From the Director
Hey everyone! Hope you had a good week. We had fantastic
flu shot blitz participation - competition results to follow soon! Will Kirby Society be the champs again? Stay tuned!
Block 3 for the interns ended today! 1/4 of the way there- pretty amazing! Thanks to everyone for your hard work. Chiefs and SARs had fun at Tyler's Friday night. Coming soon is chief JAR and chief intern nights. And hopefully
Hassan Dakik was able to direct everyone to Turkey Bowl practice. If you don't get the joke, watch
Matt Chung's movie. Thanks also to
Schuyler Jones for guest precepting JAR
Lindsay Anderson's outstanding chairs conference.
Get ready...it's almost the first Doctoberfest! Fun, competition, kudos, community service.....see below for details.
This weeks Pubmed from the program goes to SAR
Paul Park who will be presenting at the
Eighth Annual CFAR Fall Scientific Retreat on September 27, 2012.
Have a great week! Aimee
What Did I Read This Week (Dave Butterly, MD)
[box] Sirolimus and Secondary Skin-Cancer Prevention in Kidney Transplantation, Euvrard et al NEJM 367: 329-339, 2012 [/box]
This article appeared in the July issue of
NEJM and reports on the efficacy of converting transplant patients with skin malignancies from standard immune suppression to a Sirolimus based regimen. I was particularly interested in this topic due to a patient I am currently seeing with metastatic SCC of the skin whose oncologist sent him back to our clinic for our recommendations regarding immune suppression. He is 11 years out from transplant with excellent allograft function. The question is whether altering the immunosuppression can have a positive impact on the tumor?
With current immunosuppression ( Tac, MMF, and Prednisone with or without Induction) rejection rates now are in the 10-15% range with one year graft survival approaching 90-95%. The "cost" of this success and such potent inhibition of the immune system is increased rates of infection (CMV, Polyoma, and EBV related PTLD) and malignancy. Squamous cell carcinoma and Basal cell carcinomas account for greater than 90% of skin malignancies in transplant recipients. The incidence increases with duration of immune suppression and ultimately affects 50% or more of recipients. These cancers appear to be more aggressive than in non-immunosppressed individuals and both recur locally and metastasize at a higher rate. To a large extent, skin cancers result from a decrease in usual tumor surveilance, but whether differences in immunosuppressant properties may ameliorate tumor progression is not entirely known. A newer class of immunosuppressants, the Tor-inhibitors (Sirolimus and Everolimus), may have specific properties that may be advantageous. For example, Everolimus has been used for treatment in metastatic renal cell carcinoma and in neuroendocrine tumors. These authors investigate whether converting to a Rapamycin based regimen in transplant recipients with skin carcinoma may decrease the risk of further skin cancers.
Kidney transplant patients who developed at least one squamous cell carcinoma and had stable allograft function were eligible for the study. In this multicenter trial, patients were randomly assigned to continue current immune suppression or convert from their CNI (Cya or Tac) to Sirolimus. Immunosuppressant regimens at time of randomization were similar to ours and included a CNI along with either MMF or Azathioprine along with Prednisone. Patients were randomized in a 1:1 fashion to either Sirolimus or to continue current therapy. The protocol is shown in figure 1: 64 patients were assigned to Sirolimus arm and 56 continued their current regimen. Demographics are shown in table 1. The mean age was 62-63 and patients had been on immune suppression for more than 10 years ( 148 vs 143 months). 55% in each group had experienced a single lesion prior to enrollment and 45% had multiple lesions.
Survival free of Squamous Cell Carcinoma was reduced. Primary outcome is shown in Figure 2. New Cutaneous SCC developed in 14 (22%) on Rapa vs 22 (39%) in the CNI group. Relative risk 0.56. This effect was most pronounced among recipients with only a single SCC prior to randomization and less so in recipients with more than 1 lesion prior to entry into study ( Figure 2 B and C). There were no graft losses and no episodes of acute rejection. However, majority of patients converted into the Sirolimus group did experience some side effects of the medicine. In conclusion, conversion to Sirolimus may reduce the risk of secondary skin malignancies in this cohort. Obviously, the risks of conversion will need to be weighed individually with these patients, but conversion to Sirolimus may offer some promise in these patients.
[hr]
From the Chief Residents
Grand Rounds
| Date |
Division |
Speaker |
Title |
| 28-Sep-12 |
Endocrine |
Dr. Jen Perkins |
Thyroid Disorders |
Please Note: A special M&M conference that will involve Medicine, General Surgery, and Orthopedics discussing a recent case of necrotizing fasciitis will be held on 10/3/12 from 7-8am in 103 Bryan Research Building.
Anybody interested should plan to attend, and senior residents on Duke General Medicine are strongly encouraged to attend. DRH AM report will be cancelled in lieu of this conference so that amb people can go to this conference.
Thanks –Jeff, Nicole, Jason
Noon Conference
| Day |
Date |
Topic |
Lecturer |
Time |
Vendor |
Room |
| Monday |
9/24 |
Outpatient Management of Diabetes |
Diana McNeill |
12:00 |
Chick-fil-A |
2002 |
| Tuesday |
9/25 |
COPD |
Peter Kussin |
12:00 |
Dominos |
2002 |
| Wednesday |
9/26 |
Movement Disorders |
Mark Stacy |
12:00 |
The Pita Pit |
2002 |
| Thursday |
9/27 |
HIV Part # 1 |
Chuck Hicks |
12:00 |
Papa John's |
2002 |
| Friday |
9/28 |
Research Conference |
|
12:00 |
Panera |
2002 |
The Influenza Vaccine Blitz Is On!!
Our goal is 100% participation!
From Sept. 24-28, you can get your flu shot on Duke Hospital’s first floor outside of 1700A (in the connector hallway where the Mars Gallery display cases are located) at the times noted below. Bring your valid Duke ID.
Kick-Off Day Last Week Was a Big Success ! Upcoming opportunities are:
Thursday, Sept. 20: 7:30 a.m.-3:30 p.m.
Friday, Sept. 21 7:30 a.m.-3:30 p.m.
Monday, Sept. 24 7:30 a.m.-3:30 p.m.
Tuesday, Sept. 25 7:30 a.m.-3:30 p.m.
Wednesday, Sept. 26 7:30 a.m.-3:30 p.m.
For a full vaccination calendar, which includes listings for off-site locations, visit: http://intranet.dukemedicine.org/influenza/
[divider]
From the Residency Office
Duke Medicine Fleece - Time To Place Your Order
First, a BIG thank you to
Matt Chung for getting this project launched last year. Now that he is ACR, and being kept busy by his Chief Resident, we thought it best for the Med Res Office to lend a hand and coordinate the fleece order. We elected to use this survey to collect the required information. Use the following link to place your order and for further details - but to be sure, note that this opportunity is open for ONLY TEN DAYS, closing down on Wednesday, October 3, 2012.
https://www.surveymonkey.com/s/MED_RES_FLEECE_2012
Doctober Fest is Coming:
Be on the look out for "Doctober Fest", the first of a new annual event!
- The highly anticipated Duke Gnome will be arriving next week. Watch for his travels around the hospital, but in the meantime, we invite you to participate in our “Name the Gnome” contest. We will have a sheet posted in the Med Res office to list your suggestions. The names will then be voted on and the winner will be announced in the 9/30 Weekly Updates.
- Food - Can't celebrate with out consuming calories, and the month of Doctober is no exception. Lauren is working her magic, so be on the lookout for her goodies.
- Residency Program Wall of Recognition - to be posted in the Med Res Office - more details in next week's issue
- Stead Groups - various options are being considered to celebrate
The culmination of the month is the annual kick of to the recruiting season which will be held on October 25th
Now Accepting Applications for Global Health Elective Rotations
Developing the next generation of globally educated, socially responsible healthcare professionals dedicated to improving the health of disadvantaged populations.
The Hubert-Yeargan Center for Global Health (HYC) is now accepting applications for Global Health Elective Rotations for July 2013 and March 2014. Application is open to residents from Departments of Medicine: Internal Medicine (PGY 2); Med-Peds (PGY 3) and Med-Psych (PGY 4). Access the application form and FAQ at
http://dukeglobalhealth.org/education-and-training/global-health-elective-rotation.
What factors should I consider when deciding which sites are my top choices?
You should think about what you are hoping to get out of the experience. Many sites offer excellent hands on clinical experience. Other sites offer opportunities for research, teaching, or learning about other health care systems.
Application deadline is October 5, 2012. Interviews will be held between October 8 and November 7. We encourage you to speak with past participants to get a better idea of what daily life is like on the wards of your top sites. For more information, contact Tara Pemble, Program Coordinator at
tara.pemble@duke.edu or 668-8352.
Application deadline is October 5, 2012. Interviews will be held between October 8 and November 7. We encourage you to speak with past participants to get a better idea of what daily life is like on the wards of your top sites. For more information, contact Tara Pemble, Program Coordinator at
tara.pemble@duke.edu or 668-8352.
MKSAP - Available to Loan
Dr. Alex Wong (Cardiology) was kind enough to donate a hard-copy of MKSAP 16 Part A to our office. We will make them available to residents to borrow as needed. Each book will be available on a check-out basis and can be kept for a maximum of 2 weeks. We ask that you only check out one book at a time. Please see
Jen Averitt in the MedRes office if you are interested in borrowing any of these materials.
Project Homeless Connect (from Julia Gamble, NP)
Project Homeless Connect is a one day, one-stop event that brings together services (among other things housing, benefits, healthcare, and haircuts) and people who are in need. It takes place at the
Durham Bulls ballpark from 10-4 pm on October 11. Last year the Lincoln Community Health Center Healthcare for the Homeless Clinic and Duke's Internal Medicine Department provided health consultations to 25 people in need. A sign up sheet will be posted in the Med Res Office for those who are able to help provide coverage.
An Important Note About Coverage During ITE
As you are all aware, the ITE schedule starts on Friday, October 5. The latest schedule with revisions is posted in the ITE folder on MedHub and each individual schedule on Amion and MedHub. Several interns and residents are taking the ITE while on inpatient teams in all three hospitals. To ensure that coverage is maintained, residents on Pre-Call will need to stay on duty until the resident taking the exam returns to be On Call.
Dates to Add to Your Calendars /Contact Information/Opportunities
Sept 19-20 Flu Shot BLITZ
8831_FLU_Clinic_Template_Final
Oct 25 Recruiting Kick Off Event
December 1 DoM Holiday Party
Opportunities
Hospitalist Position in Tennessee and Georgia
EAST TX IM
Useful links
With current immunosuppression ( Tac, MMF, and Prednisone with or without Induction) rejection rates now are in the 10-15% range with one year graft survival approaching 90-95%. The "cost" of this success and such potent inhibition of the immune system is increased rates of infection (CMV, Polyoma, and EBV related PTLD) and malignancy. Squamous cell carcinoma and Basal cell carcinomas account for greater than 90% of skin malignancies in transplant recipients. The incidence increases with duration of immune suppression and ultimately affects 50% or more of recipients. These cancers appear to be more aggressive than in non-immunosppressed individuals and both recur locally and metastasize at a higher rate. To a large extent, skin cancers result from a decrease in usual tumor surveilance, but whether differences in immunosuppressant properties may ameliorate tumor progression is not entirely known. A newer class of immunosuppressants, the Tor-inhibitors (Sirolimus and Everolimus), may have specific properties that may be advantageous. For example, Everolimus has been used for treatment in metastatic renal cell carcinoma and in neuroendocrine tumors. These authors investigate whether converting to a Rapamycin based regimen in transplant recipients with skin carcinoma may decrease the risk of further skin cancers.
Kidney transplant patients who developed at least one squamous cell carcinoma and had stable allograft function were eligible for the study. In this multicenter trial, patients were randomly assigned to continue current immune suppression or convert from their CNI (Cya or Tac) to Sirolimus. Immunosuppressant regimens at time of randomization were similar to ours and included a CNI along with either MMF or Azathioprine along with Prednisone. Patients were randomized in a 1:1 fashion to either Sirolimus or to continue current therapy. The protocol is shown in figure 1: 64 patients were assigned to Sirolimus arm and 56 continued their current regimen. Demographics are shown in table 1. The mean age was 62-63 and patients had been on immune suppression for more than 10 years ( 148 vs 143 months). 55% in each group had experienced a single lesion prior to enrollment and 45% had multiple lesions.
Survival free of Squamous Cell Carcinoma was reduced. Primary outcome is shown in Figure 2. New Cutaneous SCC developed in 14 (22%) on Rapa vs 22 (39%) in the CNI group. Relative risk 0.56. This effect was most pronounced among recipients with only a single SCC prior to randomization and less so in recipients with more than 1 lesion prior to entry into study ( Figure 2 B and C). There were no graft losses and no episodes of acute rejection. However, majority of patients converted into the Sirolimus group did experience some side effects of the medicine. In conclusion, conversion to Sirolimus may reduce the risk of secondary skin malignancies in this cohort. Obviously, the risks of conversion will need to be weighed individually with these patients, but conversion to Sirolimus may offer some promise in these patients.
Application deadline is October 5, 2012. Interviews will be held between October 8 and November 7. We encourage you to speak with past participants to get a better idea of what daily life is like on the wards of your top sites. For more information, contact Tara Pemble, Program Coordinator at tara.pemble@duke.edu or 668-8352.