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News from the Duke Department of Medicine
Updated: 4 hours 20 min ago

Meet your chief resident: Bonike Oloruntoba, MD

Tue, 07/22/2014 - 15:54

Bonike Oloruntoba, MD

Bonike Oloruntoba, MD, took over as chief resident for Duke Regional Hospital and Ambulatory Medicine this month. Going into her chief resident year, Dr. Oloruntoba is looking forward to serving as a mentor and teacher, to contributing to the residency program and working with her co-chief residents.

As chief resident, Oloruntoba will oversee residents at Duke Regional and the outpatient clinics.

“At Duke Regional, I’ll be working mostly with senior assistant residents and preliminary interns,” Oloruntoba said. “It’s an opportunity for the senior residents to learn how to run a team. There is a lot of autonomy at Duke Regional, and one of the challenges for the senior residents is teaching preliminary interns who are not necessarily as interested in pursuing internal medicine as a career as the categorical interns.

“On the ambulatory side, we focus on the outpatient setting, teaching residents how to take care of basic primary care issues and transitioning patients from the hospital to the outpatient setting,” she said. “It’s an opportunity for residents to focus on other providers and specialty services and to learn how to take care of patients outside of the hospital.”

Oloruntoba said her approach to teaching at Duke Regional when she was a senior resident was finding ways to engage interns. Oloruntoba would start off by asking her trainees what they wanted to gain from the rotation and then, throughout the rotation, she would try to give trainees opportunities to see how they progressed.

“I think that a way you learn medicine and learn it well is through repetition,” Oloruntoba said.

Though medical students and interns often want to work on unique cases, she said, Oloruntoba also encouraged her trainees to focus on more common cases, such as chronic obstructive pulmonary disease (COPD) and diagnosing and treating chest pains, so trainees could chart their progress.

“When I was a senior resident, I wanted my medical students to see at least two examples of each (common case) so they could see how much they were learning,” Oloruntoba said. “The first time they see a COPD exacerbation, it may take a whole day to do the work up, but by the time they do a second one it will be quicker.”

Oloruntoba said she has seen students light up at the end of the week when she’s pointed out their improvement. “I think this is a better way for medical students to feel like they are getting better and building on their experience,” she said.

As chief resident, Oloruntoba will help current senior residents become better teachers as they lead teams of medical students and interns. She hopes to encourage senior residents and help them see teaching as an opportunity to gain new skills.

“I really enjoy serving as a mentor. I think every physician wants to be a teacher,” Oloruntoba said. “It’s great to see the growth and development of your students. I enjoyed that as a senior resident, and it’s great to see my interns where they are now – they are like an extension of me.”

Oloruntoba said that confidence for trainees, like learning to practice medicine, comes with experience. She likes to be honest about the learning curve and her expectations but also reminds trainees that she has been where they are, too.

“Confidence comes with time,” she said. “It’s by telling them up front that it will take longer for you to work up a particular patient and letting them know that’s hard and that I’ve been through that. They will build up their confidence when they see how things end up at the end of the month, when they can actually tell the difference and see their progress.”

In addition to teaching and mentoring, Oloruntoba said she is looking forward to listening to resident feedback and making a contribution to the residency program.

“The residency program collects feedback and evaluations from residents, and they actually make changes,” Oloruntoba said. “In other programs, being a chief resident is more like being a figure head. Here you can get things done, so it makes it exciting to see what our contribution to the program will be. The changes always stem from the residents.”

Oloruntoba said the support and interest in resident feedback is something that set Duke apart for her, and having the flexibility to make changes will make her job as chief resident a little easier.

One goal Oloruntoba has set for herself during her chief resident year is improving and promoting the program’s diversity.

“One of the things that attracted me to Duke when I came here as an intern is the diversity of the program,” she said. “A lot of the applicants don’t see Duke’s diversity, not just in the internal medicine residency program, but across divisions and departments. Improving and promoting diversity is something I really want to focus on this year.”

Oloruntoba also said she is looking forward to working with her co-chief residents Nilesh Patel, Coral Giovacchini and Aaron Mitchell.

“Working with the other chiefs will be the best part,” she said. “We all knew each other as residents and respect each other. This year is an opportunity to get to know each other even better.”

Oloruntoba earned a bachelor’s degree from Washington University in St. Louis and attended the University of Maryland School of Medicine before coming to Duke for residency. She said growing up she never thought about a career outside of medicine.

“The people I looked up to were physicians, and I liked what they did and was able to shadow them when I was young,” she said. ‘That was when I made the decision, and I never really thought about doing anything else.”

Oloruntoba completed her first year of Gastroenterology fellowship at Duke last year, which she will continue after her chief resident year. She is interested in transplant hepatology and said her first year of fellowship really solidified what she wants to do.

In her spare time, Oloruntoba said she likes to shop, and she tries to plan one big trip each year. Oloruntoba traveled to Zanzibar in April and said one of her most memorable trips was one she took with her mother to Italy and Greece.

“I don’t know if it was the place or just that I had so much fun with my mom, but it was a very memorable experience.”

Meet the chief residents:

Internal Medicine Residency News – July 21, 2014

Mon, 07/21/2014 - 08:33
From the Director

Hi Everyone!

Thank you for doing your new RL Solutions SRS training modules! The new reporting mechanism for patient safety events is more user friendly than before, and a great resource to use if you notice a “near miss” or other event as you are caring for patients. We had another great QI conference this week as well – Thanks to Lish Clark and Aaron Mitchell for running our first M and M of the year.  We continued to have outstanding SAR talks…Allyson Pishko, Adam Banks and Hal Boutte, as well as a rock star chair’s conference by Gena Foster.  As heard by Dr. Corey “That was great!”  Titus N’geno got the diagnosis…nice work.  Other kudos go to Anubha Agarwal from Dr. Adrian Hernandez for making a great diagnosis on the Heart Txp service.  It’s been great to hear all the compliments about what amazing work everyone is doing.

We are looking forward to the Summer Celebration at Dr. Klotman’s on Friday, and also the first JAR dinner on Tuesday.  This Friday, Dr. Aubrey Jolly-Graham from Hospital Medicine is doing Grand Rounds on Handoffs.  Please be sure to come out and support what is certain to be a fantastic talk.

I’m looking forward to starting meetings with the interns — there is nothing to prepare, it’s just a great chance to catch up on how the year is going, and show you how to keep your portfolio, use Medhub, interpret evaluations, etc.

Are you interested in helping screen people for HIV? Join the VA in a great screening effort.  The ID section is planning to offer walk-in HIV testing on August 29, 2014 (Friday) as part of  HIV prevention effort.

Details of the HIV testing event:

Date: August 29, 2014

Location: 8B clinic (clinic rooms requested, awaiting approval)

Walk-in HIV testing: Appointment or registration not required

Providers’ role:  Provide counseling, obtain verbal consent and order HIV test in CPRS.  You can also check out the new rational clinical exam article on acute HIV in this weeks JAMA!

This weeks pubmed from the program goes to Aparna Swaminathan Lower Extremity Amputation in Peripheral Artery Disease: Improving Patient Outcomes, Swaminathan A, Vemulapalli S, Patel MR, Jones WS Published Date July 2014 Volume 2014:10 Pages 417 – 424

Have a great week!

Aimee

 

What Did I Read This Week? submitted by: Charles Hargett, MD

Gottlieb DJ et al. CPAP versus oxygen in obstructive sleep apnea. N Engl J Med 2014 Jun 12; 370:2276. (http://dx.doi.org/10.1056/NEJMoa1306766)

Background/Clinical Question:

Obstructive sleep apnea (OSA) is a risk factor for hypertension, coronary heart disease, stroke, and death, and moderate-to-severe OSA is present in an estimated 4% and 9% of middle-aged women and men, respectively. Only about half of patients with OSA use the most effective therapy, continuous positive airway pressure (CPAP). For many patients declining CPAP, supplemental oxygen is employed in hopes of ameliorating nocturnal hypoxemia. However, although oxygen therapy improves arterial oxygen saturation during sleep, it increases the severity of apnea-hypopnea events.

In the Heart Biomarker Evaluation in Apnea Treatment (HeartBEAT) study, the authors sought to determine the effectiveness of both CPAP and supplemental oxygen as compared with usual care for reducing markers of cardiovascular risk in patients with OSA recruited from cardiology practices.

Reference: Gottlieb DJ et al. CPAP versus oxygen in obstructive sleep apnea. N Engl J Med 2014 Jun 12; 370:2276. (http://dx.doi.org/10.1056/NEJMoa1306766)

Methods

Design – Randomized (stratified permuted block design), parallel-group clinical trial

Setting – Outpatient cardiology practices associated with 4 academic medical centers

Patient Population – Patients aged 45 to 75 years with established coronary heart disease or multiple cardiovascular risk factors were screened for OSA. 5747 patients assessed for eligibility, 1034 eligible for home sleep testing (846 enrolled), 318 with moderate to severe OSA and known cardiovascular disease or multiple cardiovascular risk factors underwent randomization

Intervention / Control – Participants were assigned to one of three interventions: healthy lifestyle and sleep education (HLSE) alone (control), CPAP with HLSE, or supplemental oxygen (2L via NC) with HLSE

Blinding – Unblinded

Analysis – ANCOVA model with adjustment for the baseline value and stratification variables (study site and the presence or absence of coronary artery disease). Due to outliers, a regression model was used to analyze values for C-reactive protein and N-terminal pro-BNP. A logistic-regression model was used to model the log-odds rate of non-dipping blood pressure at 12 weeks

Outcomes –The primary outcome measure was 24-hour mean arterial blood pressure. Patients were also assessed for systemic inflammation, reactive hyperemia, fasting glycemia, and dyslipidemia, and adherence to therapy was compared across the active treatment groups

Follow-up – Outcomes were measured at baseline and 12 weeks after randomization. 301 participants completedthe study, 281 (93%) underwent 24-hourblood-pressure monitoring at both baseline and 12 weeks

 Validity

Patients were randomized. Treatment groups generally similar at baseline. Patients accounted for at conclusion and analyzed in groups to which they were randomized. Again, patients and clinicians were not blinded. Groups were likely treated similarly outside of the intervention.

 Results

Both CPAP and nocturnal oxygen improved nighttime hypoxemia (had similar reductions in frequency of desaturation events and proportion of sleep time with oxygen saturation <90%). However, at 12 weeks, 24-hour MAP was significantly lower (by about 2.5 mm Hg) in the CPAP group than in the supplemental-oxygen or control groups.

 Comments

Even in a clinical setting in which cardiovascular risk factors (including blood pressure, average MAP 89 mm Hg at baseline), were well managed the present study shows that among patients with previously undiagnosed moderate-to-severe obstructive sleep apnea, treatment with CPAP resulted in reduced 24-hour mean arterial pressure. Though the reduction may seem modest, it’s certainly of a magnitude which has been associated with a meaningful reduction in cardiovascular risk. Of note, this was a unique population (not from sleep clinics but cardiology clinics) with a high risk for adverse consequences of OSA but who were not seeking treatment and he benefits were seen even in patients without daytime sleepiness. Additionally, there was no “threshold” for CPAP use, with a benefit from only 3.5 hours of use, and with a suggestion that each additional hour of use reduced BP by an additional 1 mm Hg systolic. There was also a suggestion of attenuation of relative nocturnal hypertension (aka “non-dipping” blood pressure), which has been shown to be more closely associated with target organ damage and worsened cardiovascular outcomes. From a physiologic POV, the reversal of intermittent hypoxemia doesn’t fully explain the blood pressure–lowering effect of CPAP in patients with OSA.

Future studies should be longer (e.g. 12 months) to assess sustainable changes and impact on clinical outcomes like MI. Also, these patients had relatively few symptoms and it would be interesting to see the effects on patients with worse sleep apnea and more poorly controlled variables (e.g. high BP) and who might perhaps have worsening surges in BP at night.

Bottom Line: Continuous positive airway pressure, but not oxygen, lowered mean arterial blood pressure.

Clinic Corner

Welcome new interns.  Looking forward to a great year.  Please meet with your team and review your schedules and let your attending and team know who will be covering your CPRS alerts and any issues you see coming up with your schedule.  Remember communication is key. Also please remember to reach out to your new intern(s) on your team, please give any pointers, quick tips, time saving ideas that will help make their lives easier.  If anyone has any questions please remember we are here for you in PRIME.

Just a couple of things to remind everyone:

  1.  Patients are scheduled at 15 and 45 on the hour for nurse check-in, residents are expected to see their patients on the hour and half hour, so for your am clinic, your first patient is scheduled for 8:45 for the nurse so that you can see the patient at 9am
  2. Remember, we now have walk-in PRIME psychiatry appointments at 11am and 3p every day EXCEPT Thursdays, please offer any patients that are having active psychiatric issues a same day appointment if you feel it would be beneficial
  3. The nurses wanted to remind everyone that they prioritize checking in patients before exit interviews, so remember to place the routing slips in the check –out bins and let patients know to sit in waiting room for exit interview, that way nurses can keep your clinic flowing
  4. Mini-CEX’s- please try to get them completed when clinic is not busy, this is a great way to receive feedback
  5. Don’t forget to huddle with your nurse when you arrive in clinic, they love chatting with you/getting to know you and also this is a great way for the nurses to get a heads up on any issues you foresee during your clinic
  6. Monday mornings we have a resident/staff meeting, this is the time for all of us to put our heads together to make PRIME great, if you are assigned to Monday morning continuity clinic please arrive by 8:45 for the meeting (your first appointment of the day should be blocked off)

Thank you for all that you do in taking care of our veterans and making PRIME all it can be.

Sonal Patel, MD

PRIME  Clinic Director

Durham VA Medical Center

 

QI Corner

We had a great kick-off meeting for the Patient Safety and Quality Council last week! Highlights of what we talked about that everyone should be aware of:

First, the GME incentive program: our performance on 4 different measures is going to be tracked over the academic year, at the end of which we will get a $200 bonus in our paycheck for each measure where we hit our target! That’s up to $800 on the table! The four measures for the year are:

Patient satisfaction score

30-day hospital readmission rate

Time responding to admission consults from the ED

Increased usage of SRS (Safety Reporting System)

I’ll be updating from time to time to let you know how our progress towards the $800 is going.

We also discussed the potential interest in getting personalized performance data for certain quality metrics. We already have the annual sharepoint ambulatory self-assessment tools, but would medicine housestaff like to see personalized feedback on an even higher level? Would you want to see readmission rates for the patients you took care of? Patient satisfaction scores? Use of DVT prophylaxis? If Maestro could be used to generate this feedback, would you find it useful?

If you have more ideas, or want to get involved in making a program like this work, let us know!

Another topic (as well as a treasure-trove of resident-led QI projects!) was the many areas of potential low hanging fruit to improve the quality of care at Duke by reducing the use of low-value tests and treatments. You will be learning more about this when the High-Value Cost-Conscious Care curriculum kicks of in September. But in the mean time, if you think Duke should be doing a better job by streamlining its biomarker testing for ACS, reducing inappropriate blood culturing, reducing routine daily lab ordering, or more judiciously treating asymptomatic hypertension (just a FEW of the ideas we’ve had thus far!), then let me know of your interest.

Finally, grand rounds this week will be on a patient safety topic – Dr. Jolly-Graham will be presenting on handoff safety. See you there!

-Aaron

From the Chief Residents Grand Rounds

Friday, July 25th – General Medicine/Hospitalist, Dr. Aubrey Jolly-Graham

“Consult Communication”

Noon Conference Date Topic Lecturer Time Vendor 7/21/14 SAR Emergency Series: Hyperkalemia and Hypercalcemia Jay Mast 12:15 Subway 7/22/14 SAR Emergency Series: Acute Liver Failure Amit Bhaskar 12:15 Pita Pit 7/23/14 SAR Emergency Series: ICU Admission Indications Amera Rahmatullah 12:15 Cosmic Burritos 7/24/14 SAR Emergency Series: DNR Discussions Sajal Tanna 12:15 Sushi 7/25/14 Chair’s Conference  Chiefs 12:00 Dominos     From the Residency Office Duke List

Duke List is a valuable online resource that is just like Craigslist but exclusively for Duke faculty, staff and students. You can buy tickets to local events, furniture, even cars and houses from fellow Duke employees. Another helpful resource is the Lost and Found section of Duke List. You can look for an item you may have misplaced or post one that you found. Please take a look at a very helpful website that the wonderful Duke community offers!

http://dukelist.duke.edu/

Survival Guides and End of Year Gifts – Please Pick Up by 7/25/14!

The 2014 Survival Guides are in and they are awesome.  If you are a continuing Internal Medicine resident, please come by the MedRes office and pick up your copy during normal business hours.  We can only provide one copy per resident.  If you are interested in purchasing a copy, please contact Jen Averitt.  An electronic version of the guide is currently in development and we should have more information on when that will be available soon!

For all continuing Internal Medicine residents, please also pick up your copy of “The Evidence – Classic and Influential Studies Every Medicine Resident Should Know” with the compliments of the program for a great year!

Ambulatory Evaluations – Resident Identify Supervisor

As of July 1, 2014, we have activated the Resident Identify Supervisor (RIS) tool in MedHub for use during all ambulatory rotations.  What this means is that 7 days before the end of your ambulatory block, you will receive a request, via email/MedHub to identify a minimum of one (1) supervisor for evaluation during that block.  This is intended only for your continuity clinic experiences during the block!  If you are unable to identify at least one attending from your continuity clinic time during the block, or have recently submitted an evaluation request for the same attending, please email Jen Averitt and she will remove the requirement for you for that particular block.  Our hope is to increase the consistency with which your clinic experiences are evaluated, as well as your clinic attendings are evaluated.  If you have questions about how this system will work, please feel free to contact the MedRes office.

Stead Resident Research Grants- Request for Proposals

For All Internal Medicine, Med-Peds, and Med-Psych Residents

We are pleased to announce the Request for Proposals for the inaugural “Stead Resident Research Grant” applications. We are grateful to the leadership of the Stead Scholarship Society for their generosity to support resident research and our Stead Leaders for their mentorship and for promoting your scholarly activities !

The applications due on September 1, 2014 for a funding start date on October 1, 2014.

Please find attached the Stead Resident Research Grant Instructions-2014, Stead Resident Research Grant Application Forms-2014, Human Subjects example,  and NIHSAMPLE Biosketch Form.   Please include your mentor’s NIH Biosketch and support letter with your application.

Please see  link below for Biostatistical Support resources available to you for your projects and discuss with your mentor.

http://residency.medicine.duke.edu/duke-program/resident-research/biostatistics-and-data-management-support

Each proposal must have a Human subjects section that describes the protections of the patients and patient data, describe the consent procedure if applicable, status of IRB protocol (to be submitted, already submitted or already approved, as appropriate) etc. This section is required whether to not your project is a retrospective or prospective study, whether patient identifiers are exposed (or not) during data collection/analysis, whether consent is to be obtained or there is a waiver for consent. Please see attached example language that you can adapt to your own protocol after discussing with your research mentor who has already thought about the Human subjects issues.

Wishing you continued success with your research projects !

Murat Arcasoy and Aimee Zaas

 

Interview Skills

Whether you are going to interview for hospitalist position, primary care or attending position after fellowship, there are some skills to learn for the interview and essential questions to ask. Come to this session for dinner, sponsored by the North Carolina American College of Physicians, and get the answers you need before your job interview. Welcome to all medical students, residents, interns and fellows.

Panelists: Dr. Jon Bae, Dr. Saumil Chudgar, Dr. David Simel, Dr. Pooh Setji, Dr. Poonam Sharma, Dr. Bruce Peyser, Dr. Sharon Rubin

Location: Duke Internal Medicine Library, Durham, NC

Date: Wednesday August 6, 2014

Time: 7:00 PM to 8:30 PM

Please RSVP to Dr. Sharon Rubin by August 4, 2014

Sincerely,

Sharon Rubin, MD, FACP

Assistant Professor, Duke University Medical Center

Residency Director at Pickett Road

 

Information/Opportunities

Announcement Geriatrician Opportunity

Elkin Hospitalist

Elkin Internal Medicine

Montana Hospitalist

Summit Placement Service

Upcoming Dates and Events

July 25th- Summer Celebration at Dr. Klotman’s House

August 6th- Interview Skills Session

August 17th- Kerby Society Hosting Durham Bulls Game Gathering

Useful links

 

Internal Medicine Residency News – July 14, 2014

Mon, 07/14/2014 - 09:22
From the Director

Week two is in the books! Thank you to all of the interns, JARs, SARs, chiefs, fellows and attendings for making the transition to our new year such a smooth one.  I have received so many compliments about the outstanding care and teaching you are all providing…kudos this week to Dinushika Mohottige from a patient’s family for outstanding care overnight, to Sajal Tanna from Carter Davis for great supervision on 9100 nights, to Jess Tucker, Andrea Sitlinger and Lakshmi Krishnan from Susan Gurley for great work at the VA, to Sneha Vakamudi and Alyson McGhan for outstanding SAR talks, to our former prelim intern now radiologist Mike Malinzak for his noon conference as well (and to Brian Griffith for the EPIC noon conference), and to Kevin Shah for chair’s conference.  Chair’s had really strong audience participation which was much appreciated as well.  Kevin Trulock and Brittany Dixon represented us at the ICGME (that is all the house staff programs) meeting on Wednesday…they are your GME representatives, and can provide you with information about what is being talked about at the institution level regarding GME.

Fellowship applications are able to be downloaded by fellowship programs starting JULY 15th! If anyone applying has last minute questions, please let me know.  Don’t forget to also register for the NRMP once you have uploaded your application to ERAS.  Mock interviews will be offered soon, so be on the lookout for information about this great opportunity as well.  Starting next week, we will be bringing program information to you right before noon conference starts..look for information about how we address issues that arise in rotation evaluations, confidential comments, and other program admin related issues.

Please don’t forget to do your RL Solutions (that’s the new SRS system) training! It is due July 15th for ALL MEMBERS OF THE MEDICAL STAFF (that’s you!).

This week’s pubmed from the program goes to Ragnar Palsson for his review written with Dr. Uptal Patel…Palsson R, Patel UD. Cardiovascular Complications of Diabetic Kidney Disease. Advances in Chronic Kidney Disease, May 2014 (in press).

Have a great week! Looking forward to seeing you at the upcoming summer celebration at Dr. Klotman’s on July 25th!

Aimee

What Did I Read This Week? submitted by: Aimee Zaas, MD

What I read this week is brought to you by some clinical questions we had on gen med 1.  Here are some short answers to a few items that came up for our team. 

Clinical questions from this week (with some answers)

Does my patient have iron deficiency anemia?

It can be difficult to tease out iron deficiency and anemia of chronic inflammation in hospitalized patients because they often have comorbidities making them “chronically inflammed”, thus there is often overlap between the two.  This is a nice paper from JGIM that studies a group of medically complex VA patients, comparing lab values with the gold standard of bone marrow biopsy for detecting iron deficiency.  The money is in the ferritin.  All the other parameters (MCV, TIBC, iron, % sat) are essentially equivocal.  The cutoff they come up with is 100.  If the serum ferritin is <100 then that gives a 65% sensitivity and 96% specificity for iron deficiency. (Thank you to VA ACR Tim Mercer for this information!)

What is cryptosporidiosis?

Cryptosporidium is a parasite that causes watery diarrhea, which is self limited in immunocompetent folks.  Diarrhea can last longer in the immune compromised, but there are still no effective treatments except time.  It is famous for an outbreak in the Milwaukee water supply in 1993, and has been detected in swimming pools, and other public water supplies.  We test for it using a stool antigen test, and this PLUS giardia are what you get with a standard “O and P” at Duke. I misspoke and it was cyclospora that was associated with a strawberry and raspberry associated diarrhea.

What are the anticoagulation guidelines after atrial fibrillation?

Cardioversion?

As Kevin Shah mentioned in chairs, the American College of Cardiology has great guidelines for all things cardiac, including post atrial fib anticoagulation. We were asking about post-chemical cardioversion duration of anticoagulation. Here are the Class 1 and II a recommendations..

6.1.1. Thromboembolism Prevention: Recommendations

Class I

1. For patients with AF or atrial flutter of 48-hour duration or longer, or when the duration of AF is unknown, anticoagulation with warfarin (INR 2.0 to 3.0) is recommended for at least 3 weeks prior to and 4 weeks after cardioversion, regardless of the CHA2DS2-VASc score and the method (electrical or pharmacological) used to restore sinus rhythm (320-323).

(Level of Evidence: B)

2. For patients with AF or atrial flutter of more than 48 hours or unknown duration that requires immediate cardioversion for hemodynamic instability, anticoagulation should be initiated as soon as possible and continued for at least 4 weeks after cardioversion unless contraindicated.

(Level of Evidence: C)

3. For patients with AF or atrial flutter of less than 48-hour duration and with high risk of stroke, intravenous heparin or LMWH, or administration of a factor Xa or direct thrombin inhibitor, is recommended as soon as possible before or immediately after cardioversion, followed by longterm anticoagulation therapy.

(Level of Evidence: C)

4. Following cardioversion for AF of any duration, the decision regarding long-term anticoagulation therapy should be based on the thromboembolic risk profile (Section 4).

(Level of Evidence: C)

Class IIa

1. For patients with AF or atrial flutter of 48-hour duration or longer or of unknown duration who have not been anticoagulated for the preceding 3 weeks, it is reasonable to perform a TEE prior to cardioversion and proceed with cardioversion if no LA thrombus is identified, including in the LAA, provided that anticoagulation is achieved before TEE and maintained after cardioversion for at least 4 weeks (164). (Level of Evidence: B)

2. For patients with AF or atrial flutter of 48-hour duration or longer, or when the duration of AF is unknown, anticoagulation with dabigatran, rivaroxaban, or apixaban is reasonable for at least 3weeks prior to and 4 weeks after cardioversion (230, 324, 325).

(Level of Evidence: C)

What is the JAK-2 mutation and what does it signify?

We were discussing this in relation to polycythemia vera.  PCV, Essential thrombocythemia and primary myelofibrosis are all part of the “myeloproliferative disorders” or “myeloproliferative neoplasms”, and these three are the BCR-ABL mutation negative myeloproliferative neoplasms (CML is BCR-ABL positive). These are clonal marrow disorders, and all have a risk of transforming into acute myeloid leukemia. The JAK2-V617F mutation in exon 14 characterizes these disorders, and is present in 95% of PV, 50–70% of ET and 40-50% of MF. With this mutation, the JAK2 tyrosine kinase is activated constitutively, resulting in cellular proliferation.  This is an oversimplification of the pathogenesis, as There are other activating mutations found in these disorders within the JAK-STAT signaling cascade as well. Lowering thrombosis risk is the major goal in PV treatment  and Age and history of thrombosis are the prominent risk factors that predict future thrombosis risk. The efficacy and safety of low-dose aspirin (100mg daily) in PV has been assessed in the European Collaboration on Low-dose Aspirin in Polycythemia (ECLAP) double-blind, placebo-controlled, randomized clinical trial.

When do you treat candiduria?

The IDSA guidelines are a great place to look for how to manage various infections (www.idsociety.org). For asymptomatic candiduria, most individuals don’t require treatment. Recommendations are shown below.

Recommendations: asymptomatic candiduria

1. Treatment is not recommended unless the patient belongs to a group at high risk of dissemination (A-III). Elimination of predisposing factors often results in resolution of candiduria (A-III).

2. High-risk patients include neutropenic patients, infants with low birth weight, and patients who will undergo urologic manipulations. Neutropenic patients and neonates should be managed as described for invasive candidiasis. For those patients undergoing urologic procedures, fluconazole administered at a dosage of 200- 400 mg (3-6 mg/kg) daily or AmB-d administered at a dosage of 0.3-0.6 mg/kg daily for several days before and after the procedure is recommended (B-III).

3. Imaging of the kidneys and collecting system to exclude abscess, fungus ball, or urologic abnormality is prudent when treating asymptomatic patients with predisposing factors (B-III).

Recommendations: symptomatic candiduria

1. For candiduria with suspected disseminated candidiasis, treatment as described for candidemia is recommended (A-III).

2. For cystitis due to a fluconazole-susceptible Candida species, oral fluconazole at a dosage of 200 mg (3 mg/kg) daily for 2 weeks is recommended (A-III). For fluconazole-resistant organisms, AmB-d at a dosage of 0.3-0.6 mg/kg daily for 1-7 days or oral flucytosine at a dosage of 25 mg/kg 4 times daily for 7-10 days are alternatives (B-III). AmB-d bladder irrigation is generally not recommended.

3. For pyelonephritis due to fluconazole-susceptible organisms, oral fluconazole at a dosage of 200-400 mg (3-6 mg/kg) daily for 2 weeks is recommended (B-III). For patients with fluconazole-resistant Candida strains, especially C. glabrata, alternatives include AmB-d at a dosage of 0.5-0.7 mg/kg daily with or without flucytosine at a dosage of 25 mg/kg 4 times daily (B-III), or flucytosine alone at a dosage of 25 mg/kg 4 times daily (B-III) for 2 weeks.

And from Carli Lehr…

In our patient with DIABETES and probably OSTEOMYELITIS…how is our physical exam? Here is an article helping us decide if our patient has osteo. Our patient had ulcer > 2 cm and an abnormal X-ray. ESR is close to the cut-off here too.

Finding Likelihood Ratio Negative Likelihood Ratio Ulcers >2 cm2 7.2 (CI 1.1-49) 0.48 (CI 0.31-.076) Positive “probe to bone” test* 6.4 (CI 3.6-11) 0.39 (CI 0.20-0.76) ESR >70 11 (CI 1.6-79) 0.34 (CI 0.06-1.9) Abnormal plain X-ray** 2.3 (CI 1.6-3.3) 0.63 (CI 0.51-0.78) Abnormal MRI 3.8 (CI 2.5-5.8) 0.14 (CI 0.08-0.26)

 

*Probe to bone test: the examiner gently and in a sterile fashion, probes the ulcer with a steel probe to determine if the probe can advance to bone

**abnormal X-Ray findings include: focal loss of trabecular pattern, periosteal reaction, and frank bone destruction. 2 or 3 views can be selected

CMEonPCVandET

Iron Deficiency Anemia in Patients with Medical Problems – JGIM

milwaukeewatercryptosporidiosis

RCEfootulcer

Clinic Corner

Congratulations to the new Jars and Sars and welcome to the new interns. Welcome to Dr. Boinapally who is our new attending on Wednesday morning!

Renaming Pickett Road Resident Clinic: We are revamping the clinic here at Pickett and what better why to start out fresh but with a new name. Dr. Peyser is asking all the residents to nominate a NEW name for the Pickett Road Clinic. The top names will be selected and then voted on in August! Please send me an email with nomination for new clinic name. Jars and Sars will be paired with intern for their first day. Let the intern shadow you and give them pearls of advice to succeed in clinic.

Make sure to ADD the Interns: go to Inbasket, Attach, #2 Grant Access

Eric Black Maier EWB16

Dave Kopin DJK23

Tim Hinohara TTH10

John Musgrove JLM 138

Rachel La Voy/Hu REL 31

Pascale Khairallah PK110

Get ready for Mini CEX: for the interns our goal is to get one done in the first 4-5 visits you are here. Mini cex is observation of the history, PE or assessment part of the visit. I schedule these for when attendings: residents are 1:2. Congrats to Myles who completed the first CEX of the year! TBA is because you are not in clinic enough for CEX in July and August.

Resident Mini Cex 2014-2015 Resident Attending 1st CEX Plan for CEX Black-Maier Boinapally 7/9/14 Hinohara Brown 8/19/14 Hu/La Voy Rookwood 7/25/14 Khairallah Boinapally 7/9/14 Kopin TBA Musgrove Boinapally 8/6/14 Cupp Boinapally 7/16/14 Eisenberg Waite 8/6/14 Erdmann Rubin 7/29/14 Matta Rookwood 7/11/14 Ng’eno Wolf 8/7/14 Nicklolich Rubin 7/1/2014 Ray Peyser 7/10/14 Verma Rookwood 8/15/14 Zhu Rubin 8/11/14 Beri Brown 8/5/14 Boehm TBA Lehr Wolf 7/31/14 Lloyd Rubin 7/7/14 Kirtane Waite 8/13/14

For future lab orders:

It is the correct process to have all lab patients check in at the front desk in an effort to have their lab orders released prior to presenting to the lab. If you have not received your business cards please let Erin Payne know to order more. You can give out your cards to patients in the hospital and act as their Outpatient PCP.

Best,

Sharon Rubin

 

QI Corner

This week the internal medicine Patient Safety and Quality Council will be having its first meeting of the new academic year. Come by the medicine library at 5:30 on Wednesday to learn about what the group has done in the past, get connected for any QI ideas that you might have, and eat some pizza.
Time: Wednesday, July 16, 5:30pm
Place: Med Res Library

Confusingly, I also want to let everyone know about a similarly-named but separate group, the GME Patient Safety and Quality Council. For anyone interested in quality improvement, health care systems, or patient safety issues, this forum is a great place to get to sit down with some of the top safety officers at Duke. Meetings are monthly. If you are interested and would like to be know when the first meetings this year will be, let me know!
Next week will also be the first of our monthly Morbidity and Mortality noon conferences. Dr. Alicia Clark and I will be preparing a case for discussion. This is a great opportunity to learn from our collective past “experiences” – because we doctors never make “mistakes,” right? 
Time: Wednesday, July 16, 12pm
Place: Med Res Library

Have a good week everyone!
Aaron

 

From the Chief Residents Grand Rounds

Friday, July 18th – Palliative Care/Oncology, Dr. Amy Abernethy

Noon Conference Date Topic Lecturer Time Vendor 7/14/14 SAR Emergency Series: Delirium Hal Boutte 12:15 Picnic Basket 7/15/14 SAR Emergency Series: Undifferentiated Shock – Initial Mgmt Adam Banks 12:15 Rudinos 7/16/14 Resident M&M QI Team 12:15 China King 7/17/14 SAR Emergency Series: Inpatient Diabetes Management Allyson Pishko 12:15 Chick-Fil-A 7/18/14 Chair’s Conference  Chiefs  12:00 Dominos   Books4Cause This year the IM program will be participating in Books4Cause, a for-profit social venture with the mission to provide economic opportunities globally through education. The program is extending an opportunity to Help Build Libraries in Africa and are collecting now for a shipment in July to Swaziland. Books4Cause accepts any CD, DVD and book in good condition, Journals, periodicals, custom course manuals, old encyclopedias or magazines are not accepted. More information is found on the website.  Please drop your donation in the MedRes office by July 16th!Thanks!     From the Residency Office Survival Guides and End of Year Gifts

The 2014 Survival Guides are in and they are awesome.  If you are a continuing Internal Medicine resident, please come by the MedRes office and pick up your copy during normal business hours.  We can only provide one copy per resident.  If you are interested in purchasing a copy, please contact Jen Averitt.  An electronic version of the guide is currently in development and we should have more information on when that will be available soon!

For all continuing Internal Medicine residents, please also pick up your copy of “The Evidence – Classic and Influential Studies Every Medicine Resident Should Know” with the compliments of the program for a great year!

Stead Resident Research Grants- Request for Proposals

For All Internal Medicine, Med-Peds, and Med-Psych Residents

We are pleased to announce the Request for Proposals for the inaugural “Stead Resident Research Grant” applications. We are grateful to the leadership of the Stead Scholarship Society for their generosity to support resident research and our Stead Leaders for their mentorship and for promoting your scholarly activities !

The applications due on September 1, 2014 for a funding start date on October 1, 2014.

Please find attached the Stead Resident Research Grant Instructions-2014, Stead Resident Research Grant Application Forms-2014, Human Subjects example,  and NIHSAMPLE Biosketch Form.   Please include your mentor’s NIH Biosketch and support letter with your application.

Please see  link below for Biostatistical Support resources available to you for your projects and discuss with your mentor.

http://residency.medicine.duke.edu/duke-program/resident-research/biostatistics-and-data-management-support

Each proposal must have a Human subjects section that describes the protections of the patients and patient data, describe the consent procedure if applicable, status of IRB protocol (to be submitted, already submitted or already approved, as appropriate) etc. This section is required whether to not your project is a retrospective or prospective study, whether patient identifiers are exposed (or not) during data collection/analysis, whether consent is to be obtained or there is a waiver for consent. Please see attached example language that you can adapt to your own protocol after discussing with your research mentor who has already thought about the Human subjects issues.

Wishing you continued success with your research projects !

Murat Arcasoy and Aimee Zaas

 

 

Interview Skills

Whether you are going to interview for hospitalist position, primary care or attending position after fellowship, there are some skills to learn for the interview and essential questions to ask. Come to this session for dinner, sponsored by the North Carolina American College of Physicians, and get the answers you need before your job interview. Welcome to all medical students, residents, interns and fellows.

Panelists: Dr. Jon Bae, Dr. Saumil Chudgar, Dr. David Simel, Dr. Pooh Setji, Dr. Poonam Sharma, Dr. Bruce Peyser, Dr. Sharon Rubin

Location: Duke Internal Medicine Library, Durham, NC

Date: Wednesday August 6, 2014

Time: 7:00 PM to 8:30 PM

Please RSVP to Dr. Sharon Rubin by August 4, 2014

 

Information/Opportunities

Announcement Geriatrician Opportunity

Elkin Hospitalist

Elkin Internal Medicine

Montana Hospitalist

Upcoming Dates and Events

July 25th- Summer Celebration at Dr. Klotman’s House

August 6th- Interview Skills Session

August 17th- Kerby Society Hosting Durham Bulls Game Gathering

Useful links

 

Meet your chief resident: Coral Giovacchini, MD

Fri, 07/11/2014 - 09:54

Coral Giovacchini, MD

Coral Giovacchini, MD, started in her new role as chief resident of internal medicine at the Durham VA Medical Center this month. Dr. Giovacchini says this is a role she is particularly excited about because it offers many teaching and learning opportunities.

There are several things that make the Durham VA a unique place for residents to train, Giovacchini said. This year, for example, rotations for junior assistant residents at the Durham VA will return to the 24-hour call structure, so JARS will have more continuity with their patients overnight.

“The Durham VA is an exciting place to train, because you get autonomy earlier, within a framework of support,” Giovacchini said. “Your attendings and chief resident are always available, but what I really enjoy most about being at the VA hospital is the fact that you have the opportunity to lead a team early in your career.”

This opportunity to lead is an example of the type of hands-on learning Giovacchini found valuable when she was a resident and, as a chief resident, still values, as a teaching tool.

This year residents will have another unique hands-on learning opportunity at the Durham VA in the newly established Simulation Center. In the Simulation Center, residents will have opportunities to run simulated procedures and other challenging clinical scenarios to better prepare them for work on the wards and in the ICU. The planned curriculum will include education on basic ultrasound skills, central venous catheter placement and a variety of other ultrasound guided procedures, Rapid Response and Code Blue simulations, as well as an optional emergency airway management course, among other things.

“Rather than getting thrown into learning how to do procedures in real time, we hope to help the residents develop a solid foundation of clinical tools in a safe environment prior to translating this into their practice on the wards. I hope that this will not only improve the residents’ clinical skills sets and confidence in patient care, but also improve resident-to-resident teaching for the future, and potentially even translate into improved patient outcomes,” Giovacchini said.

Giovacchini is looking forward to other teaching opportunities at the Durham VA, especially the one-on-one time she has with residents during evening “sign out” rounds that will allow her to focus on individual learning.

“Part of my role as chief resident is figuring out how other people learn,” Giovacchini said. “Teaching isn’t always about having a structured approach to teach one topic to everyone, but rather involves adapting to individual learning styles and finding how you can best teach each of your learners.”

Though residents also will have larger group learning sessions, Giovacchini hopes that the case-based learning during her one-on-one time with on-call teams will be beneficial.

Giovacchini said one of her goals for the year is making sure interns and residents know how approachable she is.

“I want to focus on making sure that education in our program is accessible. We have very high standards for our residents, but I hope to facilitate a friendly and functional environment in which people can ask questions and not feel like they are supposed to know everything about internal medicine walking in the door,” she said.

Giovacchini said she remembers what it feels like to make the transition from medical school to residency.

“As an intern, you’ve prepared, you’ve gone to medical school, you’ve done a lot of book learning and have some clinical experience, but all of a sudden you are thrown into this new role of being an actual doctor where you are the point person for your patient and that can be intimidating,” Giovacchini said. “It’s important for everyone to know that they have help. There is nothing wrong with asking for help when you need it.”

During Giovacchini’s first week as an intern at Duke, she remembers being on the general medicine ward and taking care of a very sick patient.

“I got called because my patient, who had been admitted for a urinary infection, had a low blood pressure” she said. “I remember working through my algorithm to resuscitate the patient, but I got to a point where I felt a bit in over my head as a first week intern.”

Giovacchini discussed the case with one of her chief residents, Brian Griffith, MD, who was happy to help, lending an extra set of eyes and hands during a critical patient care moment.

“I think everyone has that moment early in their career when you need a bit of reassurance and validation of your plan, and it is nice to know that, at Duke, you will always have back up when you need it.”

Besides encouraging residents to ask questions and seek out help when necessary, Giovacchini said she would also recommend that they try to find balance between medicine and their personal lives.

When Giovacchini was a resident, she said her goal was try to try to learn one thing every day and spend a previously set amount of time reading every day, then that was it.

“It is important to take care of yourself, so that you can continue to take good care of your patients. I think as long as you set ground rules for yourself coming in and make an effort to actually stick to them, it makes a big difference during residency and is an important skill going forward in your career.”

Outside of medicine, Giovacchini likes to spend time on creative interests, including photography, and staying active outdoors with her friends, husband and large dog, Sumo.

Giovacchini majored in anthropology at Harvard University and got interested in medicine when she studied evolutionary biology. Her undergraduate research involved the effects social interactions on physiologic responses of great apes. This ultimately branched into human endocrinology studies, and through that she became interested in human physiology and medicine. Giovacchini attended The Ohio State University for medical school and then came to Duke for internal medicine residency.

Giovacchini spent last year as a fellow in Pulmonary, Allergy and Critical Care Medicine. She will complete her fellowship after her chief resident year.

Meet the chief residents:

Internal Medicine Residency News – July 7, 2014

Mon, 07/07/2014 - 09:24
From the Director

Week one is in the books! Great job by our new interns, JARs and SARs (and chiefs and office team and attendings) – it is nice to have orientation done, and everyone settling in on the wards and in the clinics. It has been fun seeing the teams around the hospital, and many new interns, including Logan Eberly, were overheard teaching their MSII’s!  I hope you all could enjoy part of the holiday weekend outside of the hospital as well.  There was fun to be had at the VA on July 4th (See the photo proof!)

Kudos this week go to our fantastic SARs who set the bar very high for the new SAR talk/intern emergency lecture series…thank you to Angela Lowenstern, Kevin Trulock and Carli Lehr for fantastic talks! We are looking forward to more great teaching from our SARs.  Also kudos from George Cheely to Jesse Tucker for help on Gen Med and to Dave Kopin and med student Arthika Chandramohan from Adva Eisenberg for an awesome start on VA Gen Med, and as well to GI fellow Matt Kappus for his great email to the outgoing interns and JARS.  Kudos from (cardiology fellow!) Phil Lehman to Bhavana Singh and Adam Banks for great JAR/SAR level work in the CCU.  Also welcome to our ACRs – Alyson McGhan (Duke), Tim Mercer (VA) and Aparna Swaminathan (DRH/amb).  Thank you as well to Katie Broderick-Fosgren and Brittany Dixon for representing the residency council at our annual “Program Evaluation Committee” meeting last week.  We will be bringing you highlights from the meeting, as well as reporting our efforts to improve the program in a variety of venues, including before noon conference, in MedHub, at town halls and via the Med Res News.  Feel free to stop by the chiefs offices, my office, your advisors or APDs offices anytime to chat as well.

Congratulations also to Lynsey Michnowicz! She is officially the new program coordinator for Med-Psych. Lucky for us, she will still be in the office on the 8th floor, so stop by and say congratulations!

Coral and I had the opportunity to visit the new Simulation Center at the VA.  Dr. Park Chan and his team are excited to work with us to bring airway, line, and other simulation training to the medicine residents.  We will be planning times for you to go to the sim center as part of the ICU, procedures, VA gen med and ambulatory rotations.

I hope that you all like your new copy of “The Evidence”,  written by Cardiology Fellow Rob McGarrah. We are excited to bring you this great resource…and now you can get it on your phone! The iOS app is now available on the Apple app store for iPhone and iPad (easily found by searching “The Evidence: classic studies”).  It will be $0.99 during the first two weeks of July, priced for those of you who have the book.

This weeks pubmed from the program goes to John Wagener for his publication with Dr. Sunil Rao…. “Strategies to Avoid Bleeding in the Management of ACS.” Medscape Online. Released July 30, 2013.

Have a great week!

Aimee

What Did I Read This Week? submitted by: Sharon Rubin, MD

Bloomfield, Olson, Greer et al. “Screening Pelvic Examinations in Asymptomatic, Average Age Risk Adult Women: An Evidence Report for a Clinical Practice from the American College of Physicians.” Annals of Internal Medicine 2014; 161 (1):46-53.

 

 

When I was a medical student I could not believe a British patient who told me in England they do pelvic/pap smears every 5 years. Fast forward 10 years there is no supporting evidence to perform pelvic exam and due to improvements with technology and detection of HPV, pap smears interval can be increased to 5 years for women > 30 -65 with normal pap smear and negative HPV testing.

This was a systematic review article via Medline and Cochrane to evaluate the benefits and harms of routine screening pelvic exam and that focused the positive predictive value of pelvic exam to detect nonce rvical cancer, PID, other GYN conditions. They wanted to answer; does a pelvic exam reduce mortality and morbidity from any condition? What are the harms and benefits of a routine pelvic exam?

Results: Diagnostic Accuracy of Screening Pelvic exam: (only from 3 studies) only for ovarian cancer PPV was 1.2 to 3.6%. There were no studies that looked at morbidity or mortality benefits for detection of cancer or nonmalignant conditions. Harms: limited evidence suggested that women associate pelvic exam with pain, discomfort, fear, anxiety, embarrassment and 1 study showed indirect harm: screening pelvic exam led to unnecessary surgery in 1.5% of women. Importantly victims of sexual violence are more likely to avoid pelvic and Pap smear and would experience harm from a routine pelvic screening exam.

Split in recommendation: ACOG recommends annual routing pelvic exams but this is based on expert opinion. USPTSF recommend against pelvic exam for screen for ovarian cancer (Grade D recommendation). Many providers still perform pelvic exam: for screen for ovarian cancer, before prescribing hormonal contraception, to dx STDs or part of well woman visit.

High value care: Balancing clinical benefit with cost and harms with the goal of improving patient outcomes. From Medicare 2013 Pelvic exam #38.11 and pap $45.93. The estimated cost of preventative GYN exams + lab + radiology $2.6 billion. 1/3 = $850 billion spent on unnecessary cervical cancer screening in women < 21 years old; indeterminate % on other pelvic exams.

Conclusions: continue the Cervical cancer screening, there is evidence but consider stopping pelvic exam in asymptomatic women not at increased risk of gynecological cancer.

Clinic Corner

Hi guys! Welcome to the new year at the Duke Outpatient Clinic! We are excited to meet all of our new interns and welcome back our JARs and SARs in their new roles. The DOC is organized into three Firms, or Steads – Stead A is led by Lynn Bowlby, Stead B by Dani Zipkin, and Stead C by Larry Greenblatt. Each stead also has a nurse, one or more CNAs, and a front desk staff person linked to the group. Check out the posted, color-coded grid in clinic to see your group – it is also attached here. And, when you’re in clinic, ask us how to manage in-basket messages to be efficient and leverage the help of your Stead staff in connecting with patients and getting things done.

We will share information with you in emails, in the DOC Newsletter 2014 July (see attached here!!), and even on the Duke Outpatient Clinic Facebook page – which you can join without sharing your personal info. Contact Matt Atkins to get hooked up, or check it out on FB.

For Maestro Tips for the clinic, Dani Zipkin has created lots of helpful videos – check them out here:
http://news.medicine.duke.edu/2014/02/maestro-care-tips-from-your-colleague-zipkin-screensharing/

See you all soon!
Dani

From the Chief Residents Grand Rounds

Friday, July 11th – Duke University Health System – Kevin Sowers/Dr. Tom Owens

Noon Conference Date Topic Lecturer Time Vendor 7/7/14 SAR Emergency Series: Radiology Essentials Mike Malinzak 12:15 Subway 7/8/2014 SAR Emergency Series: Acute/Decompensated Heart Failure Sneha Vakamudi 12:15 Pita Pit 7/9/2014 SAR Emergency Series: EPIC/Maestro Care Brian Griffith 12:15 Cosmic-Quesadillas 7/10/2014 SAR Emergency Series: GIB Alyson McGhan 12:15 Sushi 7/11/2014 Chair’s Conference  Chiefs  12:00 Dominos   From the Residency Office Survival Guides and End of Year Gifts

The 2014 Survival Guides are in and they are awesome.  If you are a continuing Internal Medicine resident, please come by the MedRes office and pick up your copy during normal business hours.  We can only provide one copy per resident.  If you are interested in purchasing a copy, please contact Jen Averitt.  An electronic version of the guide is currently in development and we should have more information on when that will be available soon!

For all continuing Internal Medicine residents, please also pick up your copy of “The Evidence – Classic and Influential Studies Every Medicine Resident Should Know” with the compliments of the program for a great year!

Change in Parking Location (continuing trainees)

Trainees who entered Duke in 2013-14 and are currently parking in the Research Drive lot, are being relocated to PG2 (across from Duke North),  effective July 1.  Continuing trainees currently in PG2 will remain in the PG2 Garage.  Parking Decals are in the mail and, per the parking office, should arrive at your home soon (to the address listed in duke at work).  Your current decal will remain active until July 11th  which will allow plenty of time for you to receive the new decal.  Exceptions to this are the departments of Dermatology (assigned to and remain in PG1)  and the departments of Ophthalmology and Nephrology (all trainees are assigned to and remain in Research Drive).

Stead Resident Research Grants- Request for Proposals

For All Internal Medicine, Med-Peds, and Med-Psych Residents

We are pleased to announce the Request for Proposals for the inaugural “Stead Resident Research Grant” applications. We are grateful to the leadership of the Stead Scholarship Society for their generosity to support resident research and our Stead Leaders for their mentorship and for promoting your scholarly activities !

The applications due on September 1, 2014 for a funding start date on October 1, 2014.

Please find attached the Stead Resident Research Grant Instructions-2014, Stead Resident Research Grant Application Forms-2014, Human Subjects example,  and NIHSAMPLE Biosketch Form.   Please include your mentor’s NIH Biosketch and support letter with your application.

Please see  link below for Biostatistical Support resources available to you for your projects and discuss with your mentor.

http://residency.medicine.duke.edu/duke-program/resident-research/biostatistics-and-data-management-support

Each proposal must have a Human subjects section that describes the protections of the patients and patient data, describe the consent procedure if applicable, status of IRB protocol (to be submitted, already submitted or already approved, as appropriate) etc. This section is required whether to not your project is a retrospective or prospective study, whether patient identifiers are exposed (or not) during data collection/analysis, whether consent is to be obtained or there is a waiver for consent. Please see attached example language that you can adapt to your own protocol after discussing with your research mentor who has already thought about the Human subjects issues.

Wishing you continued success with your research projects !

Murat Arcasoy and Aimee Zaas

Information/Opportunities

www.summitsps.com

Upcoming Dates and Events

July 25th- Summer Celebration at Dr. Klotman’s House

August 17th- Kerby Society Hosting Durham Bulls Game Gathering

Useful links

 

Internal Medicine Residency News: June 30, 2014

Sun, 06/29/2014 - 11:48
From the Director

It’s here! Shadow day for the new interns is Monday, and first day on the rotation is Tuesday! A final congratulations and thank you to our graduating SARs and to the entire GME group for an amazing year.  We are really excited to get started, and Nilesh, Coral, Bonike and Aaron kicked off the year with their first week as chiefs! Not enough thanks can go to Jen Averitt, and the rest of our phenomenal team (Randy, Lynsey, Erin and Lauren) for a smoothly run and very informative orientation week.  Amazing work!! We had a lot of fun at the new intern party at the Pit, and a great “rising JARBQ” at our house on Saturday night.

Kudos this week go to many of you….to Matt Atkins for receiving a gold star, to Gena Foster and Alan Erdmann from Myles Nickolich for covering while he presented at a national meeting, to Nick Rohrhoff for an incredible Tom Holland lecture, to Joe Brogan from Vaishali for outstanding patient care, kudos love back and forth between Vaishali and Amera Ramatullah (Amera for stepping up for extra coverage and to Vaishali from Amera for generally being awesome all year), also from Vaishali to Chris Merrick, Jesse Tucker and Brian Kincaid for coverage at the VA, and to Carli Lehr from Ryan Schulteis for team leadership at the VA.  More kudos to Matt Atkins and Myles Nickolich for leading the effort on revising the Intern Survival Guide (and to all who wrote/revised the chapters), and to Sarah Goldstein, Joanne Wyrembak, Ryan Jessee, Jonathan Hansen, Paul St. Romain, Jon Buggey and Alan Erdmann for running a fabulous intern practicum.

We kick off our new SAR talks this week with the SARs leading the intern emergency lecture series.  Please make every effort to attend and support your colleagues and to GET YOUR INTERNS TO NOON CONFERENCE! Our new equipment is almost ready for use!

Fellowship application due dates are rapidly approaching! I promise to have all of your letters ready before July 15th! Please let me know if you have any questions about the process.  ERAS registration seems to be going smoothly for everyone, and applications can be opened by fellowships on July 15th.

A special thank you to Randy Heffelfinger for his work on “Med Res News” (aka Weekly Updates). What started as a group email has grown into a great way to get information out to everyone in the program.  Starting in July, look for the news at a NEW TIME of Monday morning.   Keep sending us your kudos, your publications and your announcements!

This week’s pubmed from the program goes to Kevin Trulock for his upcoming publication with Jonathan Piccini in JACC.  Rhythm Control in Heart Failure patients with Atrial Fibrillation: Contemporary Challenges including the role of Ablation.  Trulock, KM, MD, Narayan, SM, MD, PhD, Piccini, JP, MD, MHS.

Have a great FIRST WEEK OF JULY!!!

Aimee 

What Did I Read This Week? submitted by: Vaishali Patel, MD

Wunderink RG, Waterer GW.  Clinical Practice: Community-Acquired Pneumonia.  N Engl J Med 2014; 370:543-551.

Why did I read it? 

Even thought I’m going back to being a GI fellow next week, whether I’m seeing patients on Gen Med, in clinic, or moonlighting in the good ol’ VA ED (!!), community-acquired pneumonia (CAP) is EVERYWHERE!!  This article is a few months old, but nicely delineates why we do what we do for CAP (and a great review for the start of internship!).  Because of the economic cost and mortality associated with CAP, the Joint Commission and Center for Medicaid and Medicare services (CMS) have pushed for CAP-related QI measures, institutional reporting of outcomes, and pay-for-performance initiatives.  It is important, therefore, to review the data-driven interventions that reduce both mortality and cost.  This article is consistent with the most recent IDSA-ATS 2007 guidelines for CAP, with the exception of criteria/risk factors and antibiotic recommendations for HCAP and MDR pneumonia, which are driven by newer data.  Refer to the article for very helpful tables and figures.

  • CAP needs coverage of Streptococcus pneumoniae and atypicals (mycoplasma, chlamydophila, and legionella).  Atypical coverage is especially important for outpatients and young adults (macrolides, fluoroquinolones and doxycycline).
  • For inpatients, patients with comorbidities, or antibiotic use in the previous 90 days (use a different antibiotic class), use a respiratory fluoroquinolone (moxifloxacin or levofloxacin) or a combination of a second or third-generation cephalosporin and a macrolide (reduced mortality and decreased length-of-stay with these regiments).  S. pneumoniae is the most common cause of severe CAP requiring ICU admission (treat with combination cephalosporin with either fluoroquinolone or macrolide).
  • Retrospective data from Medicare databases suggests decreased mortality if the first dose of antibiotics is given within 4 hours of presentation to the ED; however, efforts to meet this quality metric has resulted in inappropriate antibiotic use and adverse events such as C diff infections.  The main point is that antibiotics should be given as soon as possible following the diagnosis of CAP; for patients in shock, antibiotics should ideally be given within an hour of onset of hypotension.
  • The recommended duration of antibiotic therapy is 5 to 7 days (no evidence that longer courses have better outcomes, even in severely ill patients, unless immunocompromised).
  • Patients at risk for health-care associated pneumonia (HCAP), MRSA and multi-drug resistant (MDR) gram-negative pathogens need broad-spectrum coverage (see Table 2 of article). However, there is now increasing recognition that using all of the original criteria as indications for broad-spectrum coverage has led to overtreatment (use of broad-spectrum treatment in up to half of the patients with CAP in some centers).  Studies of HCAP patients show low rates of MDR pathogens, and high rates of negative cultures.  While there may be some selection bias as an explanation for this, several multi-center studies have showed increased adverse events and even increased mortality in patients given broad-spectrum therapy compared to those who received standard CAP therapy.
  • Another group of patients not included in the original criteria that is at risk for drug-resistant pathogens are those with structural lung disease (bronchiectasis) or severe COPD who have received multiple outpatient courses of antibiotics.
  • A prospective, observational, multicenter Japanese study (Shindo et al. Am J Resp Crit Care Med, 2013) identified 6 pneumonia-specific risk factors that can be used to determine risk for MDR pathogens (hospitalization >=2 days or antibiotic use during previous 90 days, non-ambulatory status, tube feedings, immunocompromised status, and use of gastric acid suppressive agents).   Using these criteria, a patient who is from a nursing home but does not have one of these risk factors would not get broad-spectrum therapy.  The presence of one MRSA risk factor (prior MRSA infection or colonization, long-term hemodialysis, heart failure) warrants MRSA coverage.
  • There is increasing recognition of exotoxin-mediated pneumonia caused by community-acquired MRSA in previously healthy patients (see Table 3); combination of vancomycin and linezolid or clindamycin (suppress toxin production) has shown decreased mortality.
  • Influenza testing should be done in the appropriate season.
  • You can use the Pneumonia Severity Index to predict short-term mortality and help make admission decisions to reduce admissions of healthier patients; however, it requires the use of an online calculator.  The CURB-65 score (1 point each for confusion, BUN>20, RR>30, SBP<90, and age >65, with a score >=2 as a cutoff for possible admission) can also be used, though is not as well validated as the PSI.
  • The presence of three or more of nine IDSA-ATS minor criteria should prompt ICU evaluation (see Table 5).  Increased attention given to these patients in the ED results in decreased mortality and fewer floor-to-ICU transfers.

Welcome to the new interns!  Have a great year!

From the Chief Residents Grand Rounds

No grand rounds this week – Holiday

Noon Conference Date Topic Lecturer Time Vendor 6/30/2014 Chief’s Intro Chiefs 12:15 Picnic Basket 7/1/2014 SAR Emergency Series: Rheumatologic Emergencies Fola Babetunde 12:15 Saladelia Wraps 7/2/2014 Emergency Series: Micro Lab Essentials Aimee Zaas 12:15 China King 7/3/2014 SAR Emergency Series: Hyper and hyponatremia Benjamin Llyod 12:15 Chick-Fil-A 7/4/2014 HOLIDAY – No Conference Domino’s   From the Residency Office Survival Guides and End of Year Gifts

The 2014 Survival Guides are in and they are awesome.  If you are a continuing Internal Medicine resident, please come by the MedRes office and pick up your copy during normal business hours.  We can only provide one copy per resident.  If you are interested in purchasing a copy, please contact Jen Averitt.  An electronic version of the guide is currently in development and we should have more information on when that will be available soon!

For all continuing Internal Medicine residents, please also pick up your copy of “The Evidence – Classic and Influential Studies Every Medicine Resident Should Know” with the compliments of the program for a great year!

Change in Parking Location (continuing trainees)

Trainees who entered Duke in 2013-14 and are currently parking in the Research Drive lot, are being relocated to PG2 (across from Duke North),  effective July 1.  Continuing trainees currently in PG2 will remain in the PG2 Garage.  Parking Decals are in the mail and, per the parking office, should arrive at your home soon (to the address listed in duke at work).  Your current decal will remain active until July 11th  which will allow plenty of time for you to receive the new decal.  Exceptions to this are the departments of Dermatology (assigned to and remain in PG1)  and the departments of Ophthalmology and Nephrology (all trainees are assigned to and remain in Research Drive).

Information/Opportunities

 

Upcoming Dates and Events

November 8:  Clinical Science Day

Useful links

 

Meet your chief resident: Nilesh Patel, MD, MS

Tue, 06/24/2014 - 11:57

Nilesh Patel, MD, MS

Nilesh Patel, MD, MS, is stepping into his role as chief resident for Duke University Hospital this week. Going into the new academic year, he has been thinking about ways to improve patient care and better support Duke’s internal medicine residents.

Dr. Patel, who completed his residency at Duke, has spent the last year as a faculty member in Hospital Medicine, rounding on general medicine in Duke University Hospital, so he has had many opportunities to observe and think about patient care and the resident experience.

One thing Patel says he’s gotten interested in is how the chief residents can help educate and support residents when they are in the hospital overnight and don’t have all the resources that residents have during day shifts, such as access to conferences or having a consult service that is immediately available. Patel would like to find ways to make more resources available for residents working at night.

Patel said supporting and providing resources for residents in general is one of his, and the three other incoming chief residents’, top priorities for the year. Patel’s co-chief residents are Coral Giovacchini, MD; Bonike Oloruntoba, MD; and Aaron Mitchell, MD.

“Our biggest goal is to make sure that we are as approachable and supportive as possible,” Patel said. “If the residents need anything this year, whether it’s taking care of patients, problems in their personal lives or finding resources for advancing their careers, we want to be easily accessible.”

Patel said there should never be a time when residents feel like they don’t have a support system, from the chief residents who are available 24 hours a day, seven days a week, to the senior assistant residents and attending physicians.

“The thing that makes Duke special is that you have an incredible group of caring, compassionate, brilliant individuals who are dedicated to caring for our patients,” Patel said. “I expect to be at the hospital late in July, August and September, and many of our faculty do, too, so our interns and residents can transition into their new roles as quickly as possible.”

Providing educational opportunities is part of the support Patel would like the chief residents to provide this year.

“One of the greatest opportunities that we have is to teach our residents and medical students not only during the structured time, but during the enormous number of reports that the chief residents lead, the unstructured reviewing of cases,” Patel said. “These learning opportunities are something that the chief residents are intimately involved in, so we can teach not only the zebra cases, but also the day-to-day cases that our residents spend most of their time thinking about.”

Other areas Patel has been thinking about over the last year include rapid response codes and quality improvement projects.

He says he would like to develop a way for residents to approach rapid response triage (RRT), so that they have the opportunity to care for some of the sickest patients on the floor before the patients go to the ICU (these are patients who are not in cardiac arrest but who are either having a respiratory problem or who are becoming ill quickly).

Patel also has been thinking about quality improvement projects that would improve patient care and allow residents and faculty who are rounding on internal medicine services to be more efficient. Patel said he is working on a project on the paging culture here at Duke, but longer term he’d like to develop broader projects on how residents and faculty are using Maestro Care or changes in the way physicians transition patients.

Patel expects other challenges to come up. The four incoming chief residents have already identified duty hours, the bed expansion, and the increase in the number of patients residents see overnight as areas they will need to watch and troubleshoot.

“The question is how can we as chief residents continue to support and make sure residents have the time and the accessibility to what they need in order to learn as much as they were from each rotation before the changes took place,” Patel said.

Patel and his co-chief residents will have many opportunities to work together and find ways to make rotations, conferences and reports good learning opportunities for residents.

One thing that Patel feels does set up the chiefs for success is that they are all graduates of the residency program and good friends.

“The four of us have been fortunate enough to go through residency together and be friends long before this year started. We’ve been coming up with ideas on our own to hopefully move the residency program forward,” he said.

After his chief resident year, Patel, who attended Emory University School of Medicine, will return to Hospital Medicine at Duke. He says it’s a good fit for him because there are so many learning and clinical opportunities – two reasons he went into medicine. “Hospital Medicine has a brilliant group of clinical faculty who are invested in the quality of this hospital and taking care of patients,” he said.

In his down time, Patel enjoys running, spending time with family, and reading. He also looks forward to spending time outside of the hospital with his fellow chiefs and residents.

Internal Medicine Residency News: June 23, 2014

Sun, 06/22/2014 - 19:02
From the Director

It’s here! The new interns start orientation on Monday!

A tremendous thank you and kudos to our chiefs Krish, Vaishali, Stephen and Joel. Only at Duke would a post op day 1 chief come to his co chiefs grand rounds. Amazing grand rounds given by Stephen Bergin!  We all can’t thank you enough for a fantastic year.

And we welcome Nilesh, Coral, Bonike and Aaron to the ranks. They completed their first task – the pull list- so we are well on our way to an amazing year.

Kudos also to Ryan Jessee for a great chairs conference and to Aparna Swaminathan and Rebecca Sadun for covering some colleagues on Friday so they could attend the VERY FUN SAR-b-q at our house. Also to Brice Lefler and Katie B-F for replying.

The SAR b-q was a great send off to a legendary class. Double benefit that they bought it at the charity auction. Looking  forward to hosting the interns (aka almost JARs) on Saturday.

Congrats also to the outgoing chiefs and Lauren Dincher on their 5 year service awards,and a special congratulations to the award recipients presented at grand rounds!

  • Bruce Dixon AwardLindsay Boole (nominees included  John Stanifer, Chris Hostler, Matt Summers, Lindsay Boole, Jim Gentry, Armando Bedoya, Meredith  Clement)
  • Fellow Teaching Award:  Zach Healy (nominee included –  Tony Tran, Jacob Doll, Megan Diehl, Ann Marie Navar Boggan) 
  • Haskel Schiff Award:  Matt Summers (nominees included  Chris Hostler, Matt Summers, Lindsay Boole, Brian Miller, Armando Bedoya, Tim Mercer)
  • Outstanding Service Award:  Randy Heffelfinger

This week’s pubmed from the program goes to Myles Nickolich for his upcoming poster presentation: “WHAT BOTHERS LUNG CANCER PATIENTS THE MOST? A PROSPECTIVE, ELECTRONIC, PATIENT-REPORTED OUTCOMES STUDY IN ADVANCED NON-SMALL CELL LUNG CANCER”

Have a great week

Aimee

What Did I Read This Week? submitted by: Krish Patel, MD

Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014 Apr 10;370(15):1402-11

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1302097

Why I read this:

This week’s JAMA had several articles about thrombolysis in acute PE.  Mostly a meta-analysis and an editorial.  Those articles were interesting, but mostly served to remind me to look for the publication of a trial I’d heard about earlier this year from Vic Tapson called the PIETHO trial.

We see a lot of patients with acute pulmonary emboli and the spectrum of presentation can vary quite widely.  We see patients with shock from PEs that require lytics and ICU admisssions to patients with no symptoms and incidental PEs on imaging of the chest intended for other purposes.  One area of uncertainty that we commonly face is what to do with “large PEs” with suggestions of RV dysfunction, but without overt hemodynamic compromise (so called intermediate risk patients).  There is little data to guide us in that regard.  The PIETHO trial was designed and undertaken to help provide more guidance in this area of clinical uncertainty….

Design: 

This study was a multicenter (Europe) double blinded, randomized, controlled trial.  The trial enrolled adult patients (n=1006) with acute PE (<15 days) and RV dysfunction (defined by specific ECHO or CT dimensional criteria) with myocardial injury (positive Troponin).  Patients with contraindication to thrombolytics, with overt hemodynamic instability, or recent IVC filter placement or thrombectomy were excluded from participation.  Patients were randomized to either single bolus dose of tenecteplase + intravenous unfractionated heparin vs. placebo + intravenous UFH.  The primary outcome was the composite of death from any cause and hemodynamic collapse within 7 days of randomization.  Secondary endpoints included 30 day all-cause mortality, recurrence of PE within 7 days of randomization, and various 7 day bleeding rates (major bleeding, intracranial hemorrhage, major extracranial bleeding).  Overall, the groups were fairly balanced in baseline characteristics and had similar proportions achieving therapeutic PTT on UFH within 24 hours of randomization. 

Results: 

So what did they find? The primary outcome occurred less often in the group receiving tenectaplase + UFH (2.6% vs 5.6%; p=0.02). However, this was primarily driven by a difference in hemodynamic decompensation (1.6% vs. 5.0%; p=0.002).  The study was not powered to detect a difference in death rate and the death rates in both groups was quite low (1.2% vs 1.8%; p=0.42).  Hemodynamic decompensation included some meaningful events (cardiac arrest, need for catecholamines for BP support) but also a perhaps less meaningful one (SBP <90mm Hg for >15mins).  Nevertheless, the occurrence of each type of hemodynamic decompensation was numerically different in both groups (statistical significance not published).

How about safety endpoints?  Well as might be expected there was notably more bleeding and hemorrhagic stroke in the tenectaplase group in comparison to the placebo group.

What does this mean for us:

Well, this trial demonstrates that patients with acute PE, RV dysfunction and myocardial injury have an increased risk of hemodynamic decompensation and that single dose tenectaplase may mitigate that risk.  However, the risk of significant bleeding, including a 2% incidence (10x relative risk) of hemorrhagic stroke ,may outweigh the benefit of the reduction in hemodynamic compromise.  Overall, this trial also tells us that the risk of death in patients with acute PE, RV dysfunction, and myocardial injury is relatively low and these patients can be managed well with careful monitoring and anticoagulation (the placebo arm) and that thrombolysis perhaps should be reserved for patient’s who fail this initial approach.

From the Chief Residents Grand Rounds

Presenter:  Dr. Mary Klotman

Chair, Department of Medicine

Topic:   State of the Department of Medicine

Noon Conference Day Date Topic Lecturer Time Vendor Monday 6/23 MKSAP Mondays – Thrombocytopenia Chiefs 12:00 Subway Tuesday 6/24 Immunizations Review Anne Phelps 12:00 Sushi Wednesday 6/25 How to Give a Talk Zaas 12:00 Cosmic Cantina Thursday 6/26 Novel therapies for staph aureus infections Ralph Corey 12:15 Domino’s Friday 6/27 Tom Holland Lecture Chiefs 12:00 Chick-Fil-A   From the Residency Office GME Resident Council

The following are your peer selected representatives to the Resident Council for 2014-2015. The Resident Council has elected Dr. Michael Barfield, General Surgery, as Chair and Housestaff Representative and Dr. Nicholas Rohrhoff, Internal Medicine, as Vice-Chair.

  • Dr. Michael Barfield - General Surgery, Chair
  • Dr. Nicholas Rohrhoff - Internal Medicine, Vice-Chair
  • Dr. Eun Eoh Anesthesiology
  • Dr. Dinesh Kurian Anesthesiology
  • Dr. Jolene Jewell Dermatology
  • Dr. Manisha Bahl Diagnostic Radiology
  • Dr. Michael Malinzak Diagnostic Radiology
  • Dr. Lauren Siewny Emergency Medicine
  • Dr. Nikki Henry Family Medicine
  • Dr. Michael Barfield General Surgery
  • Dr. Brittany Dixon Internal Medicine
  • Dr. Nicholas Rohrhoff Internal Medicine
  • Dr. Kevin Trulock Internal Medicine
  • Dr. Jesse Tucker Internal Medicine
  • Dr. Colby Feeney Internal Medicine/Peds
  • Dr. Amy Newhouse Internal Medicine/Psych
  • Dr. Owoicho Adogwa Neurological Surgery
  • Dr. David Lerner Neurology
  • Dr. Joseph Dottino Obstetrics and Gynecology
  • Dr. Jaya Badhwar Ophthalmology
  • Dr. Norah Foster Orthopaedic Surgery
  • Dr. Robert Henderson Orthopaedic Surgery
  • Dr. Richard Rutherford, Jr. Orthopaedic Surgery
  • Dr. Russel Kahmke Otolaryngology
  • Dr. Alyssa Kraynie Pathology
  • Dr. Christopher Severyn Pediatrics
  • Dr. Robert Bahnsen, Jr. Psychiatry
  • Dr. Alexander Eksir Psychiatry
  • Dr. Christina Cramer Radiation Oncology
  • Dr. Brian Gulack Surgery Research Fellowship
  • Dr. Melissa Mendez Urology
  • Snyderman Award Winner
Snyderman Award

The Snyderman Award was presented to Dr. Lindsey Boole, MD by Dr. Catherine Kuhn at the June ICGME Meeting last week. The winning submission is titled “Residents finding their roots: Resident workshops to improve patient safety on the wards while teaching root cause analysis”. Dr. Boole will receive $1000 (after taxes) and her name on the Snyderman Plaque. Congratulations to Dr. Boole and all who submitted projects for Snyderman Award consideration. More information about the Snyderman Award can be found on the GME Web site.

Moonlighting

All Internal (TSMA) Moonlighting approvals will expire on June 30, 2014.
To record moonlighting activities within MedHub, the activity must be approved through the TSMA/Moonlighting Request Forms located in the Schedule Planning section of MedHub.

The following policies apply to the moonlighting opportunities that are available to trainees:

At no time may the hours allocated for TSMA activities negatively impact training or violate duty hour policies. Residents who would like to be considered for Temporary Special Medical Activity (TSMA) in Oncology, Emergency Medicine, Cardiology, or Student Health must meet the following:

  1. Program level – either JAR or SAR
  2. Successful completion of rotations on MICU and Gen Med
  3. Be in good standing and without any active corrective action
  4. Provide written support from their advisor supporting the trainee’s request. The advisor may send an email to the attention of the Program Director, copy to the Program Coordinator, confirming their approval (to be completed prior to initiating the online TSMA form).
  5. Initiate the online TSMA form found on MedHub.
  6. Meet any additional training requirements as specified by the sponsoring department.

On notification of approval by GME, the trainee may contact the service Director and request approval to participate in the TSMA service.

Please Note: TSMA is approved only for each academic year. If you are currently participating in TSMA and plan to continue after July 1, you will need to resubmit the required forms for approval.

Duke Ahead

Information/Opportunities

Albemarle Procurement

Upcoming Dates and Events
  • Intern Welcome Celebration:  June 27 @ the PIT
Useful links

Internal Medicine Residency Program recognizes faculty, trainees with annual awards

Fri, 06/20/2014 - 09:57

Over the last few weeks as the chief residents have presented at Medicine Grand Rounds, the following faculty, fellows and residents have been honored by the Internal Medicine Residency Program for their work. Please congratulate your colleagues:

Eugene Stead Award: Louis Diehl, MD

Durham Regional Teaching Award: Jessica Chia, MD

Outstanding Service Award: Randy Heffelfinger

Ambulatory Medicine Teaching Award: Lynn Bowlby, MD

VA Faculty Teaching Award: Micah McClain, MD, PhD

Fellow Teaching Award: Zach Healy, MD

The House Staff Community Service Award: Carling Ursem, MD

Lececq Award for Outstanding Senior Resident Talk: Rebecca Sadun, MD, PhD, Alex Fanaroff, MD, Lauren Porras, MD

Haskel Schiff Award: Matt Summers, MD

Bruce Dixon Award: Lindsay Boole, MD

Joseph McClellan Award: Stephen Bergin, MD

Grand Rounds 6/20/14: Rapid Diagnostics

Mon, 06/16/2014 - 08:40

Medicine Grand Rounds on Fri., June 20 at 8 a.m. in Duke Hospital room 2002 will feature Stephen Bergin, MD, chief resident for Duke Regional Hospital/Ambulatory Medicine.

Dr. Bergin will present Rapid Diagnostics: Emerging Methods of Optimizing Antimicrobial Therapy.

Video archives If you can’t make Medicine Grand Rounds this week, watch a live stream or view the archived video at http://bit.ly/RSlrBP (ignore the security certificate warning, then use your Duke NetID & password).

Internal Medicine Residency News: June 16, 2014

Sun, 06/15/2014 - 11:47
From the Director

T-1 week until the new interns arrive for orientation! We are looking forward to having the SARs at our house this weekend, and the current interns (the nearly JARs!) at our house on the 28th.  Current interns, we will be emailing you the name of the new intern who will be shadowing you for the day on June 30th this week.  They won’t have Duke email until next week, but it would be great if you could send them a quick note to introduce yourself.

Kudos this week go to Krish Patel for his outstanding Grand Rounds, and also to our many award winners and nominees.  Congratulations to our Appleseed Teaching Award winners (given by the med students — thanks Wynn Hunter for organizing!)

Interns:  Andrea Sitlinger, Cece Zhang, Eric Yoder, Jonathan Hansen,Paul St. Romain

PGY 2+Adrienne Belasco, Hal Boutte, Tyler Black, Michael Woodworth, Sneha Vakamundi, Armando Bedoya, Brian Miller, Carling Ursem, Jay Mast, Dana Clifton, Timothy Mercer

To the Duke Regional Teaching Award Winner Jessica Chia (nominees: Nijra Nugogo, Stan Branch, Christina Barkauskas)

The Ambulatory Teaching Award winner Lynn Bowlby (nominees: Anne Phelps, Daniella Zipkin, Sharon Rubin, Diana McNeil, William Yancy, Ken Lyles, John Rubin ).

The Community Service Award winner Carling Ursem (nominees:  Meredith Clement, Mandar Aras)

We also celebrated our ACLT graduates this weekend – Kim Bryan, Lauren Porras, Jodel Giraud, Jeremy Halbe and Alex Clark.  Thanks Larry Greenblatt for hosting and to Alex Cho and Sharon Rubin for organizing! More kudos to Ben Peterson for a great chair’s conference.  Also kudos to John Stanifer for receiving grant a sub-award from Dr. John Bartlett’s MEPI grant: Medical Educational Partnership Initiative (MEPI) (#T84-HA21123) Mentored Research Training Program (MTRP) sub-award. ($25,000) Moshi, Tanzania. June 2014.

We did receive a confidential comment line comment that the work rooms are really messy at both Duke and the VA.  Yes, they are! A reminder that Environmental Services is responsible for cleaning the floors and emptying the trash ONLY.  They cannot clean the counters or throw away anything that is not already in the trash cans.  So, please be sure to recycle any PHI that is no longer needed in the confidential recycling bins, and to throw away any trash into the trash cans.  If the trash cans are not being emptied when they are full, please let Randy, Jen or I know, and we can discuss with the EVS team.  For the next couple of weeks there will be members of the Respiratory Therapy team working in rooms 8214-16.  Please be sure to give them the space they need while they are there.

Pubmed from the program this week also goes to John Stanifer for his publication in Historia Medicinae..A Peculiar Type of Dyspnea: Kussmaul, Cheyne Stokes and Biot Respirations. 

Have a great week!

Aimee

What Did I Read This Week? NEJM 2014, 370:2211-2218  June 5, 2014 Review Article: Pregnancy and Infection submitted by: Lynn Bowlby, MD

One of my areas of interest is medical problems in pregnancy. Dating back to my med school years I have been lucky to be exposed to internists working in this area. I love thinking about the changes in physiology that occur in pregnancy and how that impacts all illnesses.

As a general internist, NEJM is a great source of both original work and review/summary pieces. I check out every issue and last week’s issue had a great summary of ID and pregnancy. The evidence is slim for many pregnancy issues, with expert opinion often being dominant, but this article is a great summary of the available evidence and current thinking.

Pregnant women have an increased risk of infection, but not all infections. As any of us who took care of pts. in 2009 were reminded with the H1N1 flu epidemic, mortality and morbidity was much higher.  Pregnant women are more severely affected with the flu, Hep E , HSV and malaria.

It seems that the cardiac and pulmonary changes, with reduced lung capacity, increased HR and SV as well as urinary stasis, of normal pregnancy may increase the severity of the response to infection.

There certainly may be bias in determining severity of illness in pregnancy since they likely have more testing and hospitalization.

One very interesting fact– 5% of the deaths from H1N1 in 2009 in the US were in pregnant women, who comprise just 1% of the US population.

There is increased mortality from HEV (SE Asia, Middle East and Africa).

Primary HSV carries an increased risk of dissemination and hepatitis in pregnancy.

Pregnant women have x3 the risk of severe malaria. Mean maternal mortality from malaria is 39% in parts of Asia/Pacific region.

Coccidioidomycosis does not seem carry the increased incidence in pregnancy that once was thought.

Varicella infection seemed to have increased mortality in pregnancy based on some studies, but more recent review of data showed no change in mortality.

Increased incidence of infection as well as increased severity are both an issue in pregnancy.

Increased incidence is the clearest for P falciparum and Listeria monocytogenes.

The changes in sex hormones and the immune system are felt to affect the risk of and response to infection. Estradiol seems to increase immunity response.  The concept that the pregnant woman is immune suppressed to avoid the loss of the fetus is likely oversimplified. Pregnant women are not susceptible to all infections.

From the Chief Residents Grand Rounds

Presenter:  Dr. Stephen Bergin

Duke Regional/Ambulatory Services Chief Resident Grand Rounds

Noon Conference Date Topic Lecturer Time Vendor 6/16 MKSAP Mondays – Healthcare Maint. Bergin / Chiefs 12:00 Picnic Basket 6/17 Resistant HTN Case Studies Bergin 12:00 Pita Pit 6/18 Primary Care Controversies Zipkin 12:00 China King 6/19 QI Patient Safety Noon Conference Bae / Clark 12:00 Rudino’s 6/20 Chair’s Conference Chiefs 12:00 Domino’s From the Residency Office C Diff Shedding Study

This study is being led by Luke Chen, MD, who is asking for your assistance to identify appropriate patients as noted below:

  • When you have a patient with – suspected C-difficile associated diarrhea (CDAD)

Or

  • –PCR +ve for C. difficile and starting treatment  for CDAD

Who is able to receive any of the 3 oral antibiotics  (metronidazole/vancomycin/fidaxomicin)

  • Exclusion criteria:

–  > 1 dose of CDAD therapy

–  Receiving Other CDAD therapy (e.g. IV metronidazole

Please page Kathy Ramadanovic, Clinical Research Coordinator (CRC) at 970-11773

C-Diff Shedding Ad.

 

Information/Opportunities

North Dakota Internal Medicine

Idaho Internal Medicine

Idaho Hospitalist

Montana Hospitalist

Practice in one of Americas happiest states

 

Upcoming Dates and Events
  • Intern Welcome Celebration:  June 27 @ the PIT
Useful links

Grand Rounds 6/13/14: Learning Health Systems

Tue, 06/10/2014 - 15:34

Medicine Grand Rounds on Fri., June 13 at 8 a.m. in Duke Hospital room 2002 will feature Krish Patel, MD, chief resident in internal medicine for Duke University Hospital.

Dr. Patel will present Learning Health Systems: Bridging the Divide.

Video archives If you can’t make Medicine Grand Rounds this week, watch a live stream or view the archived video at http://bit.ly/RSlrBP (ignore the security certificate warning, then use your Duke NetID & password).

Internal Medicine Residency News: June 9, 2014

Sun, 06/08/2014 - 18:16

 

From the Director

Two weeks till the new interns show up for orientation….we start medicine orientation on June 26, with “shadow day” on the 30th…it will be here before we know it.

This past week was a pretty rough week for the Zaas house, but a really good reminder of what a fantastic family we are here in the IM residency.  To be honest, I wasn’t sure if I should bring this up in the Med Res News, but it has been a tremendous help to have support from you all that I thought I should.  Many thanks to all, and special thanks to Erin, Randy, Jen, Lynsey and Lauren; to Jon, Bill, Murat, Lish, Alex, Sharon, Diana, Lynn and Dave B, and to Bobby Aertker, Nancy Lentz, Tyler Black, Carling Ursem, Brice Lefler, and Rajiv Agarwal, to Alyson McGhan, Kevin Trulock, Marc Samsky, Hany Elmariah, Bronwen Garner Alex Fanaroff, Matt Hitchcock, Stephen Bergin, Joel Boggan, and Vaishali Patel, and also Tom Holland and Tony G.  Very very grateful for you all!

First kudos of the week goes to VAISHALI PATEL for her amazing grand rounds! Great work Vaishali.  Also congratulations to our award winners and nominees…Best SAR Talk Awards to Rebecca Sadun, Lauren Porras and Alex Fanaroff (nominees were:  Alex Fanaroff, Lauren Porras, Rebecca Sadun, Kevin Shah, Christopher Hostler, Meredith Clement).

 

The Stead Teaching Award went to the much deserving Lou Diehl (nominees were:  Kevin Harrison, Joe Govert, Lou Diehl, Chris Woods, Saumil Chudgar, Dave Butterly, Rich Riedel, Joe Rogers).

The VA Teaching Award went to an equally deserving Micah McClain (nominees were:  Ken Lyles, Chris Woods, Micah McClain, Eugene Oddone, Marie Carlson, Ralph Correy).

Kudos this week go to Murat Arcasoy for putting together a FANTASTIC resident research night. Loved seeing all the posters, and we had plenary level talks from Laura Musselwhite, Mandar Aras and Alex Fanaroff.  The Poster awards were for Nina Beri (Research) and Tim Mercer (QI). Dr. Dzau was there too! Thanks to all the faculty who support our residents in their research, and to all who presented and attended.  We have a great write up in Medicine News, so check it out! Best Grand Rounds went to Dr. Frank Neelon (nominees included Susanna Naggie and Carl Berg) and the Research Mentor Award to Brice Weinberg (nominees Jon Bae, Amy Abernethy).  Other kudos to Amanda Elliott for her chair’s case, with Audrey Metz getting the diagnosis! Kudos as well to Hany Elmariah who has gone above and beyond to help his fellow SARs get their last remaining procedures logged.

Another Kudos goes to Jon Bae whose hilarious use of the confidential comment line caused Randy’s blood pressure to go up 15 points.  I think someone has a picture of Randy trying to strangle Jon when he found out that it was a joke that residents were requesting Hot Pockets in the snack basket, and a DVD player in the call room.  Nicely played, Jon.  However, we do always welcome suggestions or concerns in the confidential comment line, found at the end of the weekly updates and a link on medhub.

Reminder to all who round on the 8th floor…WE CANNOT LEAVE ANY PHI in 8200! Really, we shouldn’t be leaving it anywhere, but an unsecure location is even more dangerous.  Please always remember to recycle any papers with PHI in the designated shred bins.  If you don’t need to print it, don’t print it.  If you need to print it, recycle appropriately when you are done.

This week’s pubmed from the Program goes to Nick Rohrhoff and Joel Boggan for their article in JAMA’s “Too Much Medicine” series..  JAMA IM – A Double Whammy – 2014

Have a great week, and please be sure to make it to Grand Rounds for Krish Patel!

Aimee

What Did I Read This Week?

Rate and Rhythm-Control Therapies in Patients with Atrial Fibrillation:  A Systematic ReviewAnn Intern Med 2014; 160(11):760-773. Al-Khatib SM, Allen LaPointe NM, Chatterjee R, Crowley MJ, Dupre ME, Kong DF, Lopes RD, Povsic TJ, Raju SS, Shah B, Kosinski AS, McBroon AJ, Sanders GD

submitted by: Joel Boggan, MD

Why did I read this?

This article was just used as part of the real-time Morning Report twitter feed series by the @MedChiefs account from the University of Chicago.  When I clicked on the article, I saw it was from Duke, and, combined with the fact that this topic comes up repeatedly on our general medical and cardiology services, I kept reading.

What is the question? 

The authors sought to determine the comparative safety and effectiveness of different rate- and rhythm-control strategies for patients with atrial fibrillation.

What did the authors do?

The authors performed a systematic review of RCTs of pharmacologic and nonpharmacologic strategies in adults with AF.  They also looked at observational studies of strict vs. lenient rate control strategies and cardiac resynchronization therapy vs. other rhythm-control strategies.  Outcomes were restoration of sinus rhythm (conversion), maintenance of sinus rhythm, recurrence of AF at 12 months, development of cardiomyopathy, death (both all-cause and cardiac), MI, CV hospitalizations, HF symptoms, control of AF symptoms, QOL, functional status, stroke and embolic events, bleeding events, and adverse events related to therapy.   When more than 3 studies were published for a particular outcome, a meta-analysis was performed, when possible.

Importantly, when looking at the rate- vs. rhythm-control strategies, they grouped all rate and rhythm control strategies together, regardless of class.  So, CCBs and BBs were grouped together for rate control.  Similarly, they lumped procedures (cardioversion, AV node ablation, pulmonary vein isolation, etc.) together for comparisons against medical therapies, although they did investigate the different procedures individually against one another.    They also reported on a set of studies comparing different procedural interventions, but I’m not commenting further on these analyses here.

What did they find?

From a group of 10,495 abstracts and 570 articles, the authors identified 200 articles from 162 studies that involved 28,836 patients.  I’m showing you a subset of their analyses, so there are others available in the article.

Rate vs. rhythm strategies

For rate- vs. rhythm-control analyses, 16 RCTs were identified.  Thirteen of these articles compared different pharmacologic options, while three compared pulmonary vein isolation with rate-control meds +/- an AV node ablation.  The meta-analysis done for 10 of these studies showed moderate strength of evidence that pharmacologic rate- and rhythm-control strategies are of comparable efficacy with regard to their effect on all-cause mortality (odds ratio [OR], 1.34 [95% CI, 0.89 to 2.02]; Q = 21.71; P = 0.003), cardiac mortality (OR, 0.96 [CI, 0.77 to 1.20]; Q = 3.55; P = 0.47), and stroke (OR, 0.99 [CI, 0.76 to 1.30]; Q = 7.02; P = 0.43).

Procedural vs pharmacologic rate control

Six studies compared a procedural vs. a pharmacologic intervention for rate control, and, in the three studies in the former category that reported outcomes at one year, heart rates were lower in those who received an intervention vs. a medication.

Medications for ventricular rate control

Sixteen studies also assessed effectiveness of ventricular rate control by pharmacologic means, where benefit was shown in reducing tachycardia-induced cardiomyopathy, HF, and MI and improving QOL with studied medications.  However, the permutations of medications used within the studies made it impossible to conclude whether one medication class (BBs, CCBs, amio, digoxin) was safer or more effective than others at controlling ventricular rates.

Strict vs. lenient rate control 

Only one high quality RCT and two observational studies looked at a strict vs. lenient rate control strategy, and the small size of these studies and the imprecision of their findings made it difficult to determine any statistically significant difference in any endpoint between these two strategies.

Pulmonary vein isolation vs. antiarrhythmic medications

One additional procedural series of results I will comment on was the 9 RCTs highlighting pulmonary vein isolation vs. antiarrhythmic medications for rhythm control.   Data from these trials provide high strength of evidence that rhythm control using pulmonary vein isolation is superior to antiarrhythmic medications in reducing recurrent AF over 12 months of follow-up (OR, 5.87 [CI, 3.18 to 10.85]; Q = 33.82; P < 0.001), particularly in younger patients with little or no structural heart disease and no or mild left atrial enlargement.

What can we conclude?

1)      In older patients with mild symptoms from AF, rate-control and rhythm-control strategies using medications are similarly efficacious for mortality endpoints and stroke, at least for the first few years of therapy.

2)      Pulmonary vein isolation is superior to antiarrhythmic medications at preventing AF recurrence in younger patients without structural heart disease.

3)      Few studies have compared different rate control medications for significant outcomes.

Further work is needed to determine longer-term (beyond 4 years) outcomes of rate vs. rhythm strategies, as there is a signal that rhythm control may lead to decreases in mortality beyond five years.  Additionally, work should focus on different rate-control medications and their effectiveness and safety to determine a preferred group in specific groups of patients.

How can this apply to your practice? 

When encountering patients with AF in the clinic or on the wards, decisions about treatment can be directed by the patient’s age and comorbidities.  If the patient is older or has more medical comorbidities that may limit longevity, one could pursue either a rate or rhythm strategy without a specific heart rate target.  If the patient is younger or has fewer medical problems that may limit longevity, a referral to EP may be warranted for consideration of pulmonary vein isolation or other procedures.

 

QI Corner (Joel Boggan, MD)

Hand Hygiene
After a long several months of work by our fabulous hand hygiene champions, all their (and your) hard work has paid off!  Here are the data through May . . . congrats on reaching our goal!

Month Location Observations Last 30 days Compliant Last 30 Days Non-Compliant Last 30 days HH Rate last 30 days Jan 7100 8 8 0 100% Jan 7300 6 6 0 100% Jan 7800 18 18 0 100% Jan 8100 6 5 0 84% Jan 8300 4 3 0 75% Jan 9100 4 4 0 100% Jan 9300 5 5 0 100%

 

“Clinic Corner” Pickett Road, submitted by Dr. Rubin and DOC by Daniella Zipkin

First up:  Duke Outpatient Clinic:  “Hey guys, there is a brand new DOC Newsletter hot of the presses – check it out here!!”   DOC Newsletter 2014 June

Next:  A lot of information shared by Dr Rubin regarding Pickett Road

Thank you to the SARs for the two Candy dispensers. The key is to turn the button on (in the back) then put your hand under the dispenser, and then turn it off! Or else there will be M&Ms everywhere!

 Download EPIC Haiku- this will CHANGE your life! Really and you can use this in patient.

  • 1. MUST be in Pickett Clinic (or in hospital) LOG into CLUBS
  • 2. Go to Maestro.duke.edu
  • 3. Go to maestro Care Mobile Apps: Learn more about apps on your mobile device
  • 4. Maestro Care Mobile Device Support
  • 5. Configure: clic on Haiku Configuration
  • 6. Log into Epic Haiku and you can take patients pictures strange rashes, look at your schedule and inbasket

Just a reminder to residents and providers that lab testing stops at 4:30 each day. The lab will continue to draw until 5:15. The tech uses the last 30 minutes of her shift to finish testing already received, perform shutdown of instruments and run daily reports.

Re: Home Health face to face encounters

Recently we have had some of our home health referrals get rejected for payment. The main reasons for the rejections are-

#1- Homebound reason states-”transportation reasons”. The quality improvement examiner is kicking out all transportation statements.

#2- Submitting the face to face encounter out of the time frame. It is taking almost 2 months for the face to face encounter to be completed.

Please see the below note from the quality improvement examiner:

Also, we cannot use transportation as a reason for the patient to be homebound. Medicare will deny the claim.

Homebound reason must include clinical documentation that supports the reason the patient is homebound.

EXAMPLE: It is a taxing effort for patient to leave her home without the assistance of another person due to her cognitive impairment from schizoaffective disorder. She also requires the use of a rollator walker for safe ambulation.

Thank you to Edva, Bassem, Alan, Audrey and Howard for coming to the town hall. I know that many of you could not make it to the meeting. These are notes from the meeting.

I asked: how to make intern orientation better

  • - FOR THE SARS- request for the handoff list to be typed (I am happy if it is just complete) and give to Sharee- ideal to give at orientation not at first day of clinic
  • - focus more on EPIC, writing a note, sharing dot phrases
  • - still unsure if I should share my favorite orders as this mixes with inpatient orders
  • - having the DPC handbook as a reference (This year the book with be printed with all the other guides)
  • - encourage them to use templates (steal templates) and use notewriter
  • - good to have staff pictures in the resident room
  • - try to make quest more check off, not need signatures
  • - explain about Acute visit (do no have to address HCM), control of session: limit pt to 1-2 complaints
  • - explain about attending pt acutes, post hospitalization visit
  • - STAT referral- walk to Danielle or Natasha
  • - try to train intern and their patients for 20-30 minute visit, not 1 hour. The template is set so they see 2,2,3,4 patients (first of 4/7 slots then 5/7 slots 2nd half of year)
  • - need to train interns how to use inbasket earlier

Questions/answers

  • 3 orders: give pt phone number to call (can steal from me)
  • 1. Mammogram .srmammogramorbonedensity
  • 919-684-7999 to call for Mammogram or bone density appointment at Duke
  • 2. DEXA .srmammogramorbonedensity
  • 919-684-7999 to call for Mammogram or bone density appointment at Duke
  • 3. Colonoscopy .srcolonoscopynumber

Your referral to GI for your colonoscopy/EGD has been ordered and is available the hospital computer system. Please call GI directly to schedule your colonoscopy. The scheduling number is 919-684-6437. They will help you set up your colonoscopy at your convenience and discuss with you the locations that are available.

  •  I looked up the Rocky Mount Spotted fever: its under LAB6815
  •  Sorry DPC does not have a social worker. I agree switch to DOC, Jan Dillard is there.
  •  Pickett Home health: .pickettHH is the dot phrase to put into your note ESP if you put order in for home health
  •  Consider earlier in the year party- Christmas party at Dr. Peyser house great way to meet the staff
  •  Laura and Wendy have been able to complete their transition list (95 and 70 patients) in one admin session. This can be done!

Thank you!   Sharon Rubin

 

From the Chief Residents Grand Rounds

Presenter:  Dr. Krish Patel

Duke Chief Resident Grand Rounds

Noon Conference 6/9 Global Health Gallops Aras / Dhawan / Papademetriou / Tolan 12:00 Subway 6/10 SAR TALKS Bedoya / Elliott 12:00 Saladelia 6/11 MSK Exam Part 4 Irene Whitt & Lisa Criscione 12:00 Cosmic Cantina 6/12 HVCC Conference George Cheely 12:00 Chick-Fil-A 6/13 Chair’s Conference Chiefs 12:00 Domino’s From the Residency Office Visiting Professor Lecture sponsored by Duke AHEAD

 Who:  Charles Prober, MD

When:  June 10, 2014;  5 – 6

Where:  Trent Semans Center 2nd floor

Make sure and let Kristen know if you are attending by emailing her at DUKEAHEAD@dm.duke.edu

Thank you.

          Charles Prober Announcement

 

Information/Opportunities

 

Upcoming Dates and Events
  • June 13: ACLT year end celebration
  • Intern Welcome Celebration:  June 27 @ the PIT
Useful links

Resident Research Night recognizes excellence in resident research

Thu, 06/05/2014 - 11:35

The Duke Internal Medicine Residency Program highlighted and celebrated resident research Tuesday night at the annual Resident Research Night, where more than 40 posters displayed resident research.

Murat Arcasoy recognizes Califf Medicine Resident Research Award winners, from left, Laura Musselwhite, Alexander Fanaroff, and Mandar Aras.

Three residents presented their work and received Robert Califf Medicine Resident Research Awards:

  • First place: Laura Musselwhite, MD, MPH, junior assistant resident, “Vitamin D, D-dimer, IFNγ and sCD14 levels are independent predictors of IRIS in a prospective international study”
  • Second place: Mandar Aras, MD, PhD, senior assistant resident, “Peripheral metabolite profiles predict cardiomyopathy in a cohort of cardiac catheterization patients”
  • Third place: Alexander Fanaroff, MD, senior assistant resident, “A simple predictive instrument to rule out acute coronary syndrome”

The award for Best Quality Improvement poster went to Tim Mercer, MD, MPH, senior assistant resident, and the Best Poster award went to Nina Beri, MD, junior assistant resident.

Additionally, Brice Weinberg, MD, professor of medicine (Hematology) and immunology, was recognized with the Greenfield Research Mentorship Award, and Francis A. Neelon, MD, associate professor of medicine (Endocrinology, Metabolism and Nutrition), Emeritus, was recognized for Best Medicine Grand Rounds.

Grand Rounds 6/6/14: Management of Obesity

Wed, 06/04/2014 - 10:07

Medicine Grand Rounds on Fri., June 6 at 8 a.m. in Duke Hospital room 2002 will feature Vaishali Patel, MD, chief resident for the Durham VA Medical Center.

Dr. Patel will present Management of Obesity: Current and Future Treatments.

Video archives If you can’t make Medicine Grand Rounds this week, watch a live stream or view the archived video at http://bit.ly/RSlrBP (ignore the security certificate warning, then use your Duke NetID & password).

Internal Medicine Residency News: June 2, 2014

Sun, 06/01/2014 - 10:57
From the Director

June 1st! That is unbelievable to me….we had a fantastic time Saturday night celebrating our AMAZING SARs.  A huge thank you to Erin and Lynsey for setting up and ensuring that we had a beautiful venue for our SARs and their significant others to enjoy toasts, roasts, and some very spot on awards!  If you want to see some highlights, ask Howard Lee who took at least 1,000 pictures.

Kudos this week go to VA QI Chief Joel Boggan for his fantastic grand rounds — the amount of work that was accomplished this year in the realm of QI is pretty unbelievable.  And Joel showed us that he is a pretty accomplished speaker as well.  Make sure to be there Friday for VAISHALI!  Other kudos go to Phil Lehman and Jess Morris from Mike Woodworth for great care of a very sick patient at the VA, to Adrienne Belasco, Nick Rohrhoff, Phil Lehman,  and John Yeatts for volunteering to cover the SARs who were supposed to be on call for the SAR dinner.  Thank you so much.

We are looking forward to seeing all of you at RESIDENT RESEARCH NIGHT on Tuesday! We have a record of 40+ posters (!) and are also looking forward to the Califf Award Presentations by Mandar Aras, Alex Fanaroff and Laura Musselwhite.  The event will take place in the Trent Siemens Center – please come out and support your colleagues.

This week starts the renovations in the Med Res library…it will be well worth it to have our favorite room on the 8th floor as “off limits” for a short time to bring us new and improved conferencing equipment.  No more calling to DRH on the shoe phone!

This week’s pubmed from the program goes to all of the residents presenting at Research Night (INSERT LIST HERE) and also to our former VA Chief Jason Webb for his recent publication with mentor Arif Kamal.

J Pain Symptom Manage. 2014 May 23. pii: S0885-3924(14)00259-0. doi: 10.1016/j.jpainsymman.2014.05.002. [Epub ahead of print]   Integrating the Biopsychosocial Model into Quality Measures in Palliative Care: A Case for Improving the Hospice Item Set.  Webb JA1, Kamal AH2.

Have a great week!

Aimee

What Did I Read This Week?

Bedside Teaching Rounds Reconsidered  JAMA 2014; 311 (19): 1971-1972;  

Author:  Steven McGee, MD

submitted by:  Suzanne Woods, MD 

Well I actually have read a lot lately given I was on gen med. But our most fascinating case on the wards may be a chairs conference, so I can’t share that reading with you!  What I truthfully just read was “Me Before You” by Jojo Moyes for my book club.  I recommend it but warn you…. Keep the Kleenex nearby as crying is expected. I would be happy to talk with anyone interested about the book!

For “real reading” I chose the following, which is actually a Piece of my Mind from JAMA.  Bedside Teaching Rounds Reconsidered  JAMA 2014

Why did I read this article: As noted above, I just finished gen med and bedside rounds are challenging to fit into the daily schedule and do not resemble the traditional bedside rounds of the past. This is a marked change from when I started my internship 20 years ago!

Authors thoughts:  Dr. McGee begins this piece by reflecting on Sir William Osler and how he stated one of his greatest accomplishments was teaching medical students on the wards.  The author comments that physicians spend less than 25% of teaching time at the bedside and rather we are holed up in workrooms or talk in the hallway about patients instead of in the patients room.  Current barriers identified to bedside teaching are “insufficient time to teach, dependence of diagnosis on technology, obstacles created by infection control, and distractions from clinical responsibilities at distant computer stations.”  Many physicians today also find teaching at the bedside difficult for a number of other reasons.  The author does list several reasons that teaching should occur at the bedside despite the obstacles.

These reasons include:

  • Helps to calm patients
  • Makes patients view physicians/trainees more favorably
  • Allows teachers to role model for residents and students
  • Patient “satisfaction and pleasure” in assisting to educate learners

Tips on how to make bedside presentations successful include:

  • Succinct presentations
  • Teacher understanding of what is best taught at the bedside vs in the classroom

Things best taught at the bedside:

  • Communication, professionalism, clinical skills
  • Examples:  “introduction to patients, address patient concerns, elicit key details, ask permission to examine, explain symptoms, avoid jargon, respect the medical team, bond with the patient”

My thoughts:  We do spend so much time in the workrooms, space behind the HUC, the bunker and other locations that physicians are with the patients far less than they are with the computers.  The push for efficiency with rounds is such that time at the bedside with the learners has gone away in many settings.  There is a tremendous amount that can be learned from seeing the patients together and talking as team with patients and families.  There are also many physical exam findings that are best seen at the bedside (rashes, skin/soft tissue infections) and the conversations with patients can be priceless.  With time and experience the challenges for the teachers will be second the benefits from derived.

QI Corner (Joel Boggan, MD)

SAQ extended for one more week
We still have until June 6th to fill out the Safety Attitudes Questionnaire from PascalMetrics (search in your inbox)!  We are pushing 70% and Med-Peds has hit near 80%.  Please fill it out this weekend if you have a few minutes!

Take my job (in 2015)!
If you are interested in applying for the CRQS position beginning in July 2015, please see the following link and let me know ASAP:  https://news.medicine.duke.edu/2014/05/call-for-applications-dvamc-chief-resident-for-quality-improvement-and-patient-safety.

Feel free to contact me with any questions!

From the Chief Residents Grand Rounds

Presenter:  Dr. Vaishali Patel

VA Chief Resident Grand Rounds

Noon Conference Date Topic Lecturer Time Vendor Room 6/2 MKSAP Mondays Chiefs 12:00 China King 2002 6/3 MED-PEDS Combined: Contraception Mgmt OR Difficult Death Debrief Beverly Gray / Galanos 12:00 Pita Pit 2002 6/4 IM-ED Combined Conference 12:00 Picnic Basket 2002 6/5 Rebekah Moehring from ID–topic TBD Rebekah Moehring 12:00 Sushi 2001 6/6 Chair’s Conference Chiefs 12:00 Domino’s 2002 From the Residency Office Housestaff Annual Survey 2014

As part of survey month at Duke University Hospital, please take note of the email that you received on Monday, May 19 from the GME Office.  The email contained a link to the Housestaff Annual Survey. This survey helps to provide information on the educational and working environment. It is important that you complete the survey as a high response rate gives a more accurate view of the successes and challenges in graduate medical education at Duke.

Changes to the Med Res Library

Reminder that this week the library will be off limits as we proceed with the 1st phase of upgrading the IT system

Information/Opportunities

 

Upcoming Dates and Events
  • June 3: Annual Resident Research Conference
  • June 6: Serve dinner at the Ronald McDonald House
Useful links

6/3/14: Resident Research Night

Fri, 05/30/2014 - 12:47

The Department of Medicine’s Internal Medicine Residency Program’s Resident Research Night is set for 5 p.m. Tues., June 3 in the Great Hall of the Trent Semans Center. Check out this video from past events and plan to attend.

The resident research poster session and reception will begin at 5 p.m., and talks will begin at 6 p.m. followed by presentations of the Califf Medicine Resident Research Awards.

The following residents will give presentations ahead of the Califf Medicine Resident Research Awards:

  • Mandar A. Aras, MD, PhD, “Peripheral metabolite profiles predict cardiomyopathy in a cohort of cardiac catheterization patients”
  • Alexander Fanaroff, MD, “A simple predictive instrument to rule out acute coronary syndrome”
  • Laura W. Musselwhite, MD, MPH, “Vitamin D, D-dimer, IFNγ and sCD14 levels are independent predictors of IRIS in a prospective international study”

Resident Research Night is coordinated by Murat Arcasoy, MD, FACP, associate professor of medicine (Hematology) and associate program director for curriculum and resident research. Please plan to attend.

Call for applications: DVAMC chief resident for quality improvement and patient safety

Wed, 05/28/2014 - 15:44

It is time to step up and state your case if you are interested in the chief resident for quality improvement and patient safety position for the 2015-16 academic year! Please schedule a time to meet with either Joel Boggan (bogga002@mc.duke.edu), Ryan Schulteis (ryan.schulteis@duke.edu), or David Simel (david.simel@va.gov), if interested. Candidates for the position should be willing to

  • Commit to the position full-time from July 1, 2015, to June 30, 2016
  • Be board eligible internal medicine physicians on or by July 1, 2015
  • Learn quality improvement and patient safety methodologies
  • Engage and teach residents both clinically and didactically
  • Facilitate and lead QI projects and teams at the Durham VA Medical Center, including work with the Simulation Scientists and our Operations Research Engineers
  • Be willing to work collaboratively with the other VA CRQS around the country
  • Have the ability to humor your future mentors: Joel Boggan, Ryan Schulteis, and David Simel.

Specific statistical or quantitative training is not required but is strongly considered.

Sample projects, teaching initiatives and publications can be found here and here. Deadline for applications is Fri., June 13.

Internal Medicine Residency News – May 27, 2014

Tue, 05/27/2014 - 09:12
From the Director

It’s getting to be that whirlwind time of year, so please be sure to mark your calendars for all of the upcoming events…research night, chief grand rounds, SAR dinner, etc.  The picnic was SO much fun, with much thanks to the chiefs and Erin for planning!

We should also take a moment to think about those who have served our country over the Memorial Day weekend.  In respect of the Memorial Day, I’d like to refer you to a wonderful column written by my residency friend Katherine Chang Chretien about working at the VA…

http://www.usatoday.com/story/opinion/2014/05/19/veterans-affairs-va-scandal-volunteers-shinseki-column/9294647/.

Kathy is a great writer (also of the Mothers In Medicine blog for those who are interested!), the clerkship director at GW, and a general internist at the VA in Washington DC.

Kudos and congratulations this week…belated congratulations to Yi Qin on her engagement! Also our incoming interns Kara Johnson and Zach Wegermann got engaged last weekend as well.  Kudos were sent for being a great night resident at the VA to Amit Bhaskar from Allyson Pishko, to Brice Lefler for a fantastic chair’s conference on a moment’s notice, to Aly Shogan from Larry Greenblatt for great work in the DOC diabetes group visit, and to Laura Musselwhite from Alyssa Stephany for great patient care overnight. Congratulations to Randy Heffelfinger on his role as father of the bride this past weekend as well!  And congratulations to Claire and David Kappa on the birth of William Parks Kappa!

 

 

 

 

 

 

 

 

 

Thanks to all who filled out the Residency Survey.  Jen and I will aggregate results next week and work with the APDs and residency council for action items.  PLEASE take the time to fill out your PASCALMETRICS SAQ! We need to help the institution get to at least 60% completion!

This weeks pubmed from the program goes to Christine Bestvina for her recent paper with mentor Yousef Zafar!

Patient-Oncologist Cost Communication, Financial Distress, and Medication Adherence

Christine M. Bestvina, et al.

Journal of Oncology Practice 10:162-167, 2014

Have a great week!

Aimee

What Did I Read This Week?

Disorders of The Eye, Chapter 28

Horton JC. Chapter 28. Disorders of the Eye. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 18eNew York, NY: McGraw-Hill; 2012.http://accessmedicine.mhmedical.com/content.aspx?bookid=331&Sectionid=40726743.

Aimee Zaas, MD 

After Brice’s fantastic Chair’s conference, I decided to read about diplopia.  This was a key feature of the patient she presented, and I find myself less comfortable localizing these types of lesions than I would like.

What did I read:  Harrison’s online, disorders of the visual system.

What did I learn:  As Brice did, the first step is to characterize whether diplopia persists in either eye after the other eye is covered.  If YES, this is called MONOCULAR diplopia, and has to have a cause that is in the eye such as corneal abrasion, cataracts, etc.  It is generally a benign diagnosis.

If diplopia resolves after covering one eye, this is BINOCULAR diplopia and is generally a result of ocular misalignment.   The reasons for this are many, and can be thought of as NEUROGENIC or due to GLOBE RESTRICTION from local orbital disease.  Common causes of restrictive diplopia are pseudo tumor, myositis (think Graves especially with proptosis/exopthalmos), infection, muscle entrapment, tumor.    NEUROGENIC causes include myasthenia (look for ptosis and other signs of fatiguability), or lesions of one of the cranial nerves controlling the eye muscles.  As Brice pointed out, if you know the path of the cranial nerve, you can figure out what might be impairing its function.

CN III  (“dilated, down and out”) — palsies of CN III can be dramatic, but a slight palsy may not have the classic findings.  Aneurysms in the circle of willis as well as basilar tumors can compress CN III and are a major part of the diagnosis of a CN III palsy. The oculumotor nucleus is in the midbrain, so midbrain strokes or tumors can lead to diplopia from CN III Palsies, but other midbrain signs are generally present as well.  Harrison’s offers up some fancy eponyms for particular midbrain syndromes, such as Nothnagel’s syndrome (ipsilateral CN III palsy and contralateral ataxia! Who knew?).  The oculomotor nerve then runs in the subarachnoid space by the temporal lobe and can be compressed by aneurysms, tumors or herniation.   It then runs through the cavernous sinus and is susceptible to thrombosis, zoster, the famous carotocavernous fistula of Corey, or tumors such as pituitary adenomas or meningiomas.

If CN IV is involved, diplopia is VERTICAL because the superior oblique muscle is affected (“SO4″).  This is made worse by tilting the head toward the side of the palsy and better when tilting contra laterally  (“the head tilt test”).   An aneurysm seldom impacts CN IV but closed head trauma is the most common reason for this to result.

CN VI (“LR 6″) lesions give horizontal diplopia, worse on the side of the lesion.  The nucleus is in the pons, so pontine strokes give lateral gaze palsies.    Once you get to the fascicle and not the nucleus, the true palsy is less likely, and LR weakness is the finding.  The  “s” mnemonic  (“seudotumor, multiple Sclerosis, sarcoid, syphilis, stroke) was taught to us by Brice and is helpful in generating a differential.  CN VI then runs along the clivus to the petrous temporal bone and enters the cavernous sinus.  Mastoiditis can cause 6th nerve palsy as can basilar meningitis, including carcinomatous meningitis, irritation from subarachnoid hemorrhage, pituitary lesions, meningiomas and nasopharyngeal CA.  Think of elevated ICP or very low iCP when you see an abducens palsy as well, due to brainstem displacement.

Harrisons has some great figures of intranuclear opthalmoplegia where the medial longitudinal fasiculus is damaged (classically in MS) and there is miscommunication between the abducens nucleus and the oculomotor nucleus.

SO….remember to think of the anatomy of the cranial nerves when evaluating diplopia.  Also refer to this monograph from the American Association of Ophthalmology http://www.aao.org/publications/eyenet/200911/feature.cfm  Other great articles to read include…Screening and Prevention of STDs.  Primary Care 2014 Jun;41(2)215-37.,    and Analysis of 3 Algorithms for Syphilis Diagnosis and Implications for Clinical Management.  CID 2014 58(8) 1116-24.

 

 

QI Corner (Joel Boggan, MD)

QI Corner
Safety Attitudes Questionnaire Survey
We are now achieving some splits in our performance, with Med-Psych > 70% and Med-Peds > 60%.  Categoricals – you’re sitting at 44%, and our goal is to reach > 80%.  Look for the email from Support@PascalMetrics to fill out the survey – time is running short!

Next QI Noon Conferences on High Value, Cost-Conscious Care and M&M
The next HVCC lecture will be this week on Wednesday at noon with Dr. Cara O’Brien.  M&M will be the following day with incoming APD, Dr. Lish Clark.  Please plan to attend and try to arrive by noon for both!

Foley Time
Loving the use of the catheter in your patients?  Or do you even know it’s there?  I know you don’t in 23% of the cases, so check under those sheets or along those bed rails and get the catheters out ASAP . . .

  The “Clinic Corner” - Duke Outpatient Clinic (submitted by Daniella Zipkin, MD )

Clinic Corner for May 25, 2014

Hey guys! We know you’re super busy when you’re not in clinic, and managing competing demands requires the strength and agility of a Cirque du Soleil performer. However, your patients really miss you, AND they don’t want to wait four weeks for their refills (who would?!). SO, here are a couple of ideas to help you help them… by responding to your in-basket messages or CPRS alerts as promptly as possible.

  1. Like all good things in life and Maestro, there’s an app for that!! Make checking up on Maestro simple and download the Epic Haiku app onto your smartphone. Here are the instructions (thanks Armando!):
    1. https://intranet.dm.duke.edu/sites/MaestroCare/Mobile/SitePages/Home.aspx
    2. Must be on Duke wifi for the link to work on either the iphone or ipad
    3. Download Epic Haiku (iphone) or Canto (ipad) respectively
    4. Once downloaded click on the appropriate configuration link on the website from your iphone or ipad
    5. It will say Duke Maestro Care on the top of app screen if it worked
  2. Once you’ve got the app, check your in-basket daily. It should take about 5 minutes per day to see if there are easy refill requests you can approve quickly. Naturally, go back to the chart for any refill you’re not sure is appropriate.
  3. Once you start checking in-basket regularly and responding to your messages, there is an increased risk of receiving hugs and kisses from Dee Baynes, our indefatigable triage nurse at the DOC.

Other DOC tid-bits:

  • Want to get a Pap done? Please put the order in and print the requisition first – then sign it and give it to your nurse. They need this to process the Pap for you.
  • What, you’re still typing “pap” into the meds and orders field? If you don’t have orders preferences set up, RUN, don’t walk, to Zipkin when you’re in clinic and let her show you how. Never type the word “pap” (or any other order) again!! With all the time you save, you can post some cool DOC selfies to the DOC Facebook page. (to join, please harass Matt Atkins!)
From the Chief Residents Grand Rounds

Presenter:  Dr. Joel Boggan

Topic: VA CRQS Chief Talk

Noon Conference Date Topic Lecturer Time Vendor 5/26 HOLIDAY 5/27 Ambulatory Town-Hall Clinic Directors/Stead Leaders 12:00 Bull Street Market 5/28 Qi Patient Safety 12:00 Cosmic Cantina 5/29 M and M Alicia Clark 12:00 Picnic Basket 5/30 Research Conference 12:00 Panera   From the Residency Office Changes to the Med Res Library

If you wonder who absconded with the PIN station and printer - not to worry.  We have relocated one of the PIN units to the first work station on your left as you enter the program office (8254 DN).

Why? To give us more space in the back for serving lunch during noon conference, and to make it more accessible for resident use whenever the library is occupied for meetings.

The other change you will see coming is a major upgrade to the IT system – all so that we can improve on transmitting conference – not only to Duke Regional Hospital, but possibly to multiple locations.  Yes, we are replacing the old digital system, installing ceiling mikes, and large flat screen monitors mounted to the walls.  This will all happen during the week of June 2nd, at which time the library will be strictly off limits.

 

The ACC is proud to extend medical residents complimentary membership in the ACC!

ACC Medical Resident membership is open to those in accredited internal medicine programs in the U.S. and Canada. Membership is also available to residents within other accredited residency programs, including general, cardiothoracic surgery and pediatrics.

Membership will help medical residents build a knowledge-base in the cardiovascular sub-specialty, make valuable career connections that will serve them well in future training and make the most informed decision about their career.

Do you know a medical resident interested in pursuing cardiovascular medicine?

ACC membership is complimentary for medical residents and simply requires they complete an application, tell us why they’re interested in pursuing a career and submit a sponsorship letter from a current Fellow of the ACC or Training Director.

Learn More About This New Membership Opportunity Here

 

Reminder: Safety Attitudes Questionnaire

What is it: Culture of Safety Survey, second full cycle for DUHS

When is it: Survey runs May 5-May 30.

Who does it: All ACGME program members will be included (if at least 8 members); other clinical departments throughout the health system also doing survey

How is it done: Participants will get an email from support@pascalmetrics.com,with subject “DUHS Safety Culture Survey from Pascal Metrics”; in the body of the email, the target/referent for the survey is listed. For GME it is the GME Program (e.g. GME-Medicine-Internal Medicine).

Last cycle, GME participation rate was 71%. We are looking for at least 80% response rate from each program! Your input is very important.

Information/Opportunities Richmond IM Flyer (HDH) (5-21-2013    Frankfort IM Flyer (1-23-14)
LGMC & Pulaski IM Hospitalist Flyer (3-5-2014) Frankfort IM Hospitalist Flyer (3-6-2014) SRMC – IM Hospitalist (3-6-2014)                Hosp $200K http://www.cdc.gov/EIS/ApplyNow.html   Upcoming Dates and Events
  • May 30: Program pictures, Trent Semans West Steps, 9:15
  • May 31: SAR Dinner, Hope Valley CC
  • June 3: Annual Resident Research Conference
  • June 6: Serve dinner at the Ronald McDonald House
Useful links

Grand Rounds 5/30/14: Quality Improvement to Optimize Healthcare Utilization

Sun, 05/25/2014 - 16:11

Medicine Grand Rounds on Fri., May 30 at 8 a.m. in Duke Hospital room 2002 will feature Joel Boggan, MD, MPH, chief resident for Quality Improvement and Patient Safety at the Durham VA Medical Center.

Dr. Boggan will present Quality Improvement to Optimize Healthcare Utilization.

Video archives If you can’t make Medicine Grand Rounds this week, watch a live stream or view the archived video at http://bit.ly/RSlrBP (ignore the security certificate warning, then use your Duke NetID & password).