From the Director
Doctoberfest begins this week! We are looking forward to a month of building community, within and outside the residency program. We will kickoff on Wednesday with our first "We Care Wednesday"..thank you to Residency Council Chairs Nick and Katie for helping us choose our charitable donation sites. Trivia starts Wednesday as well, so keep a lookout in your emails for the (almost) daily questions. I have my re-certification for ID at the end of the month, so I will do my best not to make it entirely ID themed!
Kudos this week go to the MICU team of Myles Nickolich, Amy Lee, Jon Buggey, Jon Hansen, Adva Eisenberg and Jason Zhu from Talal Dahhan and Craig Rackley. 7 weeks with a STELLAR crew. Also kudos to Mike Woodworth and Nick Wisnoski for their excellent SAR talks. Thank you also to Matt Hitchcock for encouraging Martin Society to get their flu shots. However….Kerby has done it again! The Kerby Society maintains their title of the Fastest Flu Shots in the Program…see the photo of Kerby leader Heather Whitson and her kids getting shots (no tears!) as well as the incredible team spirit of our APD for QI and Patient Safety Lish Clark... makes all of those other flu shot posters look bad! Congratulations to Kerby Society as well as to Lish and Alan on their wedding this past weekend.
Regardless of winning or not, GO GET THAT FLU SHOT!
This weeks pubmed from the program goes to Nick Rohrhoff….Rohrhoff N, Vavalle JP, Halim S, Kiefer TL, Harrison JK. Current status of percutaneous PFO closure. Curr Cardiol Rep. 2014 May;16(5):477.
Have a great week and HAPPY DOCTOBERFEST!
What Did I Read This Week?
Submitted by: Alex Cho, MD, MBA
Feinglos MN, Thacker CR, Lobaugh B, DeAtkine DD, McNeill DB, English JS. Combination insulin and sulfonylurea therapy in insulin-requiring type 2 diabetes mellitus. Diabetes Research & Clinical Practice 1998;39(3):193-99. (http://www.sciencedirect.com/science/article/pii/S0168822798000035)
It is not uncommon for patients, particularly very obese patients with Type 2 diabetes, to require high daily doses of insulin, sometimes totaling >100 U a day. However, the administration of large boluses of exogenous insulin may have its own deleterious effects, including weight gain from appetite stimulation and even atherosclerosis from the resulting hyperinsulinemic state. Thus, combinations of therapies that can reduce a patient’s insulin total insulin requirement would appear to be desirable, and may actually lead to superior control over time.
As a result, the combination of certain oral agents (i.e., metformin) with insulin in general has also become commonplace, but as the slow emergence of the use of newer GLP-1 agonists alongside long-acting insulins suggests, these combinations are not necessarily self-evident.
In this classic RCT conducted right here at Duke, Drs Feinglos, McNeill and colleagues sought to address the very important safety and efficacy questions associated with the use of insulin secretagogues such as glipizide alongside NPH and regular insulin – a combination that may strike some as odd, and perhaps potentially unsafe, but presents for our uninsured patients at the DOC a more affordable option, potentially, than even glargine insulin.
“To determine the effect(s) on glucose control, insulin dose, and circulating insulin levels of the addition of a sulfonylurea (glipizide) to the treatment regimen of patients with insulin-requiring type 2 diabetes mellitus.”
Design – Randomized, double-blind, placebo-controlled, crossover clinical trial
Patient Population – Patients were recruited at large from the Duke University Medical Center and Durham community. They were majority female, with a mean age of 56, mean BMI was 32.7, mean total daily insulin dose was 80.8 U, and mean glycated hemoglobin was 12.1%.
Intervention / Control – Participants were assigned to one of two conditions: current insulin regimen + glipizide vs. current insulin regimen + placebo, for an initial 3-month treatment period. This was followed by a one-month “wash-out” period, prior to initiating a second 3-month treatment period, with crossover to the other study drug (glipizide vs. placebo). Participants were hospitalized (in the Duke Clinical Research Unit) at the beginning and end of each three-month treatment period for initiation of treatment, measurements, and titration of insulin regimens; followed by weekly telephone calls and monthly outpatient visits.
Regimens were titrated based on patients response to therapy, resulting in glipizide doses from 5 to 40mg daily, and 1-3 NPH and regular insulin injections daily, with total daily doses ranging from 40 to 210 U.
Blinding – Blinded
Analysis – Repeated measures multi-factor analysis of variance design, which included the sequence of treatment conditions as a factor. Analysis limited to the 29 patients who demonstrated a significant C-peptide response to a test meal.
Outcomes – Fasting plasma glucose, mean 24-hour plasma glucose, glycated hemoglobin, total daily insulin dose, free insulin, BMI.
Patients were blinded and randomized, with a wash-out period in-between treatment conditions. They were also very intensively followed. Overall numbers were small, but the crossover condition guaranteed the treatment groups were more or less identical. A subset of patients was selected for analysis based on biological factors (production of endogenous insulin). The effect of treatment sequence was assessed and found not to be a significant factor.
“The fasting plasma glucose in the I+G arm was 6.8 (121.8 mg/dl) vs. 8.7 mmol/L (156.0 mg/dl) in the I+P arm, P<0.001. Mean plasma glucose over 24 hours was 9.8 (176.9 mg/dl) for I+G vs. 11.3 mmol/L (203.8 mg/dl) for I+P, P<0.00l. Glycated hemoglobin was significantly different (9.8 I+G vs. 11.4% I+P, P<0.008). The total daily insulin dose required was significantly lower with I+G (69.1 vs. 87.3 U, P<0.0005). However, there were no significant differences in free insulin levels.” BMI was also not statistically different between the two groups. Sixty-nine episodes of mild hypoglycemia were recorded, with only six instances of moderate symptomatic hypoglycemia, and only one of these required assistance from another individual.
The results of this well-done RCT show that for patients with insulin-requiring diabetes, the combination of a sulfonylurea and insulin can lead to lower total insulin requirements and improved control, and can be safely administered. An important caveat is that in order for sulfonylureas to be effective, a patient still has to be making their own endogenous insulin (this is also true for the newer GLP-1 agonists); which suggests that this option be considered relatively early in a patient with Type 2 diabetes whose insulin requirements appear to be rapidly accelerating.
One particular use case Dr Feinglos offers would be for patients whose sugars appear to spike in the early AM, to combine bedtime NPH and an oral sulfonylurea with breakfast. One also wonders if the results of this study and others that have demonstrated the long-term superiority of metformin + insulin regimens vs. insulin-only ones also suggest that closely monitored “triple therapy,” might not only be possible, but preferable.
For patients with insulin-requiring diabetes who still make their own insulin, the combination of a sulfonylurea and insulin appears to lead to lower total insulin requirements and improved control. This regimen has the added benefit for uninsured or low-income patients of being considerably more affordable.
Ambulatory Clinic Corner
Interested in doing a QI or research project in one of the continuity clinics?
Just wanted to advertise the availability of a couple of different data sets from your clinics for possible resident projects. In VA PRIME, Sonal Patel worked with NC State industrial engineering professor Javad Taheri to gather time-stamp data on clinic workflow; and produce modeling of the different steps in the patient visit. This work has informed some of the staffing requests that Sonal has made for PRIME, but could potentially answer other questions as well. Contact Sonal for more information.
At the DOC, third-year Duke medical student and MPP candidate Mark Dakkak has helped construct a database of over 250 clinical and other variables on the over 4000 patients who receive their primary care there, plus AHRQ and other “groupers” that allow the categorization of patients into relevant groups. Contact Alex Cho for more information.
From the Chief Residents
Fri., Oct. 3: Oncology, Dr. Andrew Armstrong
|9/29/14||MKSAP Mondays- Endocrine/Diabetes||Chiefs||12:15||Nosh|
|9/30/14||SAR Talks: CV Complications of Diabetic CKD||Ragnar Palsson||12:15||Dominos|
|10/1/14||Essentials of Oral Hypoglycemics: Case Studies||Diana McNeill||12:15||We Care Wednesday|
|10/2/14||IM-ED Combined Conference: Healthcare waste and excessive testing||Dr. Kaplan/Room 2001||12:00||Subway|
|10/3/14||Chair's Conference||Chiefs||12:00||Chick Fil A|
From the Residency Office
Doctoberfest is Here!
DOCTOBERFEST IS HERE! “This is OUR Community” October 1-31, 2014
Join the Internal Medicine Residency Program in our 3rd annual Doctoberfest celebration! This year our continued focus will be on building and strengthening our community – both locally and on a global scale!
October 1, 2014 will mark the start of our Doctoberfest celebration with “We Care Wednesdays.” A special treat will be provided during Noon Conference to kick things off!
How Do YOU Go Green? – Ride a bike to work? Use a recyclable water bottle? We want to hear how YOU Go Green both at home and at work! Please feel free to come by the MedRes office and post your ideas on our Go Green wall, or submit them online using the link below. All submissions will be entered in our weekly drawings for gifts and prizes and all of the ideas will be compiled and shared at the end of the month. Bleed Blue/Live Green!!
October 20 Join us for a special lunch to honor our house staff. Eat, relax and re-connect with your friends and colleagues! More details to follow!
October 22 A special German beer garden-style treat!
October 31 As Doctoberfest 2014 draws to a close, enjoy some Halloween treats of donuts and cider as we welcome our first group of applicants on our 1st official recruiting day!
Flu Vaccination Update
Congratulations to the Kerby Society for reaching 100% as of 9/26/14!
As a program, you all have done an AMAZING job getting your flus shots! As of today, 9/29/14, we are at 93.4% compliant across the program - FABULOUS job! If you have not yet gotten your shot, please see the information below for locations where you can have it done. If you have any questions, please call EOHW 684-3136
A schedule of vaccination clinics is posted on the employee intranet at https://intranet.dm.duke.edu/influenza/Lists/Calendar/calendar.aspx. This list will be updated throughout the flu season. Vaccination is also available at Employee Occupational Health and Wellness (EOHW) during business hours.
Together, we can stop the flu. Thank you for your commitment to keeping our patients, and our community, safe and healthy.
Flu Vaccination Rates by Stead Society as of 9/29/14:
Martin - 93.3%
Warren - 94.6%
Orgain - 90.9%
Kerby - 100%
Kempner - 88.6%
Program as a whole (including all combined programs) - 93.4%
Register Now for BLS Blitz - November 10-14, 2014
Use the Swank system to register for BLS classes. If you do not have an account in Swank contact the DHTS Service Desk 919-684-2243 to establish an account. You may register for one session. Detailed Registration Instructions and Informational Flyer
When you attend class, arrive 15 minutes before session begins and you must have your:
- Class Registration Confirmation
- Duke ID Badge
- AHA BLS Healthcare Provider Manual 2010
All sessions are held at Hock Plaza - G07 Auditorium.
Parking is not available at Hock Plaza.
No one will be admitted to the session after it starts or if you do not have your AHA BLS manual.
The Duke Medical Alumni Association invites you to join us for the inaugural Women in Medicine Luncheon and Program
Friday, October 17, 2014 | 11:45am-1:45pm
Great Hall, Trent Semans Center for Health Education
The luncheon program features a panel discussion of Duke Medicine alumnae followed by roundtable conversations on issues specific to women in medicine.
Now Accepting Applications for Global Health Elective Rotations
Developing the next generation of globally educated, socially responsible healthcare professionals dedicated to improving the health of disadvantaged populations.
Accepting Applications for Global Health Elective Rotations
The Hubert-Yeargan Center for Global Health (HYC) is now accepting applications for Global Health Elective Rotations for July 2015 and March 2016. Application is open to residents from Departments of Medicine: Internal Medicine (PGY 2); Med-Peds (PGY 3) and Med-Psych (PGY 4). Access the application form and FAQ at http://dukeglobalhealth.org or submit online http://bit.do/HYC-submit.
(Application addendum is available by request – firstname.lastname@example.org)
Application deadline is September 30, 2014. Interviews held during October. We strongly encourage you to speak with past participants to get a better idea of what daily life is like on the wards of your top sites. For more information, contact Tara Pemble, Program Coordinator at email@example.com or 668-8352.
18 month extended residency encompassing:
- 9 months enrolled in Duke’s Master of Science in Global Health degree program
- 9 months providing clinical care and conducting mentored research overseas
In addition to the standard salary and benefits package commensurate with post-graduate
Year, trainees benefit from:
- Masters of Science in Global Health degree tuition covered by the program ($50,000)
- $6,500 international travel stipend which also covers immunizations, passport and visa fees, foreign medical license fees, and foreign language training
- $7,450 in research grant funds for fellows enrolled in the MSc-GH
Please visit our website for an in-depth description of the core curriculum including rotations, global health competencies, and program requirements: www.dukeglobalhealth.org
ETHOS for Noon Conference Attendance Tracking!
You MUST have your Duke Unique ID entered in to you ETHOS account in order for the system to work properly! Please make sure that you enter your Duke Unique ID and NOT your Net ID! If your unique ID is entered incorrectly, you will not get credit for attending the conference!
How do I Set up an ETHOS account for the first time?
How to register with Ethos
- Go to the Duke Continuing Medical Education home page.
- In the upper right corner, click Join. The Account Information page opens.
- Complete the fields on the screen. A field with an asterisk is required.
- NOTE: Please make sure you include your Duke Unique ID– even though it does not show as a required field.
- Be sure to include your mobile phone number; you will use this number to send a text message with a code supplied at each event and get credit for CME events you attend.
- At the bottom of the account information form, click Create New Account. A green feedback message near the top of the screen informs you that a confirmation has been sent to the email address you provided.
- Open the email (from firstname.lastname@example.org) and click the top link in the body of the message.
- In your browser window, enter a password of your choice in both fields and note your user name. Click Save at the bottom of the page.
- In the same window, click the Mobile settings tab in the gray menu bar at the top of the page. If you entered your mobile number when you registered, it should appear on this page. Click confirm number. You will receive a text message to that mobile number with a confirmation code from DCRI CME.
- Enter the confirmation code in the box in your browser window and click Confirm Number. A message will appear below your number saying “Your number has been confirmed.”
- Now when you attend an event for CME credit you can use your registered mobile phone to text the provided event codes and earn CME credit.
To record your CME attendance via text message, follow these steps
- The 6-character SMS code will be provided on a slide during your CME event.
- Begin a new text message on your registered mobile phone. Note: The provided code is only good for eight hours. You must text the code the day you attend Medicine Grand Rounds.
- In the To field, enter the Duke CME phone number: 919-213-8033. Tip: Add this number to your mobile phone contacts.
- In the message area, type the 6-character SMS code that was provided during the session (note: this code is not case sensitive).
- Press send.
- If you have set up your Ethos account, you will receive the successful confirmation text message, “Your attendance has been recorded for “[Name of Session].”
To add your Duke Unique ID to your account
- Log into Ethos by visiting the Duke Continuing Education home page and click Log In at the top right of the page.
- Enter your username and password. Click My Account in the upper right corner.
- Under My Profile, click Edit
- Scroll down until you see Duke Unique ID filed. make sure it is correct
- Save the changes to you My Profile page
Upcoming Dates and Events
October 1 - DOCTOBERFEST begins!
October 27, 2014 - Recruitment Kick-Off Event
December 13, 2014 - DoM Holiday Party
- Main Internal Medicine Residency website
- Main Curriculum website
- Ambulatory curriculum wiki
- Department of Medicine
- Confidential Comment Line Note: ALL submissions are strictly confidential unless you chose to complete the optional section requesting a response