From the Director
Hi everyone!
A big thanks to all for your fantastic work during a VERY busy week at all 3 hospitals! The highlight of this week was certainly our FANTASTIC Charity Auction, held on Friday night at the Full Frame Studio at the American Tobacco Campus (Durham… it's awesome!). Carling Ursem, Christine Bestvina, Jen Chung, Allyson Pishko, Jessie Seidelman, Adrienne Belasco and Andrea Sitlinger worked incredibly hard over the past few months to put together an absolutely fantastic evening, with great silent and live auction prizes. We couldn't have done it without the support and commitment of Lynsey Michnowicz, Erin Payne, Lauren Dincher, Jen Averitt and Randy Heffelfinger before, during and after the evening. Our fearless emcee Tony G was hilarious as always, and the chiefs were remarkably good sports about getting pies in the face (I'm sorry Joel, but Ann Marie made me do it!). Hats off to Scott Evans who allowed Rob Harrison to pie him (with a "used" pie) as a symbolic representation of 1010 vs. the ED. All in good fun, we promise. Word has it that Scott was incredibly helpful in the planning of the auction as well. Overall, this auction had the BEST faculty attendance of any auction in history, as well as fantastic resident participation…thank you to everyone who donated, attended, bought, and supported our causes…SeniorPharmAssist and the DOC Patient Fund.
Other kudos this week go to Kevin Trulock from the venerable PSK for outstanding family communication in the MICU, to Claire Kappa for unsolicited coverage of a friend on night JAR, and to Brian Miller and Marianna Papademetriou for outstanding SAR talks. Kathy Andolsek from GME sends kudos to Nick Rohrhoff, Liz Campbell, Brian Kincaid and John Wagener for their assistance in hosting the congressional staffers who were visiting to learn more about GME. She tells me that the staffers were VERY impressed with our their knowledge, compassion and ability to discuss the issues affecting GME. Lynn Bowlby sends kudos to Alex Clark, Suma Das and Bronwen Garner for outstanding work at DRH!
Another HUGE KUDOS to Lindsay Boole for winning the ACP National Abstract Competition…Lindsay presented the data from our QI/PS Afternoon Report held on Thursdays at Duke with Jon Bae. Fantastic work Lindsay. Look for her work to be featured in the Med Res Library soon..her work features a great example of how all of our SARS participate in ROOT CAUSE ANALYSIS and help solve the safety issues affecting our patients.
Hold tight….the schedule will be released THIS WEEK!! We are making a couple final edits and you should receive your JAR/SAR schedule on Tuesday. Thank you VERY MUCH to Krish, Stephen and Vaishali for your hard work on such an important but time consuming part of being chief.
What's coming up??? This week we have the CPC on April 22nd at THE PIT!!! Please RSVP to the evite if you are planning on attending…a great crowd has already signed up. Next is the AMAZING THIRD ANNUAL STEAD TREAD — time to get your running shoes on, get some exercise and support a great cause (the Lincoln Community Health Center!). Sign up at www.steadtread.org….ASAP to be sure to get a T-shirt!! Can you be faster than Meredith Clement? Can Brian Schneider run with a jogging stroller and still beat you? Blink and miss Ethan (Bowlby) Ready? Whether you run faster or slower than your program director, we would love to see you there!
This week's pubmed from the Program goes to John Wagener for his article with Sunil Rao! “Strategies to Avoid Bleeding in the Management of ACS.” Medscape Online. Released July 30, 2013.
Have a great week!
Aimee
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What Did I Read This Week?
Lichtman JH, Froelicher, Blumenthal J et al. Circulation 2014;129:1350-1369
Submitted by Sarah Rivelli , MD
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Why Did I Read This?
A variety of types of studies, including prospective studies, systematic reviews, and meta-analyses have documented an association between depression and increased morbidity and mortality in a variety of cardiac populations. However, whether or not depression should be considered as a recognized risk factor for poor prognosis in patients with acute coronary syndrome has remained controversial. The purpose of this Scientific Statement by the American Heart Association was to review available evidence and conclude on whether depression should be elevated to the status of a risk factor for patients with acute coronary syndrome.
Methods
A systematic literature review was performed with clearly defined search strategies and terms. Articles were limited to the English language and were reviewed in a consistent manner. Search terms for the risk factor of interest included depression, depressive symptoms, dysthymia, mood or depressive disorder. Adverse medical outcomes after acute coronary syndrome included all-cause mortality cardiac mortality, and composite outcomes for mortality and nonfatal events.
The strength, consistency, independence, and generalizability of the studies were assessed. Studies included were those with prospective design, >=100 patients, systematic established assessment of depression and included a nondepressed comparison subgroup.
Results
A total of 53 studies were included
Depression and all-cause mortality
Out of 32 such studies, 17 reported a significant risk-adjusted association between depression and elevated all-cause mortality and an additional 4 studies found similar results in unadjusted analyses.
Depression and Cardiac Mortality
Seven of 12 studies reported a significant risk-adjusted association and one reported a significant unadjusted association between depression and increased cardiac mortality.
Depression and composite of mortality and nonfatal events
Out of 22 studies, 15 reported a significant risk-adjusted association and 2 additional studies reported a significant unadjusted association between depression and a composite of mortality and nonfatal events. These studies represented analysis of 14 of 18 unique cohorts.
Four meta-analyses were also reviewed. The overall unadjusted effect of depression on all-cause mortality was 1.8-2.6 and 2.3 to 2.9 for cardiac mortality.
Comments
The authors did a good job of systematic literature search and evaluating the quality of the studies included. They took care to consider that some publications were based on the same cohort of patients, which could lead to overstating of the results. Moreover, they excluded studies with small sample sizes, which tend to lack sufficient power to detect differences and may have false negative results. The inclusion of English language-only studies may have biased towards positive studies as negative studies may be more likely to be published in a language other than English.
Studies were heterogenous with respect to sample demographics, measurement of depression, length of follow-up, and the other risk factors included in multivariate models which limits the results. Covariates were not necessarily consistent across studies, and the severity of a co-occurring risk factor was not always included. The variability in covariate adjustment may contribute to the overestimation of depression as a risk factor above and beyond established post-ACS risk factors. The strength and precision of the positive studies varied, however only a minority of studies published were negative.
Implications
Should we screen for depression post-ACS? Yes, especially because it is an important condition to treat in its own right.
Will treating depression post-ACS save lives or prevent cardiac events? We don’t know that yet. There is really only one study to date adequately powered to detect the effect of depression treatment (ENRICHD) and in intention-to-treat analysis, it was negative. However, post-hoc analyses suggested that adequate treatment of depression leads to better survival, which is intriguing.
It will be interesting to see how we integrate this Scientific Statement in clinical practice.
The "Clinic Corner - VA PRIME"
(submitted by Sonal Patel, MD )
News from the VA… Well the VA is abuzz with rumors that we will soon be visited by our friends at The Joint Commission (formerly known affectionately as JCAHO). I wanted to take a minute and discuss what The Joint Commission is and the invaluable service it provides. Founded in 1951, The Joint Commission is the nation's oldest and largest standards-setting and accrediting body in health care . It is an independent, not-for-profit organization that accredits and certifies more than 20,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. Their mission statement is to “To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.” To earn and maintain the The Joint Commission’s Gold Seal of Approval, an organization must undergo an on-site survey by a Joint Commission survey team at least every three years. (laboratories must be surveyed every two years). Driven by a commitment to honor America’s Veterans by providing exceptional health care that improves their health and well-being, the Durham VA Medical Center is readying itself for our upcoming visit. What that means for you and me: The 2014 Hospital National Patient Safety Goals include:- Identify patients correctly: 2 out of the 3- FULL name, DOB, FULL SSN whenever you bring a patient to your clinic room. Yes, that means asking the patient 2/3 questions above before starting your visit with the patient.
- Improve Staff communication: critical test results conveyed to the correct provider- If you get a page or call about a critical result, be aware that you are expected to repeat the results over the phone and then document the results with a plan of action in CPRS immediately.
- Use Medications Safely- label medications in syringes if you are not going to use immediately for a procedure, take precautions with patients on blood thinners and perform a thorough medication reconciliation with each visit
- Use alarms safely- medical equipment alarms are heard and responded to on time- important in inpatient setting, not so much in clinic
- Prevent infection- hand hygiene, use guidelines to prevent infections from catheters, central lines, surgery
- Identify patients at high risk for suicide and refer patients appropriately to mental health, provide crisis number, counseling- remember we have PRIME-Psych residents that work with us in PRIME and have same day access most of the time
- Prevent Mistakes in surgery (or for our case in clinic procedures, ie joint injections)- all patients need “TIME OUT” procedure which includes: identify the correct patient, discuss procedure site and laterality, obtain consent, position the patient appropriately, stop and take a “TIME OUT” to review with everyone (including patient) the plan. When everyone is agreement, proceed with procedure ( you do NOT need to mark the site as long as the consent process PRECEDES the procedure in a NON-OR setting by the same provider obtaining the consent)
- Please also wear your VA PIV ID badges in clear site
- Please lock your computers
- Keep all patient paperwork on your person and not in the clinic room.
- NO food or drinks in the patient exam rooms- this one is difficult, please try to avoid this…
- Lastly if nothing else, please CLOSE YOUR EXAM ROOM DOOR when you leave the room
QI Corner (submitted by Joel Boggan, MD)
Resident M&M Noon Conference Stephen Bergin is going to be leading us through a case on Thursday, the 24th, at noon. We Follow-Up project Here are the actual numbers from your hard work contacting your patients about lab results and documenting it this year during the first half of the year and since the holiday break. DOC: Increased from 70% during the first half of the year to 76% during the second half Pickett: Increased from 89% to 94% PRIME: Increased from 84% to 92%From the Chief Residents
SAR Talks
April 22: Sarah Wingfield, Matt SummersGrand Rounds
Dr. John Williams Topic: Shared Decision MakingNoon Conference
| Date | Topic | Lecturer | Time | Vendor | Room |
| 4/21 | MKSAP Mondays - ID | Chiefs | 12:00 | Subway | 2002 |
| 4/22 | SAR TALKS | Sarah Wingfield / Matt Summers | 12:00 | Pita Pit | 2003 |
| 4/23 | Essentials of Antifungal Therapy | Zaas | 12:00 | China King | 2002 |
| 4/24 | M and M | Bergin | 12:00 | Domino's | 2001 |
| 4/25 | Research Conference | 12:00 | Panera | 2002 |
From the Residency Office
STEAD TREAD IS COMING!
For those of you who haven't already registered, wanted to take a second to invite you all to come support the Stead Tread, Kempner Society's annual charity event. It was a blast this year, and since we're due for some good weather this year, I'm sure it will be even better this time around. Some additional information:- Please access the Stead Tread 2014 website (http://www.steadtread.org) for additional details, to securely register ($25), or make a donation
- Race date/time: Saturday, May 3rd, 2014 at 10AM
- Race location: Al Beuhler Trail (on our USATF-certified course around the Washington Duke Inn and Golf Course)
- Race beneficiary: Lincoln Community Health Center
- Your registration fee includes an official Stead Tread 2014 T-shirt – register ASAP to reserve your size, they are going fast!
- Participants are welcome to run or walk, and strollers are permitted - kids under 12 can run/walk for free, so bring your families!
- In case you cannot make the race this year, individual and corporate donations can be made securely through our website
Parking Question
Last week we received the following question regarding parking on the confidential comment line: Will interns be moved to the PG2 parking deck in July? (This is where current JARs and SARs park). My hope is this will be the case, as parking in the research drive parking garage with all the construction has been a huge hassle this year? Answer: No definitive answers yet, but we anticipate that the incoming interns will also be assigned to the research drive lot. We are not aware of any plans to try and relocate anyone to PG2. We will share any further updates as they are received.Who Cleans Up After You?
Did you know that if you chose to leave a mess behind you at noon conference, or at ANY time in the Med Res Library or office, it is the office staff who most often pulls things back together and makes it look presentable. And in case you were wondering, this really is not our job. Please do not leave lunch dishes on the floor, or walk away from something you dropped or spilled.Clinical Pathology Conference (CPC)
Reminder: CPC will be held at The Pit next Tuesday, April 22nd at 7pm! The one and only, incredible Allyson Pishko will be presenting the case. Come enjoy a delicious plate of food and drinks; the presentation will start at 7:15pm. If your RSVP has changed, please contact Erin Payne directly at erin.payne@duke.edu. Enjoy!!Do you have patients with chronic pain?
The IOM in 2011 called for a “population health-level strategy for pain prevention, treatment, management, education, reimbursement and research.” On May 2-4, Duke and UNC will be co-sponsoring a joint symposium on Pain, Addiction, and the Law – which includes an intensive, boot camp-style mini-course on pain management the evening of Friday, May 2. Residents can register for the mini-course and the meeting free of charge, but spots are limited. Click the link to the attached brochure for more information. Interested residents should contact Lynn Bowlby for more information. FINAL.WEB.BrochureInformation/Opportunities
Los Angeles RSA-105 FlyerUpcoming Dates and Events
- April 22: CPC Event, 7 PM @ The Pit
- May 2: Faculty/Resident BB Game on Coach K Court
- May 3: the Stead Tread 5K www.steadtread.org
- May 30: Program pictures @ Duke Chapel 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
- https://intranet.dm.duke.edu/influenza/SitePages/Home.aspx
- http://duke.exitcareoncall.com/.
- 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