From the Director
Looking forward to Thanksgiving week….I hear there is a football game happening sometime? I have blocked out the Duke-UNC game, but the best game of the year is on Thursday. VA is currently winning the publicity competition with a hilarious and fantastic video featuring some Hall of Fame Jets. Waiting to see a video with Ricky Bobby Aertker cropping up to inspire the Marines.
Kudos to our program and the Dept of Medicine faculty who donated to our Thanksgiving Food Drive…we raised $925 to feed families in need from the DOC and the VA PRIME clinic. Other kudos this week go to Emily Ray from hospital medicine faculty Liz Hankollari for outstanding work overnight on Duke NF and to our gen med SARs at Duke for hosting applicants 3 days a week for four straight weeks…Sajal Tanna, Claire Kappa, Nina Beri, Ben Lloyd and Amera Ramatullah. Also to Ben Peterson for an awesome chair’s case, and to Bhavana Singh from Rachel Hu for her work as a VA Jar! Other thank you’s to our “Resident Share” group of Lakshmi Krishnan, Brittany Dixon, Ragnar Palsson, Cece Zhang, Jenny Van Kirk and Mike Woodworth.
SARs, please don’t forget to register for your ABIM exam! Registration opens Dec 1…after MATCH DAY if you are matching on DEC 3, go ahead and register so you get the site you want! Also, for all residents..if you haven’t met with your advisor since the year started, please schedule a meeting with them to discuss evaluations, ITEs, careers, etc.
Please see the announcement at the end regarding NC-ACP posters. It’s in Durham this year and we want to represent well! If you have a chair’s case, submit it as a case report. If you have any research projects, MAKE A POSTER! Looking forward to seeing many of you there.
This week’s pubmed from the program goes to our CLIN EPI group who presented their projects on Friday to close out a great month of CLIN EPI! I am also looking forward to seeing many of those projects as resident research grants this year.
Have a great week, and an EARLY HAPPY THANKSGIVING to you all and your loved ones.
What Did I Read This Week?
Submitted by: Omobonike Oloruntoba, MD
Early versus On-Demand Nasoenteric Tube Feeding in Acute Pancreatitis
Often times we underestimate the importance of nutrition in the care of our severely ill patient. In the case of patients with acute pancreatitis, the decision of when to advance the diet and more importantly the nutritional value of what we order for those patients (thumbs down for clear liquid diet!) is challenging. Furthermore, patient and physician discomfort with NG tube insertion may drive the physician to wait it out, and give that patient one more chance to tolerate an oral diet.
20% of patients with acute pancreatitis disease course is complicated by major infection. Disturbed intestinal motility, bacterial overgrowth and increased mucosal permeability together provokes bacterial translocation from the gut leading to infection. Meta-analysis of several RCT demonstrated that nasoenteric tube feeding compared to total parental nutrition (TPN) reduces the rate of infections and mortality among patients with severe pancreatitis. Unlike TPN, enteric tube feeds is believed to stimulate intestinal motility, which decreases bacterial overgrowth and preserves the integrity of the gut mucosa by increasing splanchnic blood flow. In addition, several studies have demonstrated that early enteric tube feeding (36 to 48 hours after admission) significantly reduced the rate of major infection. Nonetheless despite many nutritional societies recommendation on early nasoenteric tube feeding for patients with severe pancreatitis, guidelines from gastroenterologic and pancreatic societies recommend initiation of tube feeding after a patient is not able tolerate an oral diet for up to 7 days at which time the potential benefits of enteric feeding may have passed. This study compared the effects of early nasoenteric tube feeding with those of an oral diet starting 72 hours after admission with an option to switch to nasoenteric tube feeding based on insufficient oral intake.
- Adults with a first episode of acute pancreatitis at high risk for complications as defined by:
- APACHE Score (within 24 hours) ≥8
- Imrie/Glasgow score ≥3
- CRP ≥150 mg per liter
- Pancreatitis was diagnosed as having 2 of the 3 features:
- Typical abdominal pain
- Amylase/Lipase 3 times the upper limit of normal
- Characteristic findings on cross-sectional imaging
- Exclusion Criteria
- Recurrent pancreatitis
- Chronic pancreatitis
- Post-ERCP pancreatitis
- Patients with enteral or parental nutrition at home
- Pregnant patients
- Patients presenting to the ED >96 hours after symptom onset
- Patients transferred from OSH
- Multi-centered, randomized controlled superiority trial.
- Patients were assigned to either nasojejunal tube feeding within 24 hours of randomization (early group; n=102) or to an oral diet starting at 72 hours (on demand group; n=106)
- Nutrition target: 25kcal/kg per day (ICU) and 30kcl/kg/day (Wards)
- TF started at 20ml/hour during the first 24 hours. After 24 hours, the volume of nutrition was increased to 45 ml per hour, after 48 hours to 65 ml per hour and after 72 hours to full nutrition depending on patient’s actual body weight.
- Oral diet was started on patients at 72 hours
- Exceptions were made for patients that requested oral food during the 72 hour period
- If an oral diet was not tolerated after 96 hours, nasoenteric tube feeding was started
Primary Endpoint: Composite of major infection (infected pancreatic necrosis, bacteremia, pneumonia) or death within 6 months after randomization.
The primary end point occurred in 30 of 101 patients (30%) in the early group and in 28 of 104 (27%) in the on-demand group (risk ratio, 1.07; 95% confidence interval, 0.79 to 1.44; P=0.76). There were no significant differences between the early group and the on- demand group in the rate of major infection (25% and 26%, respectively; P=0.87) or death (11% and 7%, respectively; P=0.33). In the on-demand group, 72 patients (69%) tolerated an oral diet and did not require tube feeding.
This study did not show the superiority of early nasoenteric tube feeding in reducing the rate of major infection or death in patients with severe acute pancreatitis. This study challenges the concept of the gut mucosa-preserving effect of early enteral feeding during acute pancreatitis. However, the study may have been too small to detect a difference between the two groups.
Have a Happy Thanksgiving. I wanted to take a moment and congratulate Chris Merrick for winning our WOW award for last month. Please stop by and look at all of the positive comments that all of you have been receiving. Great job.
Dr. Zhang- Sr. Z is very caring and knowledgeable about her job. She is very thorough and I do appreciate her very much.
Dr. Wasserman- Dr W is a very profession al and thorough physician who also cares for his patients' well-being.
Dr. Bhaskar- PRIME D great.
Dr. Merrick- Inspection of ear problem. Doctor fit me in to schedule ear exam. Excellent service. WOW!
Dr. Merrick- annual check-up, everyone is so nice.
Dr. Giattino- follow- up visit with new questions. Everything was great!
Dr. Palsson- follow-up of emergency room visit
Just a quick reminder for the upcoming December Holidays. Please discuss with your team and have your CPRS alerts forwarded to a co-team member.
From the Chief Residents
Fri., Nov. 28: Thanksgiving Holiday - No Grand Rounds
|11/24/14||Interview Day||Lunch w/ applicants||12:00/MedRes||Pipers in the Park|
|11/25/14||SAR Lecture Series - Topic TBA||Iris Vance||12:00/2002||Chick-Fil-A|
|11/26/14||SAR Emergency Series - Acute Stroke||Joe Brogan||12:00/Room 2002||China King|
|11/27/14||THANKSGIVING!||Turkey Dinner||1:00 MedRes Library||Bullocks|
From the Residency Office
Thank You!!On behalf of the Warren Society and the Residency Council, we would like to thank our residents and faculty for your generous donations. This year, we raised $925 for the Annual Thanksgiving Food Drive and delivered 30 Walmart and Food Lion gift cards to the DOC and VA Prime. Thanks to your support, dozens of families will be able to enjoy a wonderful Thanksgiving meal this year! We were also able to deliver our final "We Care Wednesdays" donation, in the amount of $1500, to the Lincoln Community Health Center. Your continued support for your community here is Durham is tremendous!
ABIM Summer 2015 Examination DatesPlease see the attached flyer for information on dates and registration!
Stead Research Grant RFA
On behalf of the Stead Scholarship Committee, we would like to announce a Request for Applications for a clinical or translational research project involving a team of Internal Medicine, Med-Peds, and/or Med-Psych residents under the leadership of a faculty mentor in the Department of Medicine. The RFA is attached.
We are grateful to the leadership of the Stead Scholarship Committee (Chris Woods, Karen Alexander and Ravi Karra) for this generous initiative to promote and support team-research by our residents.
Best regards to all,
Murat and Aimee
ACP Abstracts Due!
Please find attached the information to submit abstracts by December 12, 2014 of your scholarly activities (case reports, research, QI projects)
American College of Physicians NC Chapter Meeting
Date: Feb 13,14 2015
Where: Sheraton RTP
Submissions for abstracts due 12/12/14
Wishing you all success with your projects !
Murat and Aimee
Partners In Health and BWH Hospitalist Program
PIH is currently seeking excellent physicians in Internal Medicine (or Internal Medicine/Pediatrics) to join our teams in Rwanda, Haiti, and Malawi for the 2015-2016 academic year . This full-time position provides an opportunity to serve as both a clinician educator at a PIH field site and as an academic hospitalist at Brigham & Women’s Hospital in Boston. Candidates interested in this exciting opportunity should submit an application at http://www.pih.org/pages/employment
before December 1, 2014, or can contact Dr. Neil Gupta at email@example.com.
Background: Partners In Health (PIH) is a health and social justice organization with a mission to build high quality, comprehensive public health systems around the world. PIH has partnered with local communities and governments over the past 25 years to provide high-quality health care to the poorest of the poor and train the next generation of physicians, nurses and public health professionals in countries around the world.
General Description: We are currently seeking excellent physicians in Internal Medicine (or Internal Medicine/Pediatrics) with strong interest in global health and medical education to join our teams in Rwanda, Haiti, and Malawi. This full-time position provides an opportunity to serve as both a clinician educator at a PIH field site and as an academic hospitalist at Brigham & Women’s Hospital in Boston.
Specific Responsibilities: Internists at PIH field sites serve as clinician educators, working with local medical staff and trainees on inpatient medical wards and outpatient clinics in rural districts hospitals and health centers as well as academic teaching centers. These clinician educators are faced with a vast diversity of diseases, including but not limited to, HIV, tuberculosis, malaria, non-communicable diseases, oncology, and other tropical infectious diseases. They also supervise international trainees and students rotating from Brigham & Women’s Hospital and other international institutions, engage in quality improvement and research activities, and help to develop and implement innovative programs to strengthen health delivery.
Financial Support: The Brigham and Women’s/Faulkner hospitalist program provides hospitalist salary support and full benefits package, including malpractice insurance and health insurance. PIH provides international airfare as well as full accommodations while at PIH sites. Successful candidates will also have the opportunity for academic appointment at Brigham and Women’s Hospital and a diversity of professional development opportunities.
- ABIM board-certification or board-eligibility in internal medicine or internal medicine / pediatrics; candidates with sub-specialty interests are welcome to apply
- Board-eligible graduating senior medical residents are eligible to apply
- A desire to gain experience with health care delivery in sub-Saharan Africa
- A talent for teaching and an interest in medical education and quality improvement
- Flexibility, humility, creativity and enthusiasm
- A two-year commitment is encouraged but not required
Application and Contact Information: If you are interested in pursuing this opportunity, please submit your application at http://www.pih.org/pages/employment. If questions, please contact Dr. Neil Gupta at firstname.lastname@example.org.
Sign up to receive a complimentary e-subscription to The American Journal of Medicine in 2015! All you have to do is to complete the online form by December 8, 2014. The subscription starts in January.
Upcoming Dates and Events
November 27, 2014 - Turkey Bowl
December 3, 2014 - SAR Match Party
December 13, 2014 - DoM Holiday Party
February 18, 2015 - Duke vs UNC @ Tyler's Tap Room
February 27, 2015 - Charity Auction
March 3, 2015 - Duke vs UNC
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