing? It is likely that we don’t need to – pursuing age and gender appropriate cancer screening at the time of unprovoked VTE is likely sufficient.
QI CORNER
Exciting announcement this week! Lish Clark and I are excited to announce a competition for High Value Care Quality Improvement Project proposals. We want YOU to work in teams to come up with a QI project that addresses high value care, make a plan for how you would implement your project and measure your success, and you will be in the running to receive mentorship and funding for your statistical support! To sweeten the deal, Lish has obtained a $5000 grant from the North Carolina ACP to support this competition, so our top three applicant teams will win a CASH PRIZE in addition to the funding for stats. Quality improvement is a team sport and so each team should be composed of at least three individuals. This ensures that the implementation phase starting in January 2016 will be able to continue through your different schedules and rotations. Please feel free to partner with other disciplines (nursing, PT, pharmacy, other departments) and discuss ideas with your attendings as you formulate your proposals. The deadline for submissions will be October 19th, 2015. See the attached flier (bottom of post) for instructions on formatting and submitting your proposal.
In other news, the next meeting of the Patient Safety and Quality Committee will be on THURSDAY Sep. 10th at 5:30pm in the Med Res Library. Join us to identify potential projects and team members for your HVC project proposal! Dinner will be provided.
CLINIC CORNER
No Clinic Corner this week. This feature will return on Tuesday, 9/8/15.
From the Chief Residents
Grand Rounds
Friday, September 4 - Gastroenterology, Dr. Manal Abdelmalek
Noon Conference
| Date | Topic | Lecturer | Time | Vendor |
| 8/31/15 | SAR Emergency Series: Syncope |
Ben Peterson |
12:00 | Domino's |
| 9/01/15 | SAR Emergency Series: COPD Exacerabation |
Eric Yoder |
12:00 | Mediterra |
| 9/02/15 | K-Grant and Career Development (ITE) |
Aimee Zaas |
12:00 | China King |
| 9/03/15 | IM-ED Combined Conference: Pulmonary Embolism |
Chiefs(ER and IM) |
12:00/2002 | Subway |
| 9/04/15 | Chair's Conference (ITE) | Chiefs | 12:00 | Firehouse Subs |
From the Residency Office
BLS Blitz - November 2015
Just a reminder that the bi-annual BLS Blitz is coming up in November. The flier posted at the end of this blog has the dates. REMEMBER - Duke only holds BLS classes during the November and March blitz each yer, so if your BLS is expiring before March, PLEASE sign up for one of the dates in November!!
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 Residency, 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.
Please visit our website for an in-depth description of the core curriculum including rotations, global health competencies, and program requirements as well as application instructions:www.dukeglobalhealth.org
Watch current global health resident John Stanifer, MD, discuss his decision to pursue global health training at Duke:
Send all application materials electronically to sarah.brittingham@duke.edu.
Applications accepted on a rolling basis until October 1, 2015. Offers will be made in November.
STEAD TREAD 2015!
Wanted to take a second to invite you all to come support the Stead Tread, the Kempner Stead Society's annual charity event, which benefits Lincoln. It was a blast this year, and since we're due for some good weather this year, I'm sure it will be even better this time around.
Some additional information:
Please access the Stead Tread 2015 website (http://www.steadtread.org) for additional information, to securely register ($25), or make a donation
Race date/time: Saturday, September 12th, 2015 at 10:00AM (registration from 8:45-9:45)
Race location: American Tobacco Trail, starting at Solite Park on Fayetteville Road in Durham (https://www.google.com/maps/place/Solite+Park/)
Race beneficiary: Lincoln Community Health Center (and all Lincoln patients walk/run for free)
Your $25 registration fee includes an official Stead Tread 2015 T-shirt – shirts are going fast, so register ASAP to reserve your size!
Participants are welcome to run or walk, and strollers are permitted - kids under 12 walk/run for free (but should be registered by their parent/guardian)
In case you cannot make the race this year, donations can be made securely through our website
Thank you for considering supporting the Stead Tread – we really hope to see you there this year. For any questions, please contact us through our website (http://www.steadtread.org), via e-mail at steadtread5K@gmail.com, or by replying directly to me (Matt Crowley, M.D. <matthew.crowley@dm.duke.edu>).
Book Club
Every few months, the Department of Internal Medicine Book Club joins together residents, fellows, and attendings to discuss the humanistic side of medicine through reading. Please join us for our first event of this academic year on Tuesday, September 8th from 5:30 - 7:30 pm in the Faculty Lounge! This time we're reading Changing the Culture of Academic Medicine by Linda Pololi, which tackles the changing roles of women and minorities in medicine and what ground is still left to cover.
The best news: all are welcome to attend, and thanks to help from the Program for Women in Internal Medicine and the Trent Memorial Foundation, this year books are free to ALL participants who RSVP (while supplies last)! Food and drinks will be provided.
For more questions or to RSVP, please email laura.caputo@duke.edu to reserve a spot now! We're looking forward to seeing you all there!
Thank you!
Laura M. Caputo, MD
Hospital Medicine, Durham VA Medical Center
Upcoming Dates and Events
September 12 - Stead Tread
December 12 - DOM Holiday Party
Useful links
https://intranet.dm.duke.edu/influenza/SitePages/Home.aspx
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
http://www.ad001.info/blasts/CKS/CKS15_05431/CKS15_05431.html