From the Director
A big thanks to all for your fantastic work during a VERY busy week at all 3 hospitals! The highlight of this week was certainly our FANTASTIC Charity Auction, held on Friday night at the Full Frame Studio at the American Tobacco Campus (Durham… it’s awesome!). Carling Ursem, Christine Bestvina, Jen Chung, Allyson Pishko, Jessie Seidelman, Adrienne Belasco and Andrea Sitlinger worked incredibly hard over the past few months to put together an absolutely fantastic evening, with great silent and live auction prizes. We couldn’t have done it without the support and commitment of Lynsey Michnowicz, Erin Payne, Lauren Dincher, Jen Averitt and Randy Heffelfinger before, during and after the evening. Our fearless emcee Tony G was hilarious as always, and the chiefs were remarkably good sports about getting pies in the face (I’m sorry Joel, but Ann Marie made me do it!). Hats off to Scott Evans who allowed Rob Harrison to pie him (with a “used” pie) as a symbolic representation of 1010 vs. the ED. All in good fun, we promise. Word has it that Scott was incredibly helpful in the planning of the auction as well. Overall, this auction had the BEST faculty attendance of any auction in history, as well as fantastic resident participation…thank you to everyone who donated, attended, bought, and supported our causes…SeniorPharmAssist and the DOC Patient Fund.
Other kudos this week go to Kevin Trulock from the venerable PSK for outstanding family communication in the MICU, to Claire Kappa for unsolicited coverage of a friend on night JAR, and to Brian Miller and Marianna Papademetriou for outstanding SAR talks. Kathy Andolsek from GME sends kudos to Nick Rohrhoff, Liz Campbell, Brian Kincaid and John Wagener for their assistance in hosting the congressional staffers who were visiting to learn more about GME. She tells me that the staffers were VERY impressed with our their knowledge, compassion and ability to discuss the issues affecting GME. Lynn Bowlby sends kudos to Alex Clark, Suma Das and Bronwen Garner for outstanding work at DRH!
Another HUGE KUDOS to Lindsay Boole for winning the ACP National Abstract Competition…Lindsay presented the data from our QI/PS Afternoon Report held on Thursdays at Duke with Jon Bae. Fantastic work Lindsay. Look for her work to be featured in the Med Res Library soon..her work features a great example of how all of our SARS participate in ROOT CAUSE ANALYSIS and help solve the safety issues affecting our patients.
Hold tight….the schedule will be released THIS WEEK!! We are making a couple final edits and you should receive your JAR/SAR schedule on Tuesday. Thank you VERY MUCH to Krish, Stephen and Vaishali for your hard work on such an important but time consuming part of being chief.
What’s coming up??? This week we have the CPC on April 22nd at THE PIT!!! Please RSVP to the evite if you are planning on attending…a great crowd has already signed up. Next is the AMAZING THIRD ANNUAL STEAD TREAD — time to get your running shoes on, get some exercise and support a great cause (the Lincoln Community Health Center!). Sign up at www.steadtread.org….ASAP to be sure to get a T-shirt!! Can you be faster than Meredith Clement? Can Brian Schneider run with a jogging stroller and still beat you? Blink and miss Ethan (Bowlby) Ready? Whether you run faster or slower than your program director, we would love to see you there!
This week’s pubmed from the Program goes to John Wagener for his article with Sunil Rao! “Strategies to Avoid Bleeding in the Management of ACS.” Medscape Online. Released July 30, 2013.
Have a great week!
What Did I Read This Week?
Lichtman JH, Froelicher, Blumenthal J et al. Circulation 2014;129:1350-1369Submitted by Sarah Rivelli , MD
A variety of types of studies, including prospective studies, systematic reviews, and meta-analyses have documented an association between depression and increased morbidity and mortality in a variety of cardiac populations. However, whether or not depression should be considered as a recognized risk factor for poor prognosis in patients with acute coronary syndrome has remained controversial. The purpose of this Scientific Statement by the American Heart Association was to review available evidence and conclude on whether depression should be elevated to the status of a risk factor for patients with acute coronary syndrome.
A systematic literature review was performed with clearly defined search strategies and terms. Articles were limited to the English language and were reviewed in a consistent manner. Search terms for the risk factor of interest included depression, depressive symptoms, dysthymia, mood or depressive disorder. Adverse medical outcomes after acute coronary syndrome included all-cause mortality cardiac mortality, and composite outcomes for mortality and nonfatal events.
The strength, consistency, independence, and generalizability of the studies were assessed. Studies included were those with prospective design, >=100 patients, systematic established assessment of depression and included a nondepressed comparison subgroup.
A total of 53 studies were included
Depression and all-cause mortality
Out of 32 such studies, 17 reported a significant risk-adjusted association between depression and elevated all-cause mortality and an additional 4 studies found similar results in unadjusted analyses.
Depression and Cardiac Mortality
Seven of 12 studies reported a significant risk-adjusted association and one reported a significant unadjusted association between depression and increased cardiac mortality.
Depression and composite of mortality and nonfatal events
Out of 22 studies, 15 reported a significant risk-adjusted association and 2 additional studies reported a significant unadjusted association between depression and a composite of mortality and nonfatal events. These studies represented analysis of 14 of 18 unique cohorts.
Four meta-analyses were also reviewed. The overall unadjusted effect of depression on all-cause mortality was 1.8-2.6 and 2.3 to 2.9 for cardiac mortality.
The authors did a good job of systematic literature search and evaluating the quality of the studies included. They took care to consider that some publications were based on the same cohort of patients, which could lead to overstating of the results. Moreover, they excluded studies with small sample sizes, which tend to lack sufficient power to detect differences and may have false negative results. The inclusion of English language-only studies may have biased towards positive studies as negative studies may be more likely to be published in a language other than English.
Studies were heterogenous with respect to sample demographics, measurement of depression, length of follow-up, and the other risk factors included in multivariate models which limits the results. Covariates were not necessarily consistent across studies, and the severity of a co-occurring risk factor was not always included. The variability in covariate adjustment may contribute to the overestimation of depression as a risk factor above and beyond established post-ACS risk factors. The strength and precision of the positive studies varied, however only a minority of studies published were negative.
Should we screen for depression post-ACS? Yes, especially because it is an important condition to treat in its own right.
Will treating depression post-ACS save lives or prevent cardiac events? We don’t know that yet. There is really only one study to date adequately powered to detect the effect of depression treatment (ENRICHD) and in intention-to-treat analysis, it was negative. However, post-hoc analyses suggested that adequate treatment of depression leads to better survival, which is intriguing.
It will be interesting to see how we integrate this Scientific Statement in clinical practice.
The “Clinic Corner – VA PRIME” (submitted by Sonal Patel, MD )
News from the VA…
Well the VA is abuzz with rumors that we will soon be visited by our friends at The Joint Commission (formerly known affectionately as JCAHO). I wanted to take a minute and discuss what The Joint Commission is and the invaluable service it provides. Founded in 1951, The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in health care . It is an independent, not-for-profit organization that accredits and certifies more than 20,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. Their mission statement is to “To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.”
To earn and maintain the The Joint Commission’s Gold Seal of Approval, an organization must undergo an on-site survey by a Joint Commission survey team at least every three years. (laboratories must be surveyed every two years). Driven by a commitment to honor America’s Veterans by providing exceptional health care that improves their health and well-being, the Durham VA Medical Center is readying itself for our upcoming visit.
What that means for you and me: The 2014 Hospital National Patient Safety Goals include:
In addition, please remember if you are approached by any of the surveyors and you do NOT know the answer to the question, please state verbatim( if you can), “I do not have the answer but I know where to find it” and then come to either myself or Renee Shopshire or one of the nurses.
The Durham VA is continuously working to strengthen the quality and safety of healthcare offered at our facilities. We look forward to a great visit from The Joint Commission and welcome any suggestions, improvements that are recommended to provide exceptional care to our veterans. Thanks and please be aware and ready for visitors soon….QI Corner (submitted by Joel Boggan, MD)
Resident M&M Noon Conference Stephen Bergin is going to be leading us through a case on Thursday, the 24th, at noon.
We Follow-Up project Here are the actual numbers from your hard work contacting your patients about lab results and documenting it this year during the first half of the year and since the holiday break.
DOC: Increased from 70% during the first half of the year to 76% during the second half
Pickett: Increased from 89% to 94%
PRIME: Increased from 84% to 92%
From the Chief Residents SAR Talks
April 22: Sarah Wingfield, Matt SummersGrand Rounds
Dr. John Williams
Topic: Shared Decision MakingNoon Conference Date Topic Lecturer Time Vendor Room 4/21 MKSAP Mondays – ID Chiefs 12:00 Subway 2002 4/22 SAR TALKS Sarah Wingfield / Matt Summers 12:00 Pita Pit 2003 4/23 Essentials of Antifungal Therapy Zaas 12:00 China King 2002 4/24 M and M Bergin 12:00 Domino’s 2001 4/25 Research Conference 12:00 Panera 2002 From the Residency Office STEAD TREAD IS COMING!
For those of you who haven’t already registered, wanted to take a second to invite you all to come support the Stead Tread, Kempner Society’s annual charity event. 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:
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.
Thanks, MattParking Question
Last week we received the following question regarding parking on the confidential comment line:
Will interns be moved to the PG2 parking deck in July? (This is where current JARs and SARs park). My hope is this will be the case, as parking in the research drive parking garage with all the construction has been a huge hassle this year?
Answer: No definitive answers yet, but we anticipate that the incoming interns will also be assigned to the research drive lot. We are not aware of any plans to try and relocate anyone to PG2.
We will share any further updates as they are received.Who Cleans Up After You?
Did you know that if you chose to leave a mess behind you at noon conference, or at ANY time in the Med Res Library or office, it is the office staff who most often pulls things back together and makes it look presentable. And in case you were wondering, this really is not our job. Please do not leave lunch dishes on the floor, or walk away from something you dropped or spilled.Clinical Pathology Conference (CPC)
Reminder: CPC will be held at The Pit next Tuesday, April 22nd at 7pm! The one and only, incredible Allyson Pishko will be presenting the case. Come enjoy a delicious plate of food and drinks; the presentation will start at 7:15pm. If your RSVP has changed, please contact Erin Payne directly at email@example.com. Enjoy!!Do you have patients with chronic pain?
The IOM in 2011 called for a “population health-level strategy for pain prevention, treatment, management, education, reimbursement and research.” On May 2-4, Duke and UNC will be co-sponsoring a joint symposium on Pain, Addiction, and the Law – which includes an intensive, boot camp-style mini-course on pain management the evening of Friday, May 2. Residents can register for the mini-course and the meeting free of charge, but spots are limited. Click the link to the attached brochure for more information. Interested residents should contact Lynn Bowlby for more information.
From the Director
Vacation was great, but it is also good to be back. I feel a bit of pressure to be as funny as Dr. Hargett writing for updates…thanks again Bill for doing an amazing job filling in. I also got to spend a few days at the Program Director’s meeting in Nashville with Drs. Woods, Trinh and Rivelli. We learned a lot about the milestone based evaluations and residency accreditation, as well as some exciting new curriculum that we hope to bring to you in the next few months. Be sure to talk with me or your advisor about the summative “reporting” milestone evaluations we complete for each of you…its a good opportunity to set goals for your upcoming rotations.
The first How to Be A JAR was a great success…many thanks to Vaishali and Krish for putting together fantastic sessions on Leadership and Dealing with Uncertainty, as well as to Cory Miller and Rob Harrison for running the Code Blue Simulation. Thanks also to Bobby Aertker, Aparna Swaminathan, Adrienne Belasco and Kevin Shah for providing JAR/SAR input and to all the participating interns for asking questions and allowing for excellent discussion. Next session is Monday, so remember to check Medhub to see if you are scheduled.
Lots of kudos to be given this week. First to Lindsay Boole who was left off (sorry!!) the ACP announcement last week. Lindsay had a platform presentation of the QI Afternoon Report data..great work Lindsay. Ashley Bock and Amanda Verma both received gold stars based on excellent patient comments. Many of our residents were mentioned by name by the medical students in the July-January clerkship evaluations….congratulations to the following residents for your recognition by the second year med students!
Bobby Aertker, Mandar Aras, Shailesh Balasubramaniam, Armando Bedoya, Adrienne Belasco, Amit Bhaskar, Hal Boutte, Schell Bressler, Kimberly Bryan, Laura Caputo, Meredith Clements, Mallika Dhawan, Alex Fanaroff, Sarah Goldstein, Jonathan Hansen, Chris Hostler, Scharles Konadu, Ashley Lane, Howard Lee, Jim Lefler, Philip Lehman, Carli Lehr, Angela Lowenstern, Jay Mast, Alyson McGhan, Brian Miller, Aaron Mitchell, Laura Musselwhite, , Ragnar Palsson, Rebecca Sadun, Paul St. Romain, John Stanifer, Matt Summers
Aparna Swaminathan, Sajal Tanna, Carling Ursem, Jonathan Yates, Jason Zhu
Also kudos to Howard Lee and Chris Hostler for fantastic SAR talks (although I missed them being at APDIM, I hear the Brian Miller especially loved Chris’s talk). More kudos as well to Brian Sullivan for his Chair’s Conference presentation, and to Lauren Porras for her noon conference on shoulder exams. Cary Ward sends kudos to Amy Lee, Jonathan Hansen, Sarah Goldstein, and Yvonne Baker for their outstanding work on CAD. Congratulations to Armando and Jennifer Bedoya on their marriage — we all had a fantastic time celebrating with you on Saturday! Congratulations as well to Tyler Black on the birth of Davis Black! Mom, Dad and baby are all doing well!
Can’t wait for the AUCTION this Friday!!! Hope to see you all there!!! While you are at it, go ahead and sign up for the STEAD TREAD as well.
This weeks Pubmed from the PRogram goes to Amy Newhouse for her work with Dr. Wei Jiang. Newhouse Jiang – Heart Failure and Depression
Have a great week
AimeeWhat Did I Read This Week? Submitted by Bill Hargett, MD
If you missed our interdisciplinary discussion at the joint IM/EM Conference on Wednesday, this is an important article that every one of our residents should read: The ProCESS Investigators. A Randomized Trial of Protocol-Based Care for Early Septic Shock. N Engl J Med. 2014 Mar 18. [Epub ahead of print] PubMed PMID:24635773.
There’s a lot of information in this trial (you can also read the Supplementary Appendix) so I’ll try to reduce the burden and simplify a few things.
Background and Question:
Sepsis is among the most common reasons for ICU admission and a top-10 cause of death in the United States. The Surviving Sepsis Campaign (SSC) Guidelines have successfully called attention to the delay in the recognition of and initiation of appropriate therapy for sepsis and septic shock. Furthermore, the Guidelines are endorsed by multiple professional and regulatory organizations, achieving de facto “standard-of-care” status. However, the evidence base for major components of the SSC is poor, and there remains significant controversy surrounding the initial hemodynamic resuscitation “bundle” (based upon early goal directed therapy (EGDT)).
The ProCESS Trial is the first published of three major trials assessing EGDT in sepsis. So what did they find? What is the efficacy of early, protocol-based, targeted resuscitation in patients with septic shock?
Investigators randomized 1341 patients with septic shock at emergency departments in 31 U.S. academic, tertiary care hospitals to one of three 6-hour resuscitation arms:
The primary outcome was 60-day mortality. Regarding validity, groups were similar at baseline (e.g. APACHE II ~ 21) and there was no evidence of contamination.
There were no differences between groups in 60-day mortality (19-21%), 90-day or 1-year mortality. Protocol adherence was very good (89.1% in EGDT, 95.6% in standard therapy).
Table 2 (Article) further details the outcomes and Table S4 (Supplement) nicely delineates the resuscitation and overall care from enrollment to 72 hours.
The results of this trial are unsurprising to many emergency or critical care providers and I could go on and on regarding the shortcoming of the SSC resuscitation bundle and the “one size fits all approach” for the treatment of severe sepsis and septic shock (e.g. transfusion threshold in critically ill patients, ScVO2 as a physiologic surrogate, inotrope selection, etc.). However, I think it’s important to emphasize a couple of major take-home points:
This may be, in part, explained by the underlying “pre-randomization protocol,” whereby most study participants, by virtue of the enrollment process, received early recognition of sepsis and antibiotic administration, which are likely the most important components of care.
Indeed, this earlier identification of septic patients and aggressive treatment may be the greatest product of the Rivers trial and the SSC… “knowing is half the battle,” as they say. Increased awareness and early treatment clearly saves lives.
For future studies, how about some more data to look more closely at individual bundle elements? Well, that may be coming – keep an eye out for the ProMISe trial in the UK and the ARISE trial in Australasia, both of which are also examining EGDT and which have been designed collaboratively to allow the results to be pooled for all three RCTs on EGDT.The “Clinic Corner – DOC” (submitted by Dr Sharon Rubin )
This is a reminder for the SARs. make sure you are letting your patients know you are leaving in June and that a great new doctor will be assuming their care. As soon as I have names I will give to each SAR. We will have 6 new interns to replace the 6 SARS. Then you can put their name on the AVS. Please RSVP for the Pickett Senior Dinner in June on the Doodle pool (let me know if you need the link).
Running your panel is possible. When you are on Administration time or as a SAR for your last clinic session will be Admin and will run your own panel. I have made instructional videos where you can
1. Run your own panel
2. Run your panel for Diabetics or hypertensives
3. Run another resident’s panel
Due to HIPPA, Sharee has access to these videos and will release them to you if you are on ADMIN or if you want to run your panel.
Please pay attention to Marie Evangelista’s emails for Maestro updates as she is our superuser.
Good news the Rapid flu works! Bad news this is a little late coming. I had a patient, in APRIL, who had classic Flu symptoms. The NURSES run the flu (order POC FLU), this takes 10 minutes but better than 2 days. At least we will be ready for next flu season.
I am proud to see the Duke residents and medical students posters at ACP. Attached are Julia and Wassim’s posters from the North Carolina ACP.
See you when I get back!
QI Corner (submitted by Joel Boggan, MD)
The Importance of Coding
Many thanks to Dr. Momen Wahidi, who led us through a discussion (and some examples) of how our documentation affects overall patient care and safety. You will be hearing more about this topic as we move into the next academic year.
We Follow-Up project
The first look at the Sharepoint project during Phase 2 is done, and it appears we are improving our rates of notifying patients about lab results. We have picked up about 6% in absolute notifications at the DOC, 5% at Pickett, and 8% at PRIME. Overall, PRIME and Pickett are neck-and-neck reporting >90% of results back within two weeks, while the DOC is lagging a little behind. Keep up the good work!
April 17: Brian Miller / Marianna PapademetriouGrand Rounds
Dr. Frank Neelon — ObesityNoon Conference Date Topic Lecturer Time Vendor Room 4/14 MKSAP Mondays – Cardiology K Patel / Chiefs 12:00 Picnic Basket Med Res Library / 8262 4/15 MED-PEDS Combined: HPV Screening and Vaccination OR Difficult Death Debrief Chip Walter / Galanos 12:00 Saladelia Wraps 2002 OR DN9242 4/16 Nephrology Board Review K Patel / Butterly 12:00 Cosmic Cantina Med Res Library 4/17 SAR TALKS Brian Miller / Marianna Papademetriou 12:00 Sushi 2001 4/18 Chair’s Conference Chiefs 12:00 Rudino’s 2002
From the Residency Office Califf Medicine Resident Research Award
Internal Medicine Residency Program and the Department of Medicine would like to invite you to submit an abstract of your research project for: The Califf Medicine Resident Research Award competition. Abstracts are due on May 5, 2014
Please see attached request for applications and abstract preparation instructions, also included within our Resident Research website link: http://residency.medicine.duke.edu/duke-program/resident-research/research-events-and-awards
All abstracts submitted for competition will also be presented as posters during Resident Research Night on June 3, 2014 at the TRENT SEMANS Center 5 pm - 7 pm.
The top 3 abstracts will be selected by a faculty committee for the Califf Research Awards and these research projects will be presented as 15 minute talks.
The best poster will be selected by the Chief Residents during the poster viewing session.
In addition, we invite all of you to present your scholarly activities during Resident Research Night as posters :
To discuss any issues related to the application process or once you have decided to submit an abstract, please e-mail firstname.lastname@example.org to declare your intention to submit, your research mentor’s name and the title of your poster. Please contact the MedRes office staff (Ms. Lynsey Michnowicz) for assistance with the poster preparation process.LPS Snapshot (submitted by Dr. Wei Duan-Porter)
Please provide feedback about your continuity clinic experiences, and help earn $$ for the charity supported by your Stead Society! Only 10 more responses per Stead will get you $150 for each of your great causes!
Thank you to all those who have already responded!
Medical Education Grand Rounds: “MAKING THE MOST OF MILESTONES”
Presented by Dr. Aimee Zaas (Program Director, Internal Medicine)
Registration for can be completed using the follwoing link: https://www.surveymonkey.com/s/MEGRregistration2013
“Due Process or Don’t Process: Medical Education & The IRB” with Dr. Mitch Heflin
“Longitudinal Curricula” with Dr. Barbara Sheline
Financial Planning Seminar for Residents and Fellows
Gerald A. Townsend, a nationally recognized financial advisor, will be at Duke on April 22nd to talk with Duke’s residents and fellows about the fundamentals of building a successful financial plan. He will cover topics such as budgeting, investing, protecting assets, retirement, and estate planning. The objective of the seminar is to provide attendees with an overview of the essential considerations necessary for creating a comprehensive financial plan and to provide a level of comfort for taking the next steps towards creating a secure financial future.
Time/Location: April 22nd at 6:30 PM in North Duke Lecture Room 2002
Please note the changes to the Step 3 test for next year. As a reminder, you cannot advance to PGY3 until you pass Step 3. We STRONGLY ENCOURAGE you to register as soon as possible and take the test as soon as possible. Please remember to clear your dates with the Chiefs and send them to me when you have them!
Changes in the USMLE Step 3 Examinations
For more information, please review the Changes to USMLE 2014-2015 document on the USMLE website.
You may contact us with any questions at http://www.usmle.org/contact/
The link containing this info:
Dr. Zaas hasn’t retired from the Internal Medicine Residency News but she continues her “Conscious Un-blogging” this week and you are stuck with me again… (thanks Jimmy Fallon, and Aimee will be back from vacation next week). All kidding aside, this was another great week in our program – here’s a few highlights:
From the Residency Baby Blog (your source for the latest news on our mamas and papas…) Congratulations to Marcus Ruopp and Nicki Frederick and lots of air hugs for Allie Michaela Ruopp.
Warmest wishes to the Erdmann’s as they welcome baby Henry into the world. Alan and his wife are now outnumbered 3 to 2 and forced to brush up on their zone defense. I don’t have a photo but, with Alan’s baby-face good looks, I can only imagine… (kidding, love ya Alan and sorry, Amanda)
KotW – Many kudos this week – the accolades for our group are flying so fast that I can barely keep up… (and likely missed quite a few!)
Special thanks to Caroline Lee, Monica Tang, Jesse Tucker, and Nancy Lentz, who all demonstrated the quintessential pull-list attitude when covering for their colleagues.
Marcus Ruopp received some good-nature ribbing as Duke ACR while Aimee and Krish were away but he really did a tremendous job in helping to lead the GenMed teams during a busy week.
This via Jon Bae – the DOC and their Care Transitions Effort is outta control, taking home the hardware by grabbing the DUH “It Takes a Team” Annual Award for their overall redesign efforts, as well as the top prize Kirkland Award at the Duke Patient Safety Conference.
Stay on top of what’s happening in your back yard and check out Laura Musselwhite’s Point of View in the News and Observer on NC Medicaid expansion.
On Wednesday, Dr. Ken Lyles earned the IronDuke Omnipresent Award, given to attendings who precept report at all sites all in one day (DRH AM report, VA Report, Duke GM SAR report, and Duke GM intern report). That’s quite the feat!
The ACP is celebrating the academic excellence of “Young Achievers” for Internal Medicine 2014 in Orlando and we should too! Kudos to:
And last, but not least, we’re also incredibly proud of our team’s record showing in the poster competitions at the Society of Hospital Medicine Annual Conference in Las Vegas, with the tally including:
A) 20 Posters from our group
-7 QI/Research (with 3 Finalists!)
-13 Clinical Vignettes
B) 11 Hospitalists represented
- 7 DUH, 3 DRH, 1 DRAH
- Many posters included residents and medical students
C) All 3 Sites Represented
-14 DUH Posters
- 5 DRH Posters
-1 DRAH Posters
Here is a complete list: SHM Posters 2014
The April News Letter for the DOC is attached below. Among the items listed check out the annoucement about the procedure clinic opening in May.
PSQC Special Meeting
For our next PSQC meeting, we’re going to be meeting at 5:30 in the Med Res Library on Wednesday, 4/9. We’ll talk briefly about some updates before being led by Dr. Momen Wahidi at 6 pm (with food courtesy of the PRMO!) on the following topic:
What: “How documentation reflects your care : it matters to you and your patient”
Hand Hygiene Updates
March was our best month yet – out of 68 MD observations on our floors, we were compliant with 67! That’s 98% for the month and brings our aggregate compliance to > 89% on the year (SO CLOSE TO 90%)! Keep up the good work!
April 8: Chris Hostler / Howard LeeGrand Rounds
Dr. Carl Berg: Topic – UNOSNoon Conference Date Topic Lecturer Time Vendor Room 4/8 SAR TALKS Chris Hostler / Howard Lee 12:00 Pita Pit 2002 4/9 MSK Exam Part 3 Irene Whitt & Lisa Criscione 12:00 Subway Med Res Library 4/10 Practical Approach to Shoulder Pain Porras 12:00 Domino’s Med Res Library 4/11 Chair’s Conference Chiefs 12:00 Chick-Fil-A 2002 From the Residency Office Strength, Hope, and Caring Award (submitted by Drs Bowlby, Greenblatt, and Zipkin)
Please join us in congratulating the Duke Outpatient Clinic residents, pharmacists, faculty, clinic leadership, nurses, and staff on winning both the quarterly and YEARLY Strength, Hope, and Caring Award this week. The award is given by Duke Hospital Leadership to a single clinical unit that demonstrates outstanding teamwork and innovation. The Duke Outpatient Clinic was recognized for its innovative transitional care program for patients who have recently been discharged and for our extensive clinic redesign efforts. Our residents serve an integral role in providing comprehensive and evidence-based transitional care and contributed greatly to the development of this program. Clearly, it is a team effort and we appreciate the ongoing effort from all members of the staff to ensure that our patients are seen promptly and we are doing all possible to help the patients recover and avoid repeat hospitalization. Come by and check out our gigantic trophy!LPS Snapshot (submitted by Dr. Wei Duan-Porter)
LPS Snapshot Update–Kirby is leading, Kempner is close behind! Don’t miss this opportunity to provide feedback about your continuity clinic experiences, and earn $400 for the charity supported by your Stead Society!
Thank you to all those who have already responded!ACP Celebrates Young Achievers (Submitted by the American College of Physicians)
“I am writing to share with you that the College will be celebrating resident(s) from your program as part of our ACP Celebrates Young Achievers initiative during Internal Medicine 2014, from April 10-12, in Orlando, Florida.
ACP is proud to have such high caliber Resident/Fellow Members, including the following from your program:QI/Patient Safety – Jennifer Anne Rymer, MD Clinical Research – Jennifer Anne Rymer, MD Clinical Vignette – Joseph D Brogan, MD Clinical Vignette – Michael Woodworth, MD
This group of early career internists demonstrates academic excellence and represents the best of what the future of internal medicine holds. We hope that you will recognize their achievements in your program. In turn, we will celebrate them at our meeting and urge our ACP chapters to celebrate them locally in any future activities being held for residents in the chapter.”Maestro Care Mobile Apps Now Available For Providers and House Staff
Maestro Care mobile apps, Haiku and Canto, are available to providers and house staff across Duke University Health System. The apps have been developed by Epic to allow access to a subset of Maestro Care features while on-the-go. Haiku is available for iOS and Android smartphones, while Canto is available for iPad.
In addition to providing convenient access to view patients’ charts, these apps also allow providers to:
To get started, simply visit the Maestro Care Mobile Device Support website from your mobile device while on the hospital intranet (i.e., “clubs” network) and follow the three simple steps to download, configure and log in to the apps.
If you have any questions regarding app configuration, please refer to the “Frequently Asked Questions”’ section on the support page. Please note that the Duke Medicine Service Desk cannot provide assistance with downloading and installing the apps on your device. Finally, prior using the apps, be sure to complete the 7-minute LMS training entitled “Maestro Care Mobile Apps Security and Compliance Considerations,” which highlights proper use of the applications. You will also receive an email reminder to complete the training within 30 days.Information/Opportunities
The third annual Stead Tread 5K fun run will take place Sat., May 3 at 10 a.m. on the Al Buehler Cross Country Trail at Duke University.
Registration fee for the race is $25. Sign up here. You can also make a donation. The registration fee includes an official Stead Tread 2014 T-shirt.
Proceeds from the race, which is organized by the Internal Medicine Residency Program, benefit the Lincoln Community Health Center. Last year’s event raised more than $6,000.
In the midst of rounding on Duke GenMed this week (go team 1A/1B!), I’m pinch-hitting Updates for Dr. Zaas. Aimee and the Zaas family say “Hi” from Caesaria and the Rosh Hanikra caves—you can see that she’s enjoying a well-deserved vacation!
The ACC built on their dismal first week in the NCAA tournament with Virginia falling to Michigan State in the Sweet 16. If your bracket is busted and you’ve shed #DukeTears, then maybe bidding on a pair of autographed, game-worn Bat Shoes at the upcoming charity auction will remind you of the glory years…. Also, the kids tell me that wearing tight kicks like these help when you’re versing the attendings at the upcoming annual Housestaff vs. Faculty Basketball game (though I suppose not many of us wear a size 14 shoe…).
Gotta give props to Trevor Posenau, Lindsay Anderson, Mike Shafique, and Kaley Tash for fantastic SAR talks (thanks, Vaishali). KotW (Kudos of the Week) @DinushikaMohottige, who wins the Feedback Triple Crown, receiving praise from a patient, a peer, and a supervising physician. Notes from Laura Musselwhite and Josh Thaden and a letter from a patient frame a wonderful narrative describing Dinushika’s hard-work, compassion, and excellent clinical care. There are other stories heard too – thanks to all of you for the extraordinary things, big and small, that you do each day here at Duke.
The proverbial cup continues to runneth over with resident accolades and accomplishments and there were several excellent choices for PubMed of the week. Take some time to check out an article by one of your colleagues:
Mitchell AP, Hirsch BR, Abernethy AP. Lack of timely accrual information in oncology clinical trials: a cross-sectional analysis. Trials. 2014 Mar 25;15(1):92. [Epub ahead of print] PubMed PMID: 24661848.The “Clinic Corner” (submitted by Alex Cho, MD)
When was the last time you saw someone in clinic (or ACC at the VA) who presented for STI screening/diagnoses/treatment?
April happens to be National Sexually Transmitted Infection Awareness Month, and to commemorate this, I wanted to follow on Sharon Rubin’s mention of HIV screening in last week’s excellent WDIRTW (re: hepatitis C prevalence and the USPSTF recommendation to screen all adults born between 1945 and 1965 at least once), by sharing a framework for using these problem-focused STI-related visits as “teachable moments” to inquire about and counsel patients about potentially high-risk sexual behaviors.
This framework comes from the RESPECT Program, an RCT-validated approach to HIV prevention. And even though this and other available evidence of the benefit of counseling has been for relatively high-intensity interventions; the same principles can be translated into your own practice.
1. Introduce and orient the patient
“I’m glad you are here.” “What would you like to know before you leave here today?” “What are your specific concerns?” “In addition to addressing today’s issue, would it be ok to use this opportunity to explore together what you might be able to do to stay safe/prevent another occurrence?”
2. Identify client’s personal risk behaviors and circumstances
(Risk Behaviors: Sex or drug use actions that in and of themselves can result in transmission of HIV/STI.) “How did you decide to get tested/treated today?” “Tell me about the event(s) that brought you to the clinic today?” “How many different people do you have sex with and how often?” “How often do you use drugs or alcohol, and how does this affect who you might have sex with, and whether you use protection?”
3. Identify potential safer goal behaviors
(Safer Goal Behaviors: These are specific actions that directly prevent or greatly reduce HIV/STI transmission and that the client is willing to try to adopt.) “Is there a specific time that you remember where you were able to practice safer sex (used needles safely, used a condom)? What did you do? What made it possible for you to do it?” “What are you presently doing to protect yourself?” “What would you like to do to reduce your risk of HIV/STI?”
4. Develop patient action steps
(Action Steps: Specific incremental steps a client can/is willing to take (and reasonably confident in their ability to carry out) to help him or her adopt a safer goal behavior.) “What do you think you can do in the next few days/weeks to reduce your risk of HIV/STI?”
5. Make any referrals necessary and provide support
6. Summarize and close visit, telling patient how you will follow up (re: test results, et al.)
Although it is obviously difficult to add yet another item to a long list of recommended prevention-related tasks, for these focused visits having a go-to “script” or routine can make it a more natural conversation, and the visit more efficient and potentially more impactful overall.
And you can always ask patients to come back to address their other sets of issues (chronic disease management, health maintenance) – particularly if you sense a real opportunity to nudge a patient towards less risky behaviors. Just take a minute to make sure they come back to you by putting down a range of dates in your follow-up instructions, as well as confirming with patients and writing out in your plans the issues you will tackle next time. (Shorter follow-up times for more frequent “prepared” visits will also increase the likelihood you will see your own patients in general, because your clinic schedules are available to the clinics about 3 months in advance.)
Lin J, Whitlock E, O’Connor E, and Bauer V. Behavioral counseling to prevent sexually transmitted infection. Ann Intern Med 2008;149:497-508.
Navy and Marine Corps Public Health Center. Fundamentals of HIV-STI Prevention Counseling Student Manual. October 2012. Available at: http://www.med.navy.mil/sites/nmcphc/Documents/health-promotion-wellness/reproductive-and-sexual-health/student-manual-hiv-sti-prevention-counseling.pdf.QI Corner (submitted by Joel Boggan, MD)
Three dates to keep on your calendar:
April 1: Armando Bedoya; Jennifer ChungGrand Rounds
Dr. Elva Arrendondo (visiting professor) .Noon Conference Date Topic Lecturer Vendor Room 3/31 MKSAP Mondays – GI V. Patel/Chiefs Chick-Fil-A Med Res Library / 8262 4/1 SAR TALKS Armando Bedoya Jennifer Chung Bullock’s BBQ 2002 4/2 IM-ED Combined Conference Trowbridge/EM Cosmic Cantina 2002 4/3 Essentials of Acute Pancreatitis Vaishali Patel Saladelia Wraps 2001 4/4 Chair’s Conference Chiefs Rudino’s 2002 From the Residency Office Charity Auction!!!
The auction is just two weeks away (April 18th). Lauren Dincher will be selling tickets at Grand Rounds and also during regular office hours in suite 8254.
What’s new this year? We now have our own credit card machine, which means you can buy your tickets with Visa or Master Card (sorry, we do not accept payment by bitcoin yet – but who knows. maybe in 2015!)
And, as special attraction for the basketball fans out there, take note that we will be putting up for bid a pair of signed basketball shoes worn by Shane Battier!!Mini CEX Madness – Week 4
As to the grand prize winner (the $50 dinner), that now belongs to Gena Foster! Congratulations!!Additions to the Event Calendar
Take note of the following additions to the event calendar that we post each week:
As a reminder for both incoming and outgoing trainees, the Duke GME website includes a link for current housing both for rent and to own:
If you are interested in posting a listing, please follow the instructions on the site and if you are interested in new housing, please check the site regularly for updates. In addition, the MedRes office will create a Resource/Document folder in MedHub for housing options, where we can also post available properties for all trainees to access. If you have a property you would like to post, please email email@example.com for more information.ACLS/BCLS Reminders (submitted by Lauren Dincher)
I just wanted to send a reminder out to everyone reiterating our policy for taking ACLS/BLS training. Before scheduling the class, please get approval from the Chiefs. Once approved, send me your date and time so that I can update your schedule. I need to do this for scheduling and location reporting purposes.
If you have recently taken one or both of the classes and it is not on your Amion/Medhub schedule, please send me the day and time frame that you took the class so that I can update your schedule. Thanks so much!Stead Tread – Sign up!
The Kempner Stead Society invites you to participate in the the 3rd annual Stead Tread 5k Run/Walk on May 3rd at 10AM, with all donations benefitting the Lincoln Clinic. This 5k Run/Walk was first organized two years ago and has been a great success, raising over $10,000 for Lincoln. We’ve had over 100 residents, faculty, staff and patients run with us each year, and we are looking to make this year’s race an even bigger success!
Go to www.steadtread.org to register or donate!NC Medicaid Expansion
On April 8th, students from the Sanford School of Public Policy will present a proposal for expanding Medicaid in North Carolina. This proposal was developed through a Medicaid Practicum course facilitated by Professor Don Taylor. The purpose of the course was to craft recommendations for the NCGA-appointed Medicaid Reform Advisory Group to consider as they looked at different ways to reform Medicaid in North Carolina. This is a unique opportunity to better understand Medicaid policy in North Carolina, and how it may affect our patients.
When: April 8, 5:30PM – 6:30PM
Where: Rhodes Conference Room, Sanford School of Public PolicyInformation/Opportunities Upcoming Dates and Events
So, clearly a HUGE week for our residency program family! Cannot possibly explain how excited we are about the new interns. And another THANK YOU to our incredible team of residents, chief residents, APDs (especially “King Of Recruitment” David Butterly), staff (especially “Goddess and Ambassador of Recruitment” Erin Payne), faculty and Dr. Klotman for showing our newest team members why Duke Medicine is the greatest. See below for the AMAZING class list!
We have another new member of our family….William Shumate! Congratulations Jenn Rymer and Daniel Shumate on the birth of your son!Cameron Hostler told me at the recruitment party that he plans to tease his “little chief” brother mercilessly, since he learned this from his dad.
Lots of kudos came my way this week about our current residents….from a patient (via Dr. Aimee Chung) to Amanda Verma for outstanding and compassionate care on Gen Med, to Ashley Bock, CeCe Zhang and Sarah Goldstein from Stephanie Norfolk for outstanding “JAR level” work in the DRH MICU, from Susan Spratt to Monica Tang, Alex Clark and Amanda Elliott for their work on the diabetes phenotyping project, to John Stanifer for his work screening for renal disease in Tanzania on WORLD KIDNEY DAY, to Laura Musselwhite, Kevin Trulock, Allyson Pishko and Venu Reddy from Kedar Kirtane for being a great Duke Night Resident team, to Joel Boggan for leading our resident M and M, to Anne Mathews and Ashley Lane for excellent SAR talks, and to Andrea Sitlinger from Alice Grey for excellent work on the pulmonary transplant service.
Things start to move really quickly at this point in the year….How to Be A JAR is coming soon, as is the auction, and a CPC, and next year’s schedule, and many other end of year activities. Keep up the MINI CEX work during CEX madness. It’s not brackets, but it’s important to your learning and development!
This week’s pubmed from the program goes to Phil Lehman, to be presented at the 2014 AHA Quality of Care and Outcomes Research Conference in June, 2014!
Title: Early Telephone Follow-up Fails to Reduce Readmission Rates for CHF & AMI; Authors: Lehman EP, Granger BM, Pura J, Lohknygina Y, McCarver C, Shah B.
HAVE A GREAT WEEK….next week, updates come at you from guest writer BILL HARGETT!
The “Clinic Corner – PRIME Clinic – VA Medical Center” (submitted by Sonal Patel, MD)
I can’t believe Spring is here and hopefully no more snow or ice. You would think living in Chicago for 12 years would make me immune to the weather but unfortunately not the case. I also can’t believe it is March and the year is wrapping up. It has been my absolute pleasure to work in PRIME clinic with you residents and while it will be bittersweet to see the seniors graduating and moving on it has also been gratifying seeing the interns and juniors graduating and gaining self confidence in their skills.
During this last month I have noticed a few things that I wanted to share:
1. All of you have been so gracious helping out your fellow residents when unforeseen hitches in clinic require another residents assistance
2. The number of ACS messages you receive are TNTC (too numerous to count) and you have been able to manage them so seamlessly with all of your other responsibilities
3. Each and every resident that has voiced a problem in clinic has also brought up possible suggestions for improvement, which is so appreciated. Please continue to think outside the box and be innovative with solutions.
4. All of the residents that are helping implement changes in PRIME clinic are doing them willingly and with full effort. I am in awe of your dedication and willingness to help.
On to the updates:
1. Monday AM huddles- The PRIME staff have enjoyed getting the residents perspectives during our Monday am huddles, please continue to speak up and voice any suggestions either in the meetings or outside of them
2. FLOW analysis- Data was gathered on Wednesday March 18, thanks to everyone in clinc that day entering the data, I will keep you posted on the results
3. Our 3rd LPN will be joining us shortly, we are so excited to have our full complement of nurses, our MSAs (Clerks) are still short staffed but hopefully we can get those positions filled ASAP
4. Chronic Pain Management- we have moved to the first of the month, seems to be working well, please let us know of any issues/suggestions
Looking forward to wrapping up the year with you.What Did I Read This Week? Submitted by Sharon Rubin, MD Denniston, Jiles, Drobeniuc, Klevens, and Others. “Chronic Hepatitis C Virus Infection in the United States, National Health and Nutrition Examination Survey 2003 to 2010.” Annals of Internal Medicine. 2014;160:293-300.
When I first read on the USPSTF web site in 2013, I was skeptical. Was Hepatitis C so prevalent that now every adult born between 1945 to 1965 should be offered Hepatitis C screening?
The USPSTF recommends screening for hepatitis C virus (HCV) infection in persons at high risk for infection. The USPSTF also recommends offering one-time screening for HCV infection to adults born between 1945 and 1965.
Grade: B Recommendation (which will be covered by Affordable Care Act)
There is an estimated >3 million people in the US have chronic HCV infection (this was extrapolation from blood samples in NHANES which underestimates the number as this did not include homeless or the incarcerated). Now with current treatments of pegylated interferon, ribavirin, and a protease inhibitor (either boceprevir or telaprevir) especially for genotype 1 can cure HCV, decrease HCC and death. There are new drugs coming down the pipeline which can improve compliance and down stream effects. Many people are unaware of their status as they are asymptotic. There are more HCV deaths now than HIV.
This NHANES study looked at data from 2003 to 2010, blood samples and interviewed patients to determine risk factors for HCV. The estimate is 1.3% patients = 3.6 million people had past or current HCV; 1%= 2.7million people have chronic HCV which is actually a decrease from past estimates (they do not attribute this decrease to treatment as people who know they have HCV do not go for further treatment). They postulate that deaths from HCV were underreported and mortality from people with HCV has increased. They attribute more of theses deaths from the “Baby Boom” generation (1945-1965). Identified risk factors were still the same: injection drug users, person who received blood transfusions before 1992. Their analysis showed that people born between 1945 -1965 had 6x greater prevalence (making up 81% of all the people with HCV). The hope is to identify 800,000 more people with HCV, guide them to treatment and save 120,000 deaths.
I needed to put this information into the perspective of HIV. HIV was a new and scary disease in the 1980 that received generous media coverage and funding for virology and for treatment. Taken from USPSTF “An estimated 1.2 million persons in the United States are currently living with HIV infection, and the annual incidence of the disease is approximately 50,000 cases. Since the first cases of AIDS were reported in 1981, more than 1.1 million persons have been diagnosed and nearly 595,000 have died from the condition. Approximately 20% to 25% of individuals living with HIV infection are unaware of their positive status.” The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults ages 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. Grade: A Recommendation The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown. Grade: A Recommendation”
For HCV there is estimated 2-3% =130-170 million people world wide with HCV and 500,000 died of HCV related conditions A YEAR compared to the 595,000 HIV deaths that in the US in total from HIV. 2.7 million people with HCV vs 1.2 million people with HV. Focusing on patients who have risk factors (homeless, incarcerated, instutionalized, IV drug abuse, blood transfusions) is a start but I understand now to at least offer the Hepatitis C screen to patients born between 1945-65 without risk factors. I am relieved that insurance, the affordable care act, will cover the screening for HCV but I do worry about the cost of evaluation and treatment of HCV as these are still new treatments, not generic, who will pay then? I understand the hopes of the CDC. HCV is a disease that can be easily identified, possibly treated, and hopefully eradicated.
QI Corner (submitted by Joel Boggan, MD)
High Value Care Lecture Series and QI Conferences
Wednesday, the 26th, features a couple of QI conferences. At noon, Dr. Alex Cho will be leading us in the next of the High Value, Cost-Conscious Care series, on ‘Balancing Benefits with Risks and Harms’ in 2002. Please be there right at noon so we can get started on time!
That evening, Dr. Bimal Shah will be presenting ‘Quality in HealthCare’ for the Incentive Task Force’s High Value Care series in Trent Semans Classroom 3 from 7-8 pm.
Hand Hygiene Update
For those of you unable to make it to M&M this week, here are our ward numbers for February. March updates will be out in two weeks . . .
Ward Compliance Rate
7100 23 / 25 92%
7300 21 / 24 88%
7800 18 / 19 95%
8100 9 / 11 82%
8300 21 / 21 100%
9100 8 / 9 89%
9300 9 / 10 90%
From the Chief Residents SAR Talks
March 25: Lindsay Anderson / Trevor Posenau
March 27: Kaley Tash / Mike ShafiqueGrand Rounds
Dr. John Williams – General Medicine
Topic: Shared Decision MakingNoon Conference Date Topic Lecturer Time Vendor Room 3/24 MKSAP Mondays – GIM Bergin/Chiefs 12:00 Picnic Basket 2002 3/25 SAR TALKS Lindsay Anderson / Trevor Posenau 12:00 Pita Pit 2002 3/26 QI Patient Safety Noon Conference Alex Cho 12:00 China King 2002 3/27 SAR TALKS Kaley Tash / Mike Shafique 12:00 Domino’s 2001 3/28 Research Conference 12:00 Panera 2002
From the Residency Office Mini CEX Madness – Week 3
Week # 3 of Mini CEX Madness. We had 7 CEXs completed this week , and our winner is Stephanie Giattino! We’ve got one more week to go – let’s keep those CEXs coming! As a reminder, everyone who has at least one completed during the month of March will be entered in a drawing to win a $50 dinner to a local restaurant of your choice (alcohol not included)!
World Kidney Day (submitted by John Stanifer)
Take note that the World Screening Kidney Day made it to the ISN website.
Information/Opportunities 140317 – INTERNAL MEDICINE-ALL Upcoming Dates and Events
The Internal Medicine Residency Program filled all of its spots – 41 categorical, 9 preliminary (6 neurology, 1 radiation diagnostic, 1 radiation oncology, 1 ophthalmology), 6 med/peds and 2 med/psych – with outstanding applicants. The categorical interns will come from 30 different institutions, including six from Duke, one from Duke-NUS and one from Beirut. Twenty of the categorical interns are female, 21 are male.
The names and medical schools of this incoming class will soon be added to the map on the Residency website. Take a look and see the geographic diversity of our residents – Duke draws from an impressive expanse of the nation.
The Department of Medicine and Internal Medicine Residency Program were well-represented at the 9th Annual Duke Medicine Patient Safety and Quality Conference. Below find a list of DoM winners and participants:
Winner: Rebecca Kirkland Award
Cefaretti, M, Smith, B, Causey, H, Bowlby, L, Cheely, G, Cho, A, Dillard, J, Johnson, B, Knutsent, K, Rutledge, C, Simo, J, Bae, JG.
“Impact of Transitions of Care Services in an Internal Medicine Clinic Population.”
Jolly Graham A, Bae JG, Clark A, Timberlake S, Isaacs P, Chen L, Wright S, Buckner C, Thompson L, Martt R, Clausen J, Stillwagon MJ, Spurney Y, Setji N.
“A Flash in the (Bed) Pan or Sustained Success? The ‘Just Pull It’ Campaign One Year Later.”
Broderick, K, Hunter, W, Sharma, P, Schulteis, R, Zaas, A, Bae, JG.
“Doctor Who? A Study of Patient Provider Awareness.”
Ruopp, M, Govert, J, Holland, T, Stillwagon, M, Velaquez, B, Shah, B, Bae, JG.
“The Accuracy of Identification of Patients with Pneumonia Through Administrative Data and Impact of Clinical Re-Classification on Readmission Rates.”
Mercer, T, Bae, JG, Velazquez, M, Setji, N.
“The Highest of Utilizers of Care: Individualized Care Plans to Coordinate Care, Improve Health Care Service Utilization and Reduce Costs at an Academic Tertiary Care Center.”
Boole, L, Seidelman, J, Zaas, A, Cheely, G, Chudgar, S, Clarke, J, Gallagher, D, Jolly Graham, A, O’brien, C, Setji, N, Shah, B, Thomas, S, Bae, JG.
“Residents Finding Their Roots: Resident Workshops to Improve Patient Safety on the Wards While Teaching Residents Root Cause Analysis.”
Seidelman, J, Hansen, J, Ray, E, Giattino, S, Zaas, A, Bae, JG, Boggan, J.
“Increasing Hand Hygiene Compliance Amongst Medicine Housestaff Through Performance Incentives.”
Elmariah, H, Thomas, S, Boggan, J, Zaas, A, Bae, JG.
“The Burden of Burnout: An Assessment of Burnout Among Duke University Internal Medicine Residents.”
Swaminathan, A, Boggan, J, Patel, S, Bae, JG.
“We Follow-Up: Improving Follow-up, communication, and documentation of outpatient test results by Duke Residents.”
Shah K, Mitchell A, Lehman EP, Oloruntoba B, Elmariah H, Halbe J, Cheely G, Bae JG.
“A Stakeholder Driven Project to Improve the Safety of Outside Hospital Transfers.”
Dotters-Katz, S, Fass, M, Ross, I, Silberman, A, Bae, JG.
“Resident Response to Wellness Tools and Interventions.”
The International Society of Nephrology blog recently featured work by internal medicine resident John Stanifer, MD.
Dr. Stanifer contributed a post about a World Kidney Day screening event held at the Kilimanjaro Christian Medical Center in Moshi, Tanzania. Check out the post and view the photos.
Hi everyone! The year keeps flying by…hard to believe that Friday is MATCH DAY! We are looking forward to welcoming the newest members of the med res family, and celebrating with everyone on Friday night!
A continued thanks to everyone for participating in MiniCEX madness…a special thanks to Jon Bae for completing 6 Minicex’s this week while on gen med (and helping Brian Sullivan and Bassem Matta log 3 MiniCex’s each!). How can you participate — ASK YOUR GEN MED, CLINIC or other ward service attending to record a MINICEX for a patient encounter they observe with you! It’s that easy.
Speaking of Jon Bae, he also led our program to an amazing showing at the Duke Patient Safety Conference. Presenters/poster authors included many from our hospital medicine group (Drs. O’Brien, Jolly-Graham, Setji, Schulties, Clarke) as well as residents Lindsay Boole, Jenn Rymer, Katie Broderick, Jessie Seidelman, Hany El Mariah, Phil Lehman, Jeremy Halbe, Kevin Shah, Bonike Olorontoba, and Tim Mercer, and medical student Wynn Hunter. Our DOC team won the highest award (the Rebecca Kirkland Award) for their work “Impact of transitions of care services on an IM clinic population” and Katie’s work on the patient centered business cards received a runner up award for best poster! This is really amazing to see such strong IM representation at this symposium.
The mock CLER visit went well, and we should be receiving some feedback soon from GME. Many thanks to Audrey Metz, Trevor Poseneau and Bobby Aertker who helped guide the CLER team through the hospital. Remember, we get 2 weeks notice for the real CLER visit, so all I can tell you is that it is not happening this week or next! More information as we receive it.
Bill Hargett and I held the second fellowship information meeting – thanks to the JARs who attended. Please look at the MedHub folder “Fellowship Information” for the roadmap to the application process. For those applying to fellowship for the 2015 cycle, please set up an appointment with me (email Erin) for late April to go over your CV, personal statement, choices of places to apply and potential letter writers.
The residency council and I had a great meeting on Thursday night – if you want to hear more about it, please contact your class rep or contact me directly.
It’s coming….many of you have heard of the iCOMPARE study, which will compare 24+4 for interns versus 16 hour limits. (see www.icomparestudy.com). We just received notice on Saturday that the ACGME is prepared to fund the study. Details to follow, but we have permission to participate, and hope to be part of the many programs who will be randomized to allowing 24+4 for interns in either 2015-16 or 2016-17, with a cross over to 16 hours in the other year. While this affects none of you directly right now, my feeling is that this will be the most impactful graduate medical education study ever performed. There is a similar study approved for general surgery as well.
Kudos this week go to Fola Babatunde who received accolades from a patient (sent to us by Lisa Pickett), and to Brian Sullivan, who was recognized by the 4300 nursing staff for great communication skills. Additional kudos to Matt Atkins for a fantastic chair’s conference, and to Jeremy Gillespie and Marcus Ruopp for their SAR talks.
This week’s pubmed from the program goes to 2 residents and one of our graduates! Bobby Aertker, Alex Clark and Dan Ong for their recently published paper “Radiation Associated Valvular Heart Disease” published in the Journal of Heart Valvular Disease J Heart Valve Dis Vol. 22. No. 5 September 2013.
Have a great week! GO DUKE, and keep counting down till MATCH DAY!
AimeeThe “Clinic Corner – Pickett Road” (submitted by Sharon Rubin, MD)
We have sadly said goodbye to Dr. Tara Obrien who left Pickett on 2/28/14 to work in Montana. She will be missed! Dr. Jennifer Brown has started 3/3/14. She is a transfer from Durham Medical Center. She trained as a resident at John’s Hopkins and will start precepting Tuesday mornings in Dr. Obrien’s place in April. Dr. Rubin will be filling in Tuesday mornings for the month of March to give Dr. Brown time to adjust to the new clinic.
The door codes have been updated (ask the attendings for code- we cannot circulate on the Internal Medicine web site) Do not however share this code information with non-Pickett Road staff.
PECOS: as per GME, residents will not be signed up (this is still in negotiation). SO any Durable Medical equipment or medical supplies for Medicare patients may have to sent by your attending. Only small pharmacies are asking for PECOS for residents. The best course of action is to prescribe as normal but if you get a message from a pharmacy NOT allowing you to send in supplies, contact your attending or Dr. Rubin.
Please make sure you are signing in under the Pickett Road with your assigned attending. If you are signed in from inpatient, ANY order, lab or radiology, will default to the Inpatient attending. Also for Tuesday and Thursday, if you are here all day, you need to CHANGE from the morning to afternoon attending (log in and then out to attach the correct attending). Make sure you are marked as reviewed for Problem List. If in annual visit, please enter the family history and update PMH, PSH, Social history. We are required to use EPIC Patient information to count as mark as review (under References).
Reminder as per DPC policy, providers are still required to call their patients for HIV results. We can result them in My chart but as per policy patient will still need a phone call of their results.
PPDs: from DPC administration: see Dr. Rubin smart phrase SRTBFORM and the letter SRTBLETTER
We will like to provide an update in regard to the PPD shortage. The manufacturer is able to fulfill orders for PPD derivative. If your site has an adequate supply of PPD, please follow the State’s guidelines for administration:
1. Resume testing for the previously deferred group, which includes –
a. Staff with direct inmate contact
b. Inmates in the custody of the Department of Correction (tested upon incarceration and yearly)
c. Staff working in licensed nursing care homes
d. Residents upon admission to licensed nursing care or adult care homes
e. Staff in adult day care center providing care to patients with HIV/AIDS
2. After verifying PPD supply level, resume regular employee testing per CDC and facility guidelines
3. Continue adherence to the June 21,2013 memo regarding administrative PPD testing for low risk individuals (e.g., teachers, child care workers, etc.)
a. Perform risk and symptom screen
i. If the screen is negative; then no further testing is required
ii. If the screen is positive; then perform a PPD test or an Interferon Gamma Release Assay
Thank you to Wassim for the HUGE poster in the resident work room. We are doing great with sending our patients new results. We can improve, especially with alert values. Always confirm with the patient when you are ordering any lab or radiology their phone number and encourage them to use my chart (use .mychart in patient instructions). You can addendum your note (you do not need a whole new telephone number for your conversation).
What Did I Read This Week? Submitted by Vaishali Patel, MD Singer AJ, Talan DA. Management of Skin Abscesses in the Era of Methicillin-Resistant Staphylococcus aureus. N Engl J Med 2014;370:1039-47.
Why Did I Read It? Skin abscesses are common, and are mostly managed by internists in clinic/urgent care, and ED physicians. Knowing how to manage small, simple skin abscesses yourself, and knowing when to consult a surgeon for larger, complex cases is important. Not surprisingly, the incidence of skin abscesses has increased with the incidence of community-acquired MRSA (caMRSA) – this has prompted reconsideration of the importance of adjunctive antibiotics with drainage. This review is largely based on randomized trials, and some small, observational studies.
What Did I Learn?
- In addition to increasing your ability to detect an abscess, bedside ultrasound can help you determine the need for further imaging, the need for incision and drainage (I&D), or for surgical consultation. In a prospective study of 126 adults with a clinical diagnosis of cellulitis, ultrasonography resulted in a change in management for 56% of patients.
- Distinguish skin abscesses, furuncles, and carbuncles from folliculitis, hidradenitis suppurativa, and sporotrichosis. In immunocompromised hosts, consider skin lesions due to Cryptococcus and Nocardia.
- Needle aspiration can make the diagnosis, but an absence of pus on aspiration does not rule out an abscess (staphylococcal abscesses have a lot of fibrin and have high viscosity, making it difficult to aspirate). Needle aspiration is inferior to I&D for adequate drainage.
- Individuals at risk for endocarditis should receive antimicrobial prophylaxis prior to I&D (IV vancomycin, or single dose of oral anti-MRSA agent is also acceptable).
- Refer the following to a surgical specialist for I&D: large (>5cm), deep, complex/multiple collections, or recurrent abscesses, abscesses in certain areas, such as the hands, neck, face, breast, or genitourinary or perirectal area, areas with critical structures such as major vessels and nerves.
- The primary treatment is I&D (use 1% lidocaine and a scalpel). The single incision should be long and deep enough to allow drainage; a small study suggested that a small incision is adequate (median length, 1cm). Check out NEJM’s Videos in Clinical Medicine (http://www.nejm.org/doi/full/10.1056/NEJMvcm071319). Small skin abscesses that you manage without surgical consultation do not need packing (associated with more pain but similar healing rates).
- Wound culture is not routinely needed for healthy patients who will not receive antibiotics, but should be done in patients with severe infection, sepsis, history of recurrent abscess, failure of initial antibiotic treatment, extremes of age, and immunocompromised states.
- Cure rates with I&D alone (without antibiotics) are high (>85%), however larger studies are needed to show smaller differences in response rates, especially in the era of ca-MRSA. Some observational studies show I&D is sufficient for immunocompetent hosts with MRSA abscesses; other retrospective data suggests that antibiotics may help prevent recurrent infection. Two large NIH RCTs are ongoing to investigate whether larger abscesses (>5cm) or surrounding cellulitis benefit from adjunctive antibiotics.
- IDSA recommends antibiotics with I&D for patients with severe disease (rapid progression, signs of systemic illness or sepsis), extensive disease, abscess>5cm, multiple sites of infection, immunosuppression, very young or very advanced age, associated septic phlebitis, or an abscess in an area that is difficult to drain (face, hands, genitalia). Otherwise, avoid over-treatment (risk of increased resistance).
- Antibiotic therapy should cover ca-MRSA (TMP-SMX, clindamycin, and doxycycline are good choices — be aware of local resistance patterns for clindamycin and tetracyclines!). For patients with systemic illness or extensive involvement, your options include vancomycin, linezolid, daptomycin, and ceftaroline. 5-7 days of therapy is usually sufficient; severe disease may need a longer duration (tailor to clinical response). For early abscess that cannot be distinguished from cellulitis, use agents with activity against MRSA and streptococci, such as TMP-SMX and a beta-lactam (like cephalexin).
QI Corner (submitted by Joel Boggan, MD)
Congrats to Patient Safety and Quality Conference Presenters
To our residents who had posters at the Duke Patient Safety and Quality Conference on Thursday. ‘Check out a couple of our presenters! Congrats as well Katie Broderick-Forsgren, who won a Runner-Up award for her poster on the business card initiative on Gen Med!
Hand Hygiene Update
We did really well with hand hygiene in February, with almost 92% compliance overall and 100% compliance on 8300 with > 20 observations. Our aggregate rate since August is inching closer and closer to the goal of 90% for the year . . .
From the Chief Residents SAR Talks
March 20: Anne Mathews / Ashley LaneGrand Rounds
Dr. Kimberly Blackwell – Breast CancerNoon Conference Date Topic Lecturer Time Vendor Room 3/17 MKSAP Mondays Chiefs 12:00 Subway 2002 3/18 MED-PEDS Combined: Transitions of Care to Adulthood OR Difficult Death Debrief Carl Cooley / Galanos 12:00 Saladelia 2002 OR DN9242 3/19 M and M Boggan 12:00 Cosmic Cantina 2002 3/20 SAR TALKS Anne Mathews / Ashley Lane 12:00 Sushi 2001 3/21 Chair’s Conference Chiefs 12:00 Rudino’s Med Res Library From the Residency Office Mini CEX Madness
Week 2 of Mini CEX Madness saw a total of 14 CEXs completed! Our winner for week # 2 is Alexandra Clark – congratulations! A special shout-out to Basem Matta and Brian Sullivan who each completed THREE CEXs in week #2! As a reminder, everyone who has a CEX done during the month of March will be entered to win a $50 dinner at the restaurant of their choice (alcohol not included.) Great job everyone!SAR’s – Licensing and Credentialing
SARS — If you would, please give all forms you have for licensing and credentialing to Lynsey Michnowicz. She will make sure that Dr. Zaas fills them out and sends them in. No need to email Dr. Zaas directly! Actually if you do there be greater risk that they may be lost in the volume of email received.Grand Rounds – Recording Attendance
Department of Medicine Grand Rounds is just one of the many learning opportunities that residents are strongly encouraged to attend. It is also one of the events that for which we track and record attendance in Med Hub. We understand that the changeover to ETHos in February may have caught a few residents off guard, which is probably why the conference attendance that we see in the data base has dropped, even though many residents can be seen sitting in the gallery. For reference, click on the following link for the directions to set up an account in ETHos, and YES – you do need log in each time to record your attendance at Grand Rounds. How to register with EthosFinancial Planning Seminar
We are sponsoring a brief financial planning seminar sponsored by The Benefit Planning Group (www.myBPGinc.com). BPG is the exclusive provider of disability and life insurance for residents and fellows at Duke. The firm works nationally with clients in every state and 600 cities. The seminar will be conversational in order to best address your topics of interest and focus particularly on the specific needs of physicians transitioning from training to practice.
Topics will include:
April 17 @ 5:00 in the Med Res Library
Marc C. Flur, CFP
Vice President, The Benefit Planning Group, Inc.
3400 Croasdaile Drive Suite 206
Durham, NC 27705
Hi everyone! Happy daylight savings time! #bestnighttobeonnightfloat!
Thanks to the chiefs for a hilarious face melding Trivia Bowl and for organizing intern day off! Gena Foster’s disbelief at the final jeopardy question was priceless. Glad to hear fun was had by all!
Week 1 of Mini CEX Madness and we are off to a great start – 10 completed! Of those, Kristen Glisinski is our first winner! Myles Nickolich and Ben Peterson share the award for “1st Trainee to have all 6 CEXs done.” Just a reminder, at the end of the month, everyone who has had a Mini CEX completed on them and submitted in MedHub will be eligible for the Grand Prize – a $50 dinner at the restaurant of your choice (alcohol not included). Many thanks to our amazing faculty for completing and submitting the evaluations as well.
Other kudos this week go to Yi Qin from Dr. Joe Rogers for a great diagnostic effort on CAD, to Jenn Rymer for a fantastic SAR talk, and to Bassem Matta and Dana Clifton from Dr Oddone for great work at the VA!
On Wednesday, we have our mock ACGME CLER visit, run by our DIO Dr. Cathy Kuhn. The real CLER visit is when the ACGME comes to see how our institution is meeting the goals of graduate medical education, and this Wednesday is our practice run. The visit will focus on patient safety (specifically how do you contribute to patient safety efforts at the hospital), supervision, fatigue management, and professionalism. What is your role? If a CLER team comes to talk to you while you are working, talk to them! Answer their questions. Be informed! Know what resources are available to you, such as the taxi service or PAS. When the real visit happens (we get 2 weeks notice), there will be a peer selection process for choosing residents to meet with the ACGME visitors.
This week’s pubmed from the program goes to Dinushika Mohogitte: Mohottige, D., Austin, C., and Hanson, L. C. (, May). Systematic Review of Decision Aids for the Seriously Ill. American Geriatric Society Annual Meeting, Orlando Florida.
Have a great week !! And, Go Duke!
AimeeThe “Clinic Corner”
We have two submissions this week, including a brief update from the Duke Outpatient Clinic (DOC) DOCMarchNews , submitted by Bronwen Garner, MD, and a 2nd submission from Alex Cho, MD, Associate Program Director for Ambulatory Care
For this week’s Clinic Corner, on Amb Care in general, wanted to reflect briefly on some of the changes in the ambulatory curriculum — and thank Stephen Bergin and Dani Zipkin for their leadership in kickstarting a makeover, beginning last year with Academic Half-Day (AHD), that will continue into next year and beyond.
The old (and wise) SARs may have dim memories of something called Pre-Clinic Conference, a case-based reading exercise that used the Yale Ambulatory Curriculum. In the words of this year’s Oscar-winning best original song, we let it go, to allow those who could to attend noon conference at DUH/DRH; and at the DOC, to enable resident participation in clinic meetings held over the noon hour, like Leadership every other Monday, and What’s Up DOC.
The focus of the general ambulatory curriculum has instead shifted to the reinvigorated AHD led by Dani, and this year, DRH/Ambulatory morning report — co-hosted by Stephen and the DRH ACR — which every week now highlights a different ambulatory topic. Next year, our ambition will be to augment these with some curated readings and other resources on important ambulatory topics like women’s health, which we (with Randy and Jen’s help) plan to make available in a central, universally accessible location like MedHub.
And all this is in addition to the movement to milestone-based observations and evaluations in the clinic (tied to graduated increases in autonomy); the annual Ambulatory QI project, led by the indomitable Jon Bae; and the ACLT.
Finally, for those who don’t like waiting, wanted to share a few resources you can access now, for ambulatory care (and medicine in general):
-Murat brought this somewhat intimidating but awesome resource to my attention, which includes full-but-quick lessons on key portions of the physical exam, including video!
-Aimee found this gem, a digital reader covering 24 different commonly encountered situations in primary care
-Last but not least, the Yale curriculum is yours to access freely — brief case-based vignettes on different ambulatory topics that include a review of relevant literature — and now we no longer have to withhold “the answers” from you!
Password for faculty section: bulldog7-5F
Password for resident section: robin7-5R
Have a great week! Alex
What Did I Read This Week? Submitted by Lynn Bowlby, MD
We often read and think about unusual diseases and cases. Equally important to get right is what we see every day. Often we become comfortable with those common conditions and don’t question our approach. But everything changes in medicine, and reviewing new information in common diseases that we think we know well is important!
This JAMA review is based on a Medline search for articles about UTI and older adults, 1946-2013.
The clinical spectrum of UTI ranges from:
Risk factors for recurrent symptomatic UTI: DM, disabled, recent sexual intercourse, urogyn surgery in past, urinary retention and incontinence.
Chronic urinary incontinence can make it very difficult to differentiate asymptomatic bacteruria from symptomatic UTI. Symptoms of urgency and incontinence can fluctuate in older women, even without infection.
One of the mainstays of evaluation,and so simple to use, the urine dipstick! There are important test characteristics to keep in mind–the sensitivity and specificity for a positive test is 82%, negative predictive value is 92-100%, so do it to R/O UTI, not necessarily to diagnose!
New dysuria is a sensitive indicator of symptomatic UTI in older women.
When to test urine in the lab? A clean catch, mid-stream, with properly cleaned labia, is the most effective, but rarely done properly.
The predominant pathogens remain E-coli at 50%, with other pathogens, Klebsiella, Proteus, and Enterococcus each < 10%.
Flouroquinolone resistance is greatest in pts aged 65 and older. 3 days of trimethoprim-sulfa is recommended as standard UTI therapy for otherwise healthy women. Nitrofurantoin is one of the first line agents for UTI, if CrCl > 60. Current evidence shows cranberry products may be helpful in prevention in older women, not so for oral estrogen. Topical estrogen may be beneficial. Chronic, suppressive antibiotics for 6-12 months can help with recurrent infections.
As simple as UTI can be, in older women especially, it can be complex to determine if a patient actually has an infection, and what the best testing and treatment can be. Challenging to make the best decisions for our patients.From the Chief Residents SAR Talks
March 11: Marcus Ruopp / Jeremyh GillespieGrand Rounds
Dr. Timothy Collins – Neurology
Topic: Migraine Evaluation
Noon conference on the 12th will offer you the opportunity to explore some of the things you might need to consider when you finish residency, including such topics as:
We don’t assume that we know ALL of the questions you might want to ask, so to help make sure yours in on the list, here is a chance to submit your question ahead of time using the following link:
The Ralph Snyderman MD GME Research Award was established in 2004 with a goal of encouraging and recognizing excellence in research involving GME. Winners are acknowledged with a prize of $1000 and their name on a plaque and will present at the May or June ICGME Meeting. The project must have substantial contributions from at least one GME Trainee (intern, resident or fellow) Examples of eligible projects include: evaluation of the impact of a new curriculum on resident knowledge and skills, using technology to increase quality of trainee “hand offs” at the end of call, using standardized patients to measure trainee’s skills at “communicating bad news”, using the patient simulator to teach and assess anesthesia. Past winners and their topics can be found at https://gme.duke.edu/trainees/snyderman-research-medical-education-award/snyderman-award-winners
Full Submission information at:
Interested in Hematology Onclology Fellowship?
Carlos DeCastro, MD, Fellowship Program Director, has arranged two times this month to meet with residents who would like to know more about Duke’s fellowship program. Both session, scheduled for March 11th and March 25th, are scheduled to be held in the Med Res Library at 4:00. For more information feel free to contact Sarah Overaker, Program Coordinator.On-Call Meal Benefit Times
Reminder that the on-call meal benefit is available to Housestaff from 7pm – 5am daily for residents who are working in house overnight. The purpose of providing a meal benefit to trainees has always been, and continues to be, to provide a meal to those trainees who are working in the hospital at night for the entire night. (e.g., at least 8 hours of continuous in-house work past 7 pm).
The meal benefit is not intended for use on the way home, or at other times of day. If you have questions, concerns, or suggestions, please contact your ICGME representatives or Dr. Christopher Hostler, head of the Resident Environment section.
Information/Opportunities Upcoming Dates and Events
The topic for this week’s Medicine Grand Rounds will be the department’s Faculty v. Resident Trivia Bowl.
This week’s Grand Rounds will not be live streamed or recorded.
Happy March! It’s the month of the match! And basketball! And hopefully warmer days! And, of course, MiniCEX Madness! We ended February well with an extraordinarily great showing at the NC ACP meeting. Congratulations to all of our presenters, and especially to Jennifer Rymer who won BEST RESEARCH POSTER, BEST OVERALL POSTER and THIRD PLACE for CLINICAL VIGNETTE and to Mike Woodworth who won BEST CLINICAL VIGNETTE. As Vaishali said, we basically swept it. Great work!
Kudos this week also go to Noah Kalman from the 8100 nurses for great communication, to Alan Erdmann from Brice Lefler for great work on VA Gen Med, and to Jennifer Creed, Lindsay Anderson, Carter Davis, Jeremy Gillespie, Trevor Poseneau, Michael Shafique and Kaley Tash for being part of DRH’s Maestro roll out! Hany El Mariah and Laura Caputo had fantastic SAR talks this week as well. Also a huge thanks to our most recent ACRs Mandar Aras, Lindsay Boole and Carter Davis for your hard work these past two months.
Thanks to Bill Hargett for the first “preparing for fellowship” meeting. A second meeting to replace the snow day will be announced ASAP.
This week’s pubmed from the program goes to Hany Elmariah for his resident burnout study poster accepted to the Duke Patient Safety and Quality Conference!
Have a great week — ask your attendings to fill out MINI CEX’s. Jen will be checking the MiniCex count at the end of the week. Those with minicex’s completed will be eligible for prize drawings.
What Did I Read This Week? Submitted by Murat Arcasoy, MD A Randomized Trial of a Three-Hour Protected Nap
What did the authors do?
The authors evaluated intern and patient outcomes associated with protected nocturnal nap periods of three hours that do not require an additional house officer to provide coverage. Two randomized controlled trials were conducted in parallel at an academic center university hospital and its affiliated VAMC. They examined the impact of the protected nap intervention on intern sleep, periods of prolonged wakefulness, sleep disturbances, an objective measure of behavioural alertness, and patient outcomes during extended duty hours (30-hours) in 2010-2011.
Why did the authors perform this study ?
As our SARs will recall, concerns about prolonged duty hours had led to the 2011 ACGME requirements mandating that duty hours for residents in PGY-1 not exceed 16 hours. For more senior residents who could still be scheduled to work 24 continuous hours + 4 hours for transfer of care, the ACGME strongly encouraged the use of alertness-management strategies such as “strategic napping” especially after 16 continuous hours of duty and especially between the hours of 10 pm and 8am. The authors asked if strategic napping during 30 hour duty could be an alternative to mandatory short shifts. Previous studies of protected sleep periods for interns resulted in increased amount slept and improved cognitive alertness but required supplemental personnel. The authors set out to determine whether a sequential protected sleep period of 3 hours (one intern sleeps from midnight to 3 am and the second sleeps from 3 am to 6 am) is feasible and effective in increasing the amount slept on extended duty overnight shift (30-hour) without extra personnel.
What was the methodology?
The authors assigned 94 interns at the VAMC and 61 interns at the university hospital to two randomized blocks during the study year, consisting of 12 four-week blocks. The standard schedule (control) months consisted of one resident and two interns on call on night float with both interns admitting patients throughout the night and responsible for cross-coverage until 7am, working a total of 30 hours (in 2010-2011). The intervention schedule incorporated the protected 3 hour nap periods as above and the interns were assigned to alternate between the early (12 midnight-3am) and the late (3am-6am) protected period. During the protected period they gave their cell phone/pagers to the night float resident. Each intern wore an Actiwatch a device that contains a sensitive accelerometer to measure physical motion, collecting data in 1-minute epochs. They completed a 3 minute Psychomotor Vigilance Test each morning and every night and filled out an electronic sleep log. Patient outcomes included length of stay, discharge to the MICU, death and 30-day readmission.
What did the authors find?
Interns with protected sleep periods were less likely to have on-call nights with no sleep (6% vs 21%), significantly longer sleep durations compared to controls and had fewer attention lapses on the psychomotor test. Proportion of interns reporting sleep disturbance was significantly lower in each of the protected sleep periods(57% vs 89% P<0.0001). There were no differences in any of the patient-level outcomes except VAMC patients cared for by the control group compared with the intervention group had shorter length of stay. Interns in both groups left the hospital at the regular time.
What are the conclusions of this interesting study?
This is the first examination of a personnel-neutral protected sleep period during extended work periods (30 hours). Strategic napping provides an alternative to mandatory short shifts, such as the 16 hour shifts, that create significant discontinuity in both care and education. Comparative effectiveness research of alternative forms of fatigue management would inform the optimum way of reducing house officer fatigue while preserving and enhancing the quality of education.From the Chief Residents SAR Talks
March 4: Amanda Elliott / Jenn RymerGrand Rounds
Chief ResidentsNoon Conference Date Topic Lecturer Time Vendor Room 3/3 MKSAP Mondays - General Internal Medicine Chiefs 12:00 Subway Med Res Library 3/4 SAR TALKS Amanda Elliott / Jenn Rymer 12:00 Bullock’s BBQ 2003 3/5 IM-ED Combined Conference 12:00 Cosmic Cantina 2002 3/6 Christina Sarubbi from ID–topic TBD Christina Sarubbi 12:00 Saladelia 2001 3/7 Chair’s Conference Chiefs 12:00 Rudino’s Med Res Library From the Residency Office Hoops Watch Invitation/Reminder ….
Join local DukeMed alumni from the classes of 2004-13, current and recent house staff to cheer the Blue Devils on to victory over our Tar Heel neighbors!Duke Blue Devils vs. UNC Tar Heels
Saturday, March 8 | 8:30 pm Tyler’s Taproom 324 Blackwell St Durham, NC 27701 (919) 433-0345
Complimentary appetizers and one drink ticket per person provided.
Pain Narrative for Primary Care
Pfizer, Community Care of North Carolina and The Governor’s Institute invite you to attend an informational program on pain management: Tuesday, March 4th, 2014
“Pain Narrative for Primary Care”, featuring Ashwin Patkar M.D.
(Please use the registration link for this program) https://prolazdurham.eventbrite.com
Immediately following the Pfizer presentation Community Care of North Carolina & The Governor’s Institute Presents: A Guide to Rational Opioid Prescribing, featuring Ashwin Patkar, M.D.
7:00 PM – Informational Program
If you are thinking about completing a fellowship in GI, the following is an opportunity to add to your schedule.
F0r more information feel free to touch base with Jill Rimmer, GI Program CoordinatorHealth Care Value For Physicians: Understanding Quality and Cost
With recent health care reforms and changes in reimbursement impacting how we practice, understanding quality and cost is an increasingly important part of medical training. The GME Incentive Plan Task Force is please to announce a 6-part lecture series: Health Care Value for Physicians: Understanding Quality and Cost led by representatives from the School of Medicine and health system administration. These lectures are geared towards house staff, but are open to anyone.
All lectures will be held in the Trent Semens Center: Time: 7:00 – 8:00pm in the Trent Semens Center
Light refreshments will be served – including cheese from around the world
The complete schedule can be found on the following attachment: Health Care Value Lecture Series
March 5: Pay for Performance under the Affordable Care Act
Jennifer Rose, Director, Performance Services, DUHS
March 19: Performance Measurement
Bill Burton, Vice President, Performance Services, DUHS
March 26: Quality in Healthcare
Bimal Shah, Director of Quality, Department of MedicineLiability Insurance Information
For those who are finding themselves filling out the vast packets of information required for fellowship or credentialing packets, please note the following information regarding liability insurance:
Hello everyone! What a great game last night, and great turnout at Tobacco Road! Krish is definately hoarse from cheering. We are gearing up for March Madness, which also brings us to the time of year for “MiniCex Madness!”
As exciting as March Madness it is not, however direct observation and feedback from your inpatient and outpatient attendings is a critical component of your development as physicians, so we want to make an effort for everyone to have at least 2 (but hopefully more) minicex’s completed during March. Each week we will check medhub, and whoever has had Minicex’s completed will be eligible for prizes, including Starbucks cards, new cars and tickets to the Duke Carolina game (well….maybe not). SO…ask your inpatient and clinic attendings to do a MiniCex while you are working with them, or ask an APD or chief to come observe you if you are on a non-medicine service.
In other big news, the “Doximity” survey rated us as one of the top residency programs in the US. They surveyed internists who are doximity members, and we did extremely well, and particularly well among program directors. Very cool to see. What they didn’t publish is what program has the best residents….clearly we are #1 in that regard!
Thank you again – we had 87% compliance on our ACGME survey! Results to come in June!
This week we have kudos to Hal Boutte for coming in on his day off to talk to some second look applicants, to Tony Lozano for his care of a patient overnight on Gen Med (from Tom Holland), and to Bobby Aertker, Jim Gentry, Alex Clarke and Lauren Porras for the past two weeks of outstanding SAR talks.
The NCACP meeting is Friday and Saturday in Greensboro! We are very proud of everyone who has posters to present! This week’s pubmed from the program goes to all who are preseentingt at the ACP – 27 posters in all, a record number. Check out the following list: ACP Presentations 2014
Have a great week!
QI Corner (submitted by Joel Boggan)
Thank yous: To Lish Clark, Alistair Smith, Drs. Teiling and Ossman from the ED, and Yvonne Spurney and Miranda from Nursing as they helped lead our first new Resident M&M discussion on Wednesday. Our next date is Wednesday, March 19th, again in 2002.
Thanks also to Ryan Schulteis for accompanying me on High Value Screening and Prevention on Thursday – our next date is March 26th with Alex Cho.
Here are our totals through the end of January, by unit – help us make a strong, compliant push to the end!
Non Compliance YTD
Hand Hygiene Rate YTD
88.1%Submited by George Cheely, MD
Subject: “Health Care Costs and the Future of Big Medicine”
What: Guest Health Policy Lecture: “Health Care Costs and the Future of Big Medicine: Perspective of the Commonwealth of Massachusetts Health Policy Commission”
Who: Stuart H. Altman, Ph.D.; Sol C. Chaikin Professor of National Health Policy; The Irving Schneider and Family Institute for Health Policy; Heller School, Brandeis University
Where: Room 3037, Duke Law School, (Across Science Dr from Cameron)
When: 12:00pm on March 3rd
Why: Come on now. Health care? It’s expensive.
Clinic Corner – Ambulatory Care submitted by Alex, Cho, MD
As the email that went out earlier this month said, our desire was to reward residents who volunteered for at least three (3) Ambulatory Mini CEX observations – and who were rated to be at or above their expected level in the clinic for their stage of training — with advancement in the level of autonomy with which they would be able to practice in clinic. Eligible residents should hear soon, if you have not already; and if you have not we encourage you to be proactive in reaching out to the site directors/clinic Stead leaders re: what areas you might work at a little more, both in additional Mini CEXs and in general.
And for those who still need more observations to qualify for consideration for advancement, the list of newly-eligible residents will be refreshed each month, for potential “promotion” the following month.
Finally, for your reference below are some links to a few documents: the Ambulatory Mini CEX form, a one-pager describing the three “precepting levels,” and courtesy of Larry Greenblatt, a brief summary of SNAPPS, one of the signout frameworks that promoted SARs can now use instead of the conventional narrative one.
In closing, I want to stress again that doing Mini CEXs is not meant to be a value statement on individual residents, but a standing invitation for mentored improvement. Or, as Sharon Rubin sez: “We still believe in performing CEXs on our residents in the second half of the year.” Because she, as all of the attendings do, believe in all of you, too.
National Trends in Patient Safety for Four Common Conditions, 2005-2011
Yun Wang, Ph.D., Noel Eldridge, M.S., Mark L. Metersky, M.D., Nancy R. Verzier, M.S.N., Thomas P. Meehan, M.D., M.P.H., Michelle M. Pandolfi, M.S.W., M.B.A., JoAnne M. Foody, M.D., Shih-Yieh Ho, Ph.D., M.P.H., Deron Galusha, M.S., Rebecca E. Kliman, M.P.H., Nancy Sonnenfeld, Ph.D., Harlan M. Krumholz, M.D., and James Battles, Ph.D.
Why did I read this? This article provides an interesting overview on the impact of the many patient safety initiatives on in-hospital adverse events in the U.S. over the past decade. It takes a pooled analysis approach of the multitude of safety campaigns, program, and initiatives and drills it down to specific adverse events with 4 DRGs. Specifically twenty one well defined clinical outcomes (CLABSI, CAUTI, falls, hosp. acquired C Diff., VAP, contrast nephropathy, hypoglycemic events and Anticoagulant complications, hosp. Acquired MRSA/VRE etc.) are evaluated instead of more surrogate markers of quality such as readmit rates, length of stay and ED throughput times. I think of it as a report a card on U.S. hospitals.
On a more personal note, this article also hit home because I started as a hospitalist just prior to this database and Hospital Medicine has often played a significant role in patient safety and quality. Lastly I read this because being an AHRQ sponsored project I thought there may be some insight into the future direction CMS may take us.
Methodology: Data was abstracted from the Medicare Safety Monitoring System for 21 adverse events in patients hospitalized in the U.S. from 2005-2011. The final sample size was 61,523 patients with 4 different conditions (AMI, PNA, CHF, and surgical conditions). Patients were from over 4000 U.S. hospitals representing a comprehensive view of care delivery in the U.S. Events were trended over the course of 6 years, cohorts were broken up into 2 year subsets (2005-6, 2007 and 2009, 2010-11). There was additional stratification by age, race, gender, and comorbidities were also assessed. In general, age and gender was generally consistent across the 3 cohorts, race was skewed with a predominantly white (85-90%) population. Patient comorbidities over time also showed mild increase as a general trends with increasing obesity (14 to 22%) being the most significant increase, there were also subtle increases in diabetes, cancer and renal disease.
What they Found: Overall, adverse event rates declined substantially among patients hospitalized for CHF and AMI but not for PNA or conditions requiring surgery. For AMI the occurrence rate for adverse events decreased from 5 to 3.7 % and for CHF 3.7 to 2.7 % but for folks with pneumonia and surgical conditions the rates overall didn’t change. Most of the deceases seen in AMI and CHF were similar to a particular adverse event (see table S5).
Looking at across different adverse events there were some trends regardless of the DRG. There was a decease with digoxin related events, hypoglycemic agents, and warfarin but increased with LMWH and Factor Xa Inhibitors. CAUTI, CLABSI, VAP and post op PNA decreased but C.Diff, MRSA, and VRE rates stayed about the same.
What is next: This is a really fascinating article and I am really just scratching the surface here. The article does not extrapolate as to why there was such a difference between DRGs and it is difficult to hypothesize why the pneumonia and surgical populations didn’t see a change in total adverse events. Are these two DRGs different populations all together or are CHF and AMI patients “seeing” a different version of care in general?
Furthermore many of these adverse events in and of themselves are worth further detailed investigation as to why they have changed over the years. Some may be explained simply by decrease usage (digoxin and IV heparin) or increased usage (LMWH and Factor Xa inhibitors) while others may be impacted by changes in the literature (hypoglycemia and the NICE-Sugar trial).
My general impression is that there have been improvements in adverse events in specific DRGs as well as in specific events (CAUTI for instance), but we are still learning how to manage newer medications such as LMWH and Factor Xa inh. We also haven’t made great improvements in some of the common infection rates (Cdiff, MRSA and VRE) despite that being a focus in many hospitals. Maybe the fact that these infection rates are not increasing is a sign of improvement although it is worrisome regardless.
Patient comorbidities and complexity also seem to be increasing in both medicine and surgery which also may pose future challenges. The jump in obesity was most alarming. However the fact that we are seeing more complex patients maybe means we are doing a better job at treating illness and prolonging survival. Its hard to say.
I suspect that once CMS teases out this data we will see a call to action and more initiatives or metrics around improving some of these opportunities. However I feel that with this first round of initiatives we have made significant inroads in world of patient safety and we are making the hospital a safer place for our patients.From the Chief Residents SAR Talks
February 25, 2013: Drs Dolger and Mouser
February 27: Drs Caputo and ElmariahGrand Rounds
February 28, 2014: Dr. LanasaNoon Conference Date Topic Lecturer Time Vendor 2/24 MKSAP Mondays – Pulmonary Chiefs 12:00 Picnic Basket 2/25 MED PEDS SAR TALK (Dolgner/Mouser) 12:00 Chick-Fil-A 2/26 MSK Exam Part 2 Irene Whitt & Lisa Criscione 12:00 Cosmic Cantina 2/27 SAR TALKS Laura Caputo / Hany Elmariah 12:00 Pita Pit 2/28 Research Conference 12:00 Panera From the Residency Office I’m Clear, Your Clear, We’re All Clear About This Consultation - with Dr. Chad Kessler (Deputy Chief of Staff, Durham VA Medical Center).
Wednesday, March 26th 12noon – 1pm (DN2003)
1. Develop a conceptual framework for communicating with and understanding different colleagues in medicine.
2. Demonstrate the 5-C’s of Consultation.
3. Integrate the clinical science of communication into daily practice.
Also, please remember to join us for our regularly scheduled March session – “Risk Management Issues Involving Learners” with Barbara Hendrix (Director, DUHS Clinical Risk Management).
Please use the following link to register:
The Warren Society is hosting a Trivia Night for all the Stead Societies this upcoming Wednesday, February 26, at 7PM at the Carolina Ale House (3911 Durham-Chapel Hill Blvd Durham, NC)! Dinner starts at 7PM and trivia starts at 8PM. We’ll donate $100 to a charity chosen by the Stead Society with the most trivia points!
Hope you can make it!
Thanks!! Steve Crowley
Hoops Watch invitation – Let’s try this again…
Join local DukeMed alumni from the classes of 2004-13, current and recent house staff to cheer the Blue Devils on to victory over our Tar Heel neighbors!Duke Blue Devils vs. UNC Tar Heels
Saturday, March 8 | 8:30 pm
324 Blackwell St
Durham, NC 27701
Complimentary appetizers and one drink ticket per person provided.
Duke-NUS Graduate Medical School Singapore: Longitudinal Integrated Clerkship (LIC) Pilot Call for LIC Teaching Fellow (Academic Year 2014-2015)
INTERESTED PERSONS SHOULD CONTACT PATRICIA JOSEPH, DIRECTOR, OFFICE OF DUKE-NUS AFFAIRS AT firstname.lastname@example.org
Details can be found in the following attachment: teaching fellow
Income-Driven Repayment Plans and Loan Forgiveness Programs
Wednesday, February 26 7:00pm – 8:00pm
The Learning Hall, Trent Semans Center for Health Education
You will not want to miss this presentation by Paul Garrard, an independent student loan consultant and national expert on educational debt management, scheduled for Wednesday night, February 26, 7:00p in the Learning Hall at TSCHE.
Mr. Garrard will be joined by Heather Jarvis (see www.askheatherjarvis.com), a national student loan expert and Duke University School of Law alumni, who does workshops nationwide on income-driven repayment and forgiveness programs.
Ms. Jarvis and Mr. Garrard will provide details on Income Based Repayment (IBR) and the new Pay As You Earn (PAYE) repayment plans, and the forgiveness programs associated with each, including Public Service Loan Forgiveness (PSLF).
This workshop is open to all residents, fellows, medical students, and health profession students at Duke. Please sign up using the following link: https://www.surveymonkey.com/s/6QWPH72
Should you have questions, please contact Amy Coppedge at email@example.com.
Assigning Your DOC In-Basket When You Are Away (submitted by Jessica Simo)
To assign your In Basket to another member of staff when you will be away from work for a while:
By popular demand board review sessions are scheduled on the following dates: March 13 and 27; April 10 and 24; May 15, 29; June 12 and 19. All sessions are held in the Med Res Library from 7-8 PM. Light dinner is served.The Commonwealth Fund: Pursuing a High Performance Health System in the ACA era”
Dr. David Blumenthalm President
February 26, 2014 4:30 – 6:00 pm Rhodes Conference Room Sanford Building, 2nd Floor 201 Science Drive
David Blumenthal, M.D., M.P.P., is president of The Commonwealth Fund, a national philanthropy engaged in independent research on health and social policy issues. He is formerly a Professor of Medicine at Harvard Medical School and Chief Health Information and Innovation Officer at Partners Healthcare System in Boston. From 2009 to 2011, he served as the National Coordinator for Health Information Technology, with the charge to build an interoperable, private, and secure nationwide health information system and to support the widespread, meaningful use of health IT. He succeeded in putting in place one of the largest publicly funded infrastructure investments the nation has ever made in such a short time period, in health care or any other field. He is the author of more than 250 books and scholarly publications, including most recently, Heart of Power: Health and Politics in the Oval Office. He is a recipient of the Distinguished Investigator Award from AcademyHealth, an Honorary Doctor of Humane Letters from Rush University and an Honorary Doctor of Science from Claremont Graduate University and the State University of New York Downstate.
Information/Opportunities W-HOSP flier- 02 2014 W-IM OP flier- 02 2014 Tal and Associates Upcoming Dates and Events
In the first-ever, large-scale survey of physicians on the quality of postgraduate training programs, Duke Internal Medicine Residency Program came in 6th.
Survey recipients were invited to name up to five programs they believe to offer the best clinical training in internal medicine. Doximity, an online network with more than 250,000 physician members, conducted the survey through a combination of Web notifications and emails sent to 18,695 members who have completed a U.S. residency in internal medicine. The response rate was 18.2 percent.
While the physician sample for the residency survey should not be considered a ranking, it appears to be the first major effort to measure doctors’ views on a formative part of medical training. In all, 2.2 percent of U.S. internists completed the survey. Read more about the survey and results.
What a crazy week! An enormous thank you to the chiefs and the entire program for your hard work and resilience during the snow. Krish, Vaishali and Stephen showed incredible leadership and organization. Special thanks to Lynsey Michnowicz for making sure you were fed during the day too! Let’s hope for only warm weather and sunshine for awhile.
Other kudos this week to Brittany Dixon from Michael Minder for great patient care on cardiology, to Eric Pollack for his gold star, to Titus Ng’eno for getting the diagnosis of Amera Ramatullah’s awesome DRH report case and to med student Adam Barnett from Michael Boniface for great work in the ED.
We will be rescheduling the fellowship meeting so watch your email.
We hit our target of 85% for the ACGME survey! It closes at midnight tonight so there is still time to do even better – so if you haven’t filled it out, please do. Thank you to everyone who filled it out – much appreciated. SARS have the best participation at 98%! Results won’t come back to us until July but we will be compiling other feedback for your review in the upcoming State of the Program.
This weeks pubmed from the program goes to John Stanifer and Scott Tolan. Included also is a photo of the first author atop Kilimanjaro!
The epidemiology of chronic kidney disease in sub-Saharan Africa: a systematic review and meta-analysis; John W Stanifer, Bocheng Jing, Scott Tolan, Nicole Helmke, Romita Mukerjee, Saraladevi Naicker, Uptal Patel
Have a great week!
AimeeQI Corner (submitted by Joel Boggan)
New M&M Conference this week
This week we have two QI-related conferences. First, on Wednesday, 2/19, Lish Clark will be debuting our new Resident M&M conference with a fantastic case. Please be sure to come for what we hope will be a lively discussion.
High-Value, Cost-Conscious Care Conference
On Thursday, 2/20, we have next installment of the HVCC series on High Value Screening and Prevention. We’ll also have hand hygiene and We Follow-Up updates to share beforehand. . .
NC ACP Posters
Just a reminder to congratulate your peers who have posters at the NC ACP meeting on 2/28!
Hand Hygiene Environmental Sampling
A special thank you to the dirtiest part of our daily hospital lives, the computer keyboard – here sampled by the incomparable Aimee Zaas! Note the awesome CONS and Bacillus colonies growing a few days later!
“Submitted by Sarah Rivelli, MD.”
Chad S. Kessler, MD, MHPE, Yalda Afshar, PhD, Gurkiran Sardar, MD, Rachel Yudkowsky, MD, MHPE, Felix Ankel, MD, and Alan Schwartz, PhD
ACADEMIC EMERGENCY MEDICINE 2012; 19:968–974
Why did I read this? I went to Medical Education Grand Rounds, and heard Dr. Chad Kessler of DVAMC (Emergency Dept and Deputy Chief of Staff) talk about his research in consultation – how to do it well and how to assess this. Communication and interpersonal skills are core competencies, and the foundation of effective consultation with other providers and specialties. We know that challenges in communication account for many medical errors, improving communication in consultation could improve patient safety. Moreover, as medicine becomes more and more multidisciplinary, consultation is something we need to do well.
As an IM/EM trained doc, Dr. Kessler recognized the importance of effective consultation – particularly in the ER where up to 40% of all ER patients get a consult. He conceptualized a framework for consultation called The Five Cs of Consultation. This framework can help you put a consult into words and elicit effective help from other specialties. The 5 Cs of Consultation was developed from a prior study he conducted on qualitative analysis of ED consultations and was also shaped by a model existing in the business world.
Here is the framework:
The 5 Cs of Consultation
Methods: In this study, they randomized 43 EM residents to an intervention or control. The intervention was a 90 minute educational session on consultation, which included didactics on the 5Cs, role-playing, trying out the 5 Cs with a simulated case and direct feedback. The control group received general education about consultation. The residents tried calling consults on two simulated cases and were recorded. The outcome measure was global ratings (GRS) by three blinded physicians who listened to the cases.
What they found: Controlling for PGY level, case, and rater covariates, residents in the intervention group had significantly higher mean GRS scores than those in the unstructured group. Interestingly, they found no progression in consulting skills with increasing PGY level, either overall or among residents unexposed to the intervention. This suggests that effective consultation needs to be taught in a structured way as opposed to trainees picking it up on the fly.
What’s next? Consider giving the 5 Cs a try next time you call a consult. To help you out, there is a checklist evaluation for this process, which has also been published. Check it out:
Validity Evidence for a New Checklist Evaluating Consultations,
The 5Cs Model
Chad S. Kessler, MD, MHPE, Priyanka S. Kalapurayil, Rachel Yudkowsky, MD, MHPE, and Alan Schwartz, PhD
Academic Medicine, Vol. 87, No. 10 / October 2012
Ambulatory Care Leadership Track (ACLT)
Congrats and an official welcome to the newest members of the Ambulatory Care Leadership Track (ACLT)!
On behalf of Stephen, Dani, and Aimee; and the Amb Care faculty and the program as a whole, I wanted to welcome Ryan, Matt, Dinushika, Amy, Adrienne, Jim (for a second time), and Jake to the ACLT, which Larry had created a couple of years ago to give our residents interested in primary care and ambulatory subspecialties the opportunity to pursue those interests through additional clinical, didactic, social and other experiences. We are excited to have you all join next year’s ACLT SARs Claire Kappa and Brice Lefler for blocks beginning in August, giving us a strong cohort of four JARs, three SARs, and – for the first time, two of our Med/Psych colleagues as well, who will be participating when schedules permit.
We were also glad to have already had some of you with us for last month’s inaugural ACLT “mid-winter classic” at Alivia’s, and look forward to having you join us again in late May/early June for a year-end dinner event to honor current ACLT SARs Kim Bryan (who just gave birth to baby boy Jason, yay!), Alex Clark, Jen Chung, Jeremy Halbe, Jodel Giraud, and Lauren Porras.
The current ACLT group has just started their February block, pioneering a new take on applied EBM w/Dani Zipkin, as well as a new pain and addiction medicine clinical experience at AIM Health Services. And we are already busy planning for the May block, which starting this year will feature a trip to DC with our government affairs office to provide experience in legislative advocacy. So there’s lots to look forward to.
Let us know if you have any questions, and once again, welcome!
“Clinic Corner” – VA Medical Center PRIME Clinic
Thank you, thank you, thank you. I wanted to take the time to write a personal note from me to you. I would like to thank each and every one of you for contributing to being the best resident run clinic I have ever had the opportunity to be a part of. Your dedication to this clinic has made it possible to carry on the VA’s mission to support the well-being and lives of our nation’s veterans.
In the past year you have been part of so many changes and accomplishments. The PRIME clinic has been essential in providing more timely access for our veterans, the percent of patients waiting >14 days for an appointment has decreased from 6% to 0.56%. This was possible because of your hard work and dedication to the clinic, seeing new patients and transferred patients from other clinics that have lost Primary care staff.
My hope for the future is to work with all of you to build on…and continue to make this the best place to learn, grow and treat our patients.
Currently there are many projects in place that I will give you updates on as we get data.
Thank you for your dedication and I look forward to working together to make PRIME clinic even better for you.
From the Chief Residents SAR Talks
February 18 2013: Alex Clark; Lauren PorrasGrand Rounds
Dr. McMahonNoon Conference Date Topic Lecturer Time Vendor Room 2/17 MKSAP Mondays – Nephrology Chiefs 12:00 Subway 2002 2/18 SAR TALKS Alex Clark / Lauren Porras 12:00 Bullock’s BBQ 2002 2/19 M&M Alicia Clark/Alastair Smith 12:00 China King 2002 2/20 QI Patient Safety Noon Conference – High Value Prevention and Screening Boggan / Schulteis 12:00 Domino’s 2001 2/21 Chair’s Conference Chiefs 12:00 Rudino’s 2002
From the Residency Office SAR Class Pictures
To be rescheduled – will let you all know when asap!Regional GI conference at the University of Virginia
“I am currently organizing a regional GI conference at the University of Virginia and wanted to be sure to reach out to you and your medicine program as we have added a new resident/fellow research symposium.
We will be accepting abstracts and the top 20 will be invited to present and receive a research award along with a free night of lodging at the conference executive inn.
Please accept our invitation below and the call for abstracts.”
Assistant Professor, Gastroenterology and Hepatology
Associate Program Director, Internal Medicine Residency
Associate Program Director, Transplant Hepatology
Please use the following link to our website where the application instructions, forms and NIH format biosketch example can be downloaded .
Please feel free to email firstname.lastname@example.org with any questions
Congrats interns on finishing a long post-holiday block! The days are getting a bit longer, and hopefully it will get a bit warmer soon, too. There are a lot of exciting things happening in the program in the next few months, so please take a look at the important dates posted at the bottom of Med Res News! This week, we have the first “Fellowship Information” meeting on Feb 12 in the Med Res Library as well as the Duke-Carolina game at Tyler’s, sponsored by the Duke Med Alumni association. The “Fellowship Information” meeting is for rising SARs thinking about applying to fellowship this summer, as well as current SARs who deferred fellowship plans this year. Looking forward to seeing you there.
We had another successful week of the new and improved noon conference! On MKSAP Monday, we proved that we know more about anticoagulation than we do about rheumatology, we heard fantastic global health themed SAR talks from Lindsay Boole and Scharles Konadu, a great review of the novel oral anticoagulants from Krish, and solved some challenging outpatient anticoagulation cases with our DOC pharmacists Shannon and Ben. We finished the week with a great Chair’s Conference presented by Carling Ursem! A belated congratulations to Rebecca Sadun and Shaliesh Balasubramanian on great SAR talks last week as well.
Thanks Lynn Bowlby and the DOC team for a great visit to the DOC this week. It was great to see the precepting process, talk with the residents and staff and also bump into Sonal Patel from VA PRIME who was visiting the DOC to learn about some of the best practices that happen there.
Congratulations to our 2014-15 Assistant Chief Residents!
Other kudos this week go to Dinushika Mohogitte from her VA JAR Carli Lehr for her great work on VA Gen Med and to Duke ACR Lindsay Boole and the recent Duke night residents from the Duke ED attendings for a stellar job managing 1010 during a very very busy month. Also another thanks to ED Program Director Josh Broder for arranging ULTRASOUND SIM TRAINING for our residents when they rotate through the ED. This is a fantastic opportunity to learn ultrasound technique. You will receive an email prior to your ED rotation telling you how to sign up. Did you already have ED this year and want to do ULTRASOUND SIM TRAINING? Please contact me and we will work with you to find a time to train.
Welcome to the newest member of the Duke Family….Jason Daryl Bryan, born on Feb 7th! Congratulations to the Bryan Family
We have hit the magic “70%” mark for the ACGME survey. Thank you to everyone who filled it out so far. This is great, but last year we got to 84%. If you have not done your survey yet, please take 10 minutes to complete your survey. Ideally, we would get 100% participation….if that doesn’t happen, let’s at least match last year! SARs are in the lead for the most participants. The survey closes on FEB 16.
This week’s pubmed from the program goes to Hany Elmariah! Hany is one of 11 residents in the United States who is a recipient of the 2013 American Society of Hematology HONORS (Hematology Opportunities for the Next Generation of Research Scientists) Award . This is Hany’s ASH HONORS project.
Mentor: Marilyn Telen, MD; American Journal of Hematology 2014 Jan 30. doi: 10.1002/ajh.23683. Factors Associated with Survival in a Contemporary Adult Sickle Cell Disease Cohort Elmariah H, Garrett ME, De Castro LM, Jonassaint J, Ataga KI, Eckman J, Ashley-Koch AE, Telen MJ.
Have a great week, and GO DUKE!
AimeeQI Corner (submitted by Joel Boggan)
Hand Hygiene 8th Floor Cultures
Thanks to our fantastic Gen Med teams who allowed us to culture the implements we use to do our every day work. Just to bring out a highlight, you can see two of my favorite pictures from the wards, along with a late push on day 2 from a foam dispenser on 8300 to grow the grossest stuff imaginable. We will have updates from our Micro lab this week on what sort of bacteria we picked up, as well as a winner (by Wednesday) of the cleanest / dirtiest item on the ward.
Our next High-Value Cost-Conscious care lecture will be on 2/20. We are also planning on leading a resident M&M format on 2/19, so stay tuned for more details and make a special effort to join us!
Save the Dates
Please plan to stop by and see your fellow residents’ work at the Duke 9th Annual Patient Safety and Quality Conference on 3/13/14. Location and time of poster sessions will be determined soon!
Next PSQC meeting
This coming Wednesday, 2/12, at 5:30 in the Med Res Library, we will be having our February meeting of the Patient Safety and Quality Council. Please RSVP if you’re able to make it so I can order enough food, otherwise please feel free to show up last minute!
What Did I Read This Week?
“Submitted by Joel Boggan, MD.”
Sanjay Saint et al. Am J Med. 2000. 109: 476-480.
I read this older article this past week after joining a Durham VA team serving as part of a VA national collaborative to reduce catheter-associated urinary tract infections (CA-UTIs). This topic was a big focus at Duke Hospital last year, and we will be working on reducing the number of catheters over at the VA over the next several months. The collaborative is being led by thefirst author of this study, who performed this study back in 2000 after previous literature had shown almost ¼ of urinary catheters to have been inappropriate by accepted indication, and that these inappropriately placed catheters accounted for up to ½ of patient catheter-days.
The authors’ hypothesis was that physician team unawareness of the presence of catheters led to these inappropriate catheters being left in place, and that catheters of which physicians were aware would be more likely to be appropriate.
Methods: Over an eight-month period, students and physicians at 4 teaching hospitals intermittently were asked a series of questions (usually once monthly) about the presence of urinary catheters in patients for whom they were responsible. They were all allowed to use whatever documentation they had with them (cards, lists, etc) to answer the questions, but they were not allowed to use records or examinations at the time they were asked. The authors then compared the student and physician responses to the actual presence or absence of a catheter corresponding to the time frame in which the provider was asked. To assess the appropriateness of catheterization in patients with catheters, the researchers then determined if the catheter was in place for one of five situations deemed appropriate.
Results: 256 providers responded to the survey over the study period, including 76 students, 72 interns, 59 residents, and 49 attendings. 25% of observed patients had an indwelling catheter, of which providers were unaware 28% of the time. Students were the most likely to know about catheters in patients they were following (21% unaware), while attendings were least aware (38% unaware). Respondents were correct 96% of the time about patients without an indwelling catheter. The only significant factor in logistic regression predicting unawareness of the catheter was the number of patients being taken care of by a team at the time of survey. 31% of catheters were in place inappropriately by their criteria, and inappropriate catheters were much less likely to be known to be in place by the primary team (21% unaware for appropriate vs 41% for inappropriate, p<0.001).
What does it mean? Overall, providers had substantial lack of knowledge about indwelling catheters in their patients, particularly if the reason for the catheter being in place was not one typically considered ‘appropriate’. This, again, is an older study, and the landscape around CA-UTIs, in particular, has changed significantly in the past fourteen years. Hospitals (and payors) track these rates of infection much more closely, and institutions have emphasized putting this information in front of providers, especially hospitalists. As a result, I would expect that 1) the overall use of catheters has been reduced and 2) that providers are more aware of ones that are present. Of course, I don’t know if that is true. So, for our housestaff, don’t be surprised if I come bug you the next time you’re rounding at the VA to ask similar questions . . . and, in the meantime, if you haven’t made presence of/need for a catheter part of your daily rounds, please do!“Clinic Corner” – Pickett Road
Hello from Pickett Road. You missed all the commotion yesterday when a transformer blew and the clinic had to close for the morning. This closed off the power for most of the block! Fortunately the power came back on and we are operating as normal. Lets hope we survive 6 more weeks of winter.
We are into our 3/6 week of the Pickett Road Weight Loss Challenge. Doctors, CMA LPN, RNAs, MA and front desk are participating. The pot is over $130 at this point. Encourage our staff to stay strong and healthy!
Miles brought up and issue on call this last week. He was getting calls for General Internal medicine. Residents at Pickett Road are only responsble for patients at Pickett Road, not the peds, or DOC or General Internal medicine. If there are issues please let your attending on call that week know and also tell the telecom that those patients need to be triaged to the appropriate practice.
Glenn has worked on the templates for the SARS, there should be no new patients on your schedule. Now is the time for SARS to let your patients know you are leaving in June. Closer to March, April you may want to assign your more difficult patients to a rising intern or Jar (let the Intern or Jar know and reassign PCP).
I have not yet gotten any emails for the Pickett Roads three committees. We have PIPS (work on patient safety), Patient satisfaction and work culture. This is NEW here at Pickett which we have implemented in the last few months. The challenge is getting here for the meetings. The PIPS and Patient Satisfaction committee meets the first Wednesday of the month from 7:30-8:20am and the Work Culture meets the 3rd Wednesday of the month from 7:30 – 8:20am. If you are interested please let me know. This is your clinic and if you have ideas to make things better we would be glad to have your input.
EPIC : try to get your patients signed up for my chart, including:
Thanks to Nina and Miles for bringing this to my attention. YES there is a problem with Medicare patients and Diabetic supplies. Residents are not signed up for Provider Enrollment Chain Ownership System (PECOS). I have brought this to the ambulatory leadership and we are trying to figure out the best way to get ALL residents enrolled. More to come later.
And lastly our Maestro Updates from Lisa Nadler incoude the following:
From the Chief Residents SAR Talks
February 4, 2013: Jim Gentry; Bobby AertkerGrand Rounds
Dr. Tim McMahon – Pulmonary/Critical CareNoon Conference Date Topic Lecturer Time Vendor Room 2/10 MKSAP Mondays – GI Chiefs 12:00 Chick-Fil-A 2002 2/11 SAR TALKS Jim Gentry / Bobby Aertker 12:00 Pita Pit 2002 2/12 MSK Exam Part 2/ Difficult Death Debrief Irene Whitt & Lisa Criscione / Galanos 12:00 Cosmic Cantina 2002/ Med Res Lib 2/13 “What about my future? Do I know what money is?” Galanos 12:00 Sushi 2001 2/14 Chair’s Conference Chiefs 12:00 Domino’s/ Treat 2002
DukeMed Triangle Hoops Watch
Join local DukeMed alumni from the classes of 2004-13, current and recent house staff
to cheer the Blue Devils on to victory over our Tar Heel neighbors!Duke Blue Devils vs. UNC Tar Heels Tyler’s Taproom 324 Blackwell St Durham, NC 27701 (919) 433-0345
Complimentary appetizers and one drink ticket per person provided.From the Residency Office SAR Class Pictures
This week – Friday, February 14th immediately after Grand Rounds. The group picture will be taken at 9:15am in the Duke Cancer Institute healing path (the lobby)
BLS BLITZ – Registration Open NOW
Each participant must register for the BLS session they prefer to attend, provided the class has open slots. If the session is full, please choose another session. Being on a wait list does NOT confirm registration.
Scheduled Class Times:
March 17 – 20, 2014
8am – 10am, 10am – 12pm, 1pm – 3pm, 3pm – 5pm, 5pm – 7pm
Additional sessions on March 17 & 19, 2014 will be held at 7 pm – 9 pm.
Friday March 21, 2014
Sessions at 8am - 10am and 10am - 12pm only
Location: Hock Plaza, Suite G07
To register: Go to Swank (https://duke.swankhealth.com)
Details: BLS Blitz 3-2014
Diabetes Management and Technology Research Study (submitted by Emily Garber)
The main reason we are writing today is to see if any residents are interested in helping us with our upcoming clinical trial!
The trial period itself will likely be from late-April through late-June of this year.
à We are looking for 1 primary resident to help with study design and coordination, which will be a paid / stipend-based position. Hopefully this person would be available starting sometime in February and able to commit to involvement at least through June of 2014.
à We are also looking for additional med students and residents who are interested in supporting our clinical trial in some way, whether it be with the study-design & recruiting between now and April, or during the actual 2-month trial period with data collection support, or after the data is in to support paper-writing and submission to professional Journals. We need all kinds of personnel! A stipend will be available for these individuals as well as a small token of our appreciation.
Please let me know if you have an interest in participating in some capacity with our study, along with a brief statement about what intrigues you most about the project.
This is a fabulous opportunity to learn about proper study-design and protocols, as you will be working with Dr. Lillian Lien (from adult Endo) and Dr. Robert Benjamin (from peds Endo) with the chance to receive mentorship from people experienced in clinical trial development. This would also be a great way to get involved in QI research as part of your experience here at Duke.
Thanks for considering, and I look forward to hearing from you!
Warm regards, Emily
Faculty Resident Research Grant applications are due on April 11, 2014.
Please use the following link to our website where the application instructions, forms and NIH format biosketch example can be downloaded .
Please feel free to email email@example.com with any questions
“How to Review a Scientific Paper” Workshops
The “How to Review a Scientific Paper” workshops summarize the peer review process, describe the elements of a high quality review and identify common errors made by authors that are missed by reviewers.
Dr. Lee will be offering two workshops this Spring for interested trainees –
Each workshop is limited to 6-8 trainees. Participants are required to complete and submit a review of a mock manuscript 2-3 weeks prior to the workshop. Reviews will be scored and provided with individualized feedback (reviews will be anonymized before instructor review and grading). During the workshop, participants will review the steps of the peer review process, identify the essential components of a high quality review, and discuss commonly missed author errors.
These workshops are intended to provide trainees with critical appraisal skills and dedicated instruction on the process of reviewing a scientific manuscript. Gaining reviewer experience and knowledge can help trainees gain opportunities to serve as peer reviewers, which can be an impressive addition to their CV.
Please fuse the registration link below if interested.
If you have any questions or concerns, please feel free to email firstname.lastname@example.org.
Resident/Fellow Survey Instructions – LAST WEEK
Duke University Hospital Program – 1403621320
Survey Timeframe: January 13, 2014 – February 16, 2014
Directions as to how to log in, complete the survey can be found on the following attachment:
Jonathan Bae, MD, assistant professor and associate medical director (Hospital Medicine) and associate program director for the Duke Internal Medicine Residency Program shares the following research news:
The Duke Internal Medicine Residency Program, in conjunction with Hospital Medicine, continue to improve the quality of the care delivered to our patients with work ranging from patient satisfaction to care transitions to resiliency.
This work will be recognized in various forums this spring, including the 9th Annual Duke Patient Safety Conference, the North Carolina ACP Scientific Session, and the Society of Hospital Medicine’s Annual Conference.
A listing of the projects accepted is included below:
“Cloudy with a Chance of Discharge: An Evaluation of General Medicine Discharge Prediction Forecasts.” Bae, JG, Ming, D, Choi, J, O’brien, C, Clark, A, Schulteis, R, Gentry, J. Society of Hospital Medicine Annual Meeting
“The Accuracy of Identification of Patients with Pneumonia Through Administrative Data and Impact of Clinical Re-Classification on Readmission Rates.” Ruopp, M, Govert, J, Holland, T, Stillwagon, M, Velaquez, B, Shah, B, Bae, JG. Society of Hospital Medicine Annual Meeting, 9th Annual Duke Medicine Patient Safety and Quality Conference and 2014 NC-ACP Annual Scientific Session.
“The Highest of Utilizers of Care: Individualized Care Plans to Coordinate Care, Improve Health Care Service Utilization and Reduce Costs at an Academic Tertiary Care Center.” Mercer, T, Bae, JG, Velazquez, M, Setji, N. Society of Hospital Medicine Annual Meeting and 9th Annual Duke Medicine Patient Safety and Quality Conference.
“Doctor Who? A Study of Patient Provider Awareness.” Broderick, K, Hunter, W, Sharma, P, Schulteis, R, Zaas, A, Bae, JG. Society of Hospital Medicine Annual Meeting, 9th Annual Duke Medicine Patient Safety and Quality Conference, and 2014 NC-ACP Annual Scientific Session.
“Residents Finding Their Roots: Resident Workshops to Improve Patient Safety on the Wards While Teaching Residents Root Cause Analysis.” Boole, L, Seidelman, J, Zaas, A, Cheely, G, Chudgar, S, Clarke, J, Gallagher, D, Jolly Graham, A, O’brien, C, Setji, N, Shah, B, Thomas, S, Bae, JG. 9th Annual Duke Medicine Patient Safety and Quality Conference and 2014 NC-ACP Annual Scientific Session.
“Increasing Hand Hygiene Compliance Amongst Medicine Housestaff Through Performance Incentives.” Seidelman, J, Hansen, J, Ray, E, Giattino, S, Zaas, A, Bae, JG, Boggan, J. 9th Annual Duke Medicine Patient Safety and Quality Conference and 2014 NC-ACP Annual Scientific Session.
“The Burden of Burnout: An Assessment of Burnout Among Duke University Internal Medicine Residents.” Elmariah, H, Thomas, S, Boggan, J, Zaas, A, Bae, JG. 9th Annual Duke Medicine Patient Safety and Quality Conference and 2014 NC-ACP Annual Scientific Session.
“We Follow-Up: Improving Follow-up, communication, and documentation of outpatient test results by Duke Residents.” Swaminathan, A, Boggan, J, Patel, S, Bae, JG. 9th Annual Duke Medicine Patient Safety and Quality Conference and 2014 NC-ACP Annual Scientific Session.
“Impact of Transitions of Care Services in an Internal Medicine Clinic Population.” Cefaretti, M, Smith, B, Causey, H, Bowlby, L, Cheely, G, Cho, A, Dillard, J, Johnson, B, Knutsent, K, Rutledge, C, Simo, J, Bae, JG. 9th Annual Duke Medicine Patient Safety and Quality Conference.
“Reducing Resident Burnout.” Ross, I, Fass, M, Dotters-Katz, S, Bae, JG. 9th Annual Duke Medicine Patient Safety and Quality Conference.
“A Stakeholder Driven Project to Improve the Safety of Outside Hospital Transfers.” Shah K, Mitchell A, Lehman EP, Oloruntoba B, Elmariah H, Halbe J, Cheely G, Bae JG. 9th Annual Duke Medicine Patient Safety and Quality Conference.
“Resident Response to Wellness Tools and Interventions.” Dotters-Katz, S, Fass, M, Ross, I, Silberman, A, Bae, JG. 9th Annual Duke Medicine Patient Safety and Quality Conference.
“Fostering competition to improve medicine resident influenza vaccination.” Huey, R, Boggan, J, Zaas, A, Averitt, J, Bae, JG. 2014 NC-ACP Annual Scientific Session.
“Working Your Core (Measures): Exercises to Improve Heart Failure Discharge Documentation.” Wachter, Adam, Smith, N. Duke 9th Annual Patient Safety Conference and Society of Hospital Medicine Annual Conference.
“Implementation of a nurse driven indwelling urinary catheter reduction program and the impact on catheter associated UTIs on General Medicine units.” Jolly Graham A, Bae JG, Clark A, Timberlake S, Isaacs P, Chen L, Wright S, Buckner C, Thompson L, Martt R, Clausen J, Stillwagon MJ, Spurney Y, Setji N. Duke 9th Annual Patient Safety Conference.
“Variation in Discharge Communication Preferences of Primary Care Providers and Hospitalists in a Hospital-Affiliated Health Network.” Stephany, A, Ming, D, Powers, B. Society of Hospital Medicine Annual Conference and Duke 9th Annual Patient Safety Conference.
Hey Everyone! We survived snow-mageddon (term courtesy of Jon Bae) and should all pat ourselves on the back for being “essential”. Thanks to Rajiv Agarwal for the essential snowman on my door. In all seriousness, thanks everyone for staying in good communication and helping out as needed during the snow. Hopefully this will be the last of the cold for this year.
Kudos this week go to Wendy Chan, Nancy Lentz (last week), Tyler Black and Jodel Giraud for fantastic SAR talks. Also to Eric Pollack for his gold star for outstanding patient care as well as Schell Bressler for her recognition by the DRH nurses for outstanding communication. Huge thanks to our very busy teams throughout the hospital for maintaining great morale during the winter season. Our other kudos double as pubmed from the program, so see below for why Lindsay Boole and Jenn Rymer deserve a big congratulations! Also thank you to Stephen Bergin and the committee of residents and faculty who are working to reshape noon conference. The first MKSAP Monday (Rheum! Yikes!) was a big hit, and Stephen gave the first focused lecture (VAP) on Tuesday. We look forward to continuing our new formats for conference, and will ask for your feedback throughout.
Thanks to everyone who has filled out their GME survey – we are inching closer to the 70% requirement, and hope to reach 100% (last year we got to 84%, so at least let’s top that!). Survey closes Feb 16, and directions are in your email from Jen Averitt.
Upcoming fun events include the following
– Fellowship Planning Meeting for JARs and SARs planning to apply in the AY2014-15 cycle — Feb 12 OR Feb 27 at 6:30 pm in the MED RES LIBRARY. Join Bill Hargett and me for an overview of the fellowship match process, including how to get letters, what goes on your CV, why do I have to write ANOTHER personal statement, and more!
– The Warren Society Blood Drive and Trivia Bowl: We would like to let you know of an upcoming blood drive by the Red Cross in the Searle Conference Center within the Seeley Mudd building (right out the back door of Duke North hospital) on Feb 13 from 9:30AM – 3PM. Here is a chance to give back some of the blood you have drawn while here at Duke. J To stimulate participation, we will award 100 trivia points to the Stead Society with the highest level of participation. We will ask each resident to notify his or her Stead group leader and Katie Broderick-Forsgren (Kathleen.email@example.com) by email after giving blood, so that we can keep a running tally of participation.
– On the evening of Wednesday, February 26, at 7PM, we will hold our next semi-annual Stead Trivia night at the Carolina Ale House (3911 Durham-Chapel Hill Blvd Durham, NC) with dinner on us at 7PM and trivia at 8PM. The team with the most blood donors on Feb 13 will begin the Trivia Night on Feb 26 with a 100-point edge!
– Duke v UNC Basketball (yes, Emily Ray, we will let you join in the fun)..sponsored by the Duke Med Alumni at Tylers on Feb 12 at 8:30. If you RSVP, there is complimentary appetizers and one drink ticket per person!
Pubmed from the program this week goes to Lindsay Boole, Jenn Rymer, Jessie Seidelman for their prize winning submissions to the National ACP meeting. Jenn will be honored as a young achiever and Lindsay gets this honor plus a platform presentation! Great work!!
Jenn’s poster (mentors include Jon Bae and George Cheely!) Incentivizing Quality Improvement Among Housestaff: The Duke University Graduate Medical Incentive (GME) Task Force”
Lindsay’s poster (with Jessie as co-author! Mentor is Jon Bae) ”Residents finding their roots: Resident workshops to improve patient safety on the wards while teaching residents root cause analysis”
Have a great week
AimeeWhat Did I Read This Week?
“Submitted by Aimee Zaas, MD.”
Daclatasvir plus Sofosbuvir for Previously Treated or Untreated Chronic HCV Infection; Sulkowski, M, et al. N Engl J Med 2014; 370:211-221
Why did I read this? I was scanning the tables of contents of recent NEJM’s and knew that I am not at all up to date in the rapidly changing treatment environment for HCV infection. Thus, it seemed like a good idea to check out an article on two newer agents for this incredibly prevalent disease process. Another fact – the lead author is a former Duke resident, although he hasn’t been at Duke for a long time. In addition to learning about 2 new drugs, I also learned a bit more about the epidemiology of HCV and refreshed some knowledge about the genotypes and their implications for treatment.
Background: HCV is common (170 million cases worldwide). HCV deaths now outnumber HIV deaths in the US. Genotype 1a is most common in US. THe old standard of Peg-IFN and ribavirin was a long and side effect laden treatment that obtained a sustained virologic response (SVR) in 40% of genotype 1 patients. Adding the newer agents boceprivir or telaprivir (protease inhibitors that bind to the HCV serine protease NS3) increases SVR in genotype 1a patients but has side effects. This treatment was not indicated for genotypes 2 and 3. Also, if you fail this treatment, there were no other options. So, more drugs are being developed to treat chronic HCV. The two drugs in this study are daclatasvir (D) and sofosbuvir (S) . Daclatasvir is a HCV NS5a replication complex inhibitor and sofosbuvir is a nucleotide NS5B polymerase inhibitor. Both are oral once daily drugs.
Study design: Evaluated D +S in non cirrhotic/minimally fibroses (as measured by biopsy, serum Fibrotest or AST:plt index of <2) patients with HCV genotypes 1,2, or 3 and no prior treatment OR similar patients who had virology failure after treatment with telaprivir OR boceprivir + peg-IFN-ribavirin. Exclusion was discontinuation of prior regimens due to adverse events, other types of chronic liver diseae or HIV or HBV confection.
roup assignment was rather complex: treatment arms were sofosbuvir x 1 week than S+D for 23 weeks (groups A and B), D+S for 24 weeks ( Groups C and D) and D+S+ribavirin for 24 weeks (Groups E and F). Genotype 1 patients were in groups A, C or E and genotype 2 and 3 patients were in groups B, D or F. Group sizes were designed to be equal. The strange seeming one week lead in for S in groups A and B was a sub study to look at reduction in “D” resistance based on a lead in with S. An amendment let in an additional set of patients to get either D+S or D+S+R, half were untreated prior and half had failed the protease inhibitors.
The primary efficacy end point was the proportion of patients with a sustained virologic response (SVR, an HCV RNA level of less than 25 IU per milliliter) at week 12 after the end of treatment. Secondary efficacy end points included a sustained virologic response at 4 weeks after treatment and at 24 weeks after treatment. Safety end points included adverse events, discontinuation of a study drug due to adverse events, and grade 3 or 4 laboratory abnormalities. Investigators also looked for virologic resistance by by sequence analysis of the NS5A, NS5B and NS3 regions of the virus in a subset of patients.
Power calculations looked at both safety and efficacy. With sample sizes of 14, 20 and 40 patients, and an assumed 10% rate of adverse events, the probability of observing one was .77, .88 or .99. With the same sample sizes, the two sided 80% CI for SVR at week 12 ranged from 58-92%. A modified ITT was used for efficacy end points. Viral load was measured throughout the study at predefined times to look for response kinetics and breakthrough.
Results: That’s a lot of groups for a relatively small study! 211 patients received treatment in the study — 44 with genotypes 2 or 3 and 167 with genotype 1 ( 126 untreated and 41 with lack of response to PI’s). 91% of patients with genotypes 2 or 3 had SVR at 12 weeks and 93% at 24 weeks. 98% of genotype 1 patients had SVR at 12 weeks (prior treatment or not). 95% of previously untreated genotype 1 patients had SVR at 24 weeks. Most common adverse events were headache, fatigue and nausea. Two discontinued due to AE (fibromyalgia and stroke). Response rates were similar despite differences in race, prior treatment, genotype or the presence of the non CC IL28B genotype (a prior risk for poor response). The use of ribavirin did not appear to enhance the effect of the D+S combination.
Conclusions: This is a relatively small study but offers great promise for new treatments of HCV, particularly in those with difficult to treat genotypes of virus, and those with failure of prior regimens. There are hints from this study that this may be a ribavirin sparing regimen, which is good for patients from the standpoint of side effects (anemia). The next phases in our understanding of HCV treatment will include cost analyses, as these drugs are very expensive. Importantly, these cost analyses should also look at time lost from work due to treatment, and the downstream costs of treatment failure (years of life lost, cost of transplant, etc).
If you have made it this far, I highly encourage you to check out a VERY cool article in this week’s NEJM Genetic PTX3 Deficiency and Aspergillosis in Stem-Cell Transplantation, as well as to definitely read the op-ed on CLER visits to GME programs by the head of the ACGME, Dr. Tom Nasca. Much more on this to come…(article attached)
Have a great week!
AimeeAmbulatory Clinics Report
We are adding a new section to Med Res News – highlighting the work that is ongoing in our ambulatory clinics. The Duke Outpatient Clinic (DOC) is the first site, with the following submitted by Larry Greenblatt, MD:
Congratulations to the DOC Team!
Residents-you are likely aware of the multifaceted effort to improve the delivery of care to our medically and socially complex patients. This effort has been implemented by our interdisciplinary leadership team, our nurses and staff, and importantly-our excellent and conscientious residents. Your efforts-to follow up, ensure comprehensive care, to communicate alternatives to the ED, etc. are making a difference.
We not only try hard to improve what we do, we measure it. We have set targets and are held accountable by the hospital leadership for meeting them. I have the great pleasure of sharing some of our early and very impressive accomplishments. Check this out:
Take a minute to acknowledge the success of yourself, your colleagues, the nurses and staff, your DOC leadership, Natasha/Julia/Marigny/Jennifer (the all woman Home Base Team), Alex Cho, and Mark Dakkak (3rd year med student getting his Master’s and working on our project). We plan to celebrate at clinic with cupcakes and other unhealthy treats.
From the Chief Residents SAR Talks
February 4, 2013: Lindsay Boole; Scharles KonaduGrand Rounds
Dr Brice Weinberg; Division of HematologyNoon Conference Date Topic Lecturer Time Vendor 2/3 MKSAP Mondays – Anticoagulation Chiefs 12:00 Subway 2/4 SAR TALKS Lindsay Boole / Scharles Konadu 12:00 Saladelia Salads 2/5 Essentials of Longterm Anticoagulation K Patel 12:00 Picnic Basket 2/6 Longterm Anticoagulation – Case Studies Causey/Smith/Bergin 12:00 Domino’s 2/7 Chair’s Conference Chiefs 12:00 Rudino’s DukeMed Triangle Hoops Watch
Join local DukeMed alumni from the classes of 2004-13, current and recent house staff
to cheer the Blue Devils on to victory over our Tar Heel neighbors!Duke Blue Devils vs. UNC Tar Heels
Complimentary appetizers and one drink ticket per person provided.From the Residency Office SAR Class Pictures
Please mark your calendars for Friday, February 14th immediately after Grand Rounds. The group picture will be taken at 9:15am in the Duke Cancer Institute healing path (the lobby).
Thankful to capture such a remarkable class!! ErinDuke Multidisciplinary Gastrointestinal Cancers
The Duke Multidisciplinary Gastrointestinal Cancers Program is hosting its 1st Annual 5K Run/Walk in honor and celebration of those whose lives have been touched by colorectal cancer. Together we can make a difference with your support and involvement. Duke CRC 5K slide
Just in case you may have not created an ETHos account – which is used to record attendance at Grand Rounds – the following attachement tells you how.
Tbhe next research blitz is scheduled for Saturday, February 8th, 8:00am – 12:30pm in the Duke South Amphitheater. The Blitz will be repeated on Saturday April 26th.
The agenda and learning objectives for the Blitz are attached.
This is part of a GME-DOCR Collaboration to provide research education to residents and fellows across Duke. Additional information is attached.
Registration Link: https://www.surveymonkey.com/s/GME_Research_TrainingMKSAP – Mid Year Opportunity
Last week to place orders for MKSAP -by using the following link
Please use the following link to our website where the application instructions, forms and NIH format biosketch example can be downloaded .
Please feel free to email firstname.lastname@example.org with any questions
Program Scheduled: Duke University Hospital Program – 1403621320
Survey Timeframe: January 13, 2014 – February 16, 2014
Directions as to how to log in, complete the survey can be found on the following attachment:NEW Rheumatology Job Opening Opportunities in the Midwest Spartanburg Regional Healthcare System Upcoming Dates and Events