Internal Medicine Residency News, December 7, 2015

December 7, 2015

From the Director

What did I read this week?

Submitted by Dani Zipkin, MD

A Randomized Trial of Intensive versus Standard Blood-Pressure Control

The SPRINT Research Group, N Engl J Med 2015; 373:2175-2178

The JNC-VIII hypertension guidelines which were published in 2013 recommended a treatment goal below 150/90 for adults over age 60 (Grade A, strong recommendation) and a goal below 140/90 for all others, including those with diabetes or kidney disease (Grade E, expert opinion). Recently, the SPRINT trial has been making big news in primary care and will likely have a major impact on practice patterns, calling JNC-VIII recommendations into question. The features of the SPRINT trial merit closer attention!

Population: Age >50, SBP 130-180, and increased cardiovascular risk defined by CVD, CKD, Framingham CVD risk >15%, or age over 75. Excluded diabetes and history of stroke.
Intervention: Systolic target <140 vs. <120, stratified by site (there were 102 clinical sites). Study personnel and participants were not blinded. Outcome adjudicators were blinded. Encouraged thiazides, CCB, ARB, beta blockers for CAD, but didn’t mandate choices.
Primary outcome: Composite of MI, ACS, stroke, acute CHF, or death from CVD.
Follow-up maximum of 6 years, planned median f/u 5 years.
Power based on expected event rate of 2.2% per year, planned to reduce it by 20% (to approx. 1.8%). Needed 9250 participants for 88% power.

RESULTS:

9361 enrolled. 28% were over 75 years of age, 28% CKD, 20% CVD
Stopped early at 3.26 years.
Primary outcome occurred in 6.8% of controls, 5.2% of intervention. ARR 1.6% at 3 years. This gap would likely have been a little smaller if they had continued to five years, based on what we know of trials stopped early carrying inflated event rates.
HR 0.75; 95% CI 0.64-0.89; benefit seen within the first year
Rate of serious adverse events was 4.7% in intervention and 2.5% in control, defined as hypotension, syncope, electrolyte abnormalities, AKI.

Zipkin’s Bottom Line: This study has methodologic features that make it easier to find a difference between groups, such as composite outcomes, lack of blinding, and stopping early. Also, there was a near doubling of serious adverse events. However, the impact of aggressive blood pressure lowering in this high risk population that included patients with CKD is compelling and will change practice. Whether we really need to aim for systolic of 120 is unclear – keep in mind that in a less controlled setting out in the world, this will invariably result in even higher adverse event rate. But it’s fair to say we should move our goals down from the 140-150 range of JNC-VII!!

QI CORNER

Join us for the next meeting of the Patient Safety and Quality Committee this Thursday 12/10 at 5:30 pm in Duke North 8262. We will be focusing on next steps in our PAGING CULTURE project.

Imagine a world where all pages are text pages...

where they always give you all the info you need to triage how quickly you need to respond...

where nurses who don't want a call-back tell you so...

where the 7-digit HUC page is a relic of the past. That world could be ours.

We have a team. We have a plan. We have some serious nursing buy-in. Join us, so one day you can say "I was there when..."

PSQC

Thursday 12/10 at 5:30pm

** DN 8262 - Note location! **

Dinner provided

CLINIC CORNER

Hi DOC Residents--

A few notices below from me , Dr. Greenblatt and Jan Dillard, MSW.

A warm welcome to Heather Hoecker, our new PA at the DOC! She began on Monday and will be working with all of your patients, HomeBASE, mental health, and more!!

She comes to us from Emory, and shares my office.

Our Redesign work continues, with Redesign 2 underway, our efforts to provide more onsite acute care for our patients.

Thanks for being creative with all options to keep pts out of the ED, esp. when you are on call.

Remember the Duke Urgent Care clinics, open 8a-8p every day.

Daniel Connors also began, Brandie's replacement. Daniel can help with scheduling patients when you are on call and want pt seen the next day, have a lab or other issue where you need pt called and scheduled. Just email him!

PAIN Group—Thursday 1-2 pm, for patients with PAIN and substance abuse issues!!

Refer on the follow-up line in Maestro,

Jan is point person (or me! Lynn ) for any questions…pts obtaining narcotics regularly should attend one session, each is 4 weeks…

On behalf of Northern Piedmont Community Care (NPCC), a network of Community Care of North Carolina (CCNC), I invite you to join us for the bi-annual meeting of our network on Tuesday, December 8, 2015 from 6:30 to 8:00 p.m. The meeting will be held at City of Medicine Academy located at 301 Crutchfield Street, Durham, NC. Dinner will be served at 6:00 p.m.

The main agenda item will be “Behavioral Health Integration.”

Please email your response to Ethel Clay, Staff Specialist at ethel.clay@duke.edu or call her at 919-681-7073 no later than Tuesday, December 1. I hope you will be able to join us.

Click on this link to get directions: https://goo.gl/maps/ahJQmEd5Z9B2. You can park in front of the building on Wisteria (preferred) or you can park behind the building.

Larry Greenblatt (DOC Attending and Medical Director of NPCC)

Be Flu Smart!

It is that time of year again…. Time for trying to sort out if the viral illness your patient (or mother!) has is a bad cold or is it the flu? Here is some help-Check out the CDC’s weekly Influenza Activity Update: http://www.cdc.gov/flu/weekly/fluactivitysurv.htm. It’s good to know how much flu is going around and what types are being identified. FYI, we are Region 3. Need to make a clinical diagnosis in clinic or on the phone? During flu season, the combination of cough and fever has an LR of 5.0 while adding acute onset of symptoms gets you and LR of 5.4. Sneezing reduces the LR and is more often seen in viral URI’s. Patients with these symptoms have about a 70-75% likelihood of influenza, in season. LG

Did you know…

You can’t get Medicaid in NC just by being poor? Medicaid is insurance for the Blind, Aged or Disabled who also have low income. Exceptions include children, pregnant women and parents/caretakers with children in the home, provided they meet the income guidelines. Family Planning Waiver Medicaid is available to those who meet the income guidelines but do not otherwise qualify. It covers an annual family planning exam and lab tests, limited screening and treatment for some STDs, HIV testing and some types of birth control. It does not cover services unrelated to family planning.
You can’t get help paying for insurance through the Affordable Care Act in NC if your income is less than $11,770?

To recap, in NC, if your income is less than $11,770 and you are not over 65, disabled, pregnant or caring for children younger than 18, you do not qualify for any free insurance.

Patients who do not qualify for Medicaid and are unable to afford to buy insurance should see the clinic financial care counselor to apply for Duke Charity Care. At DOC, Gloria Manley serves patients with last names beginning with A-L, and Johnetta Britton serves patients with last names beginning with M-Z.

Refer using the follow up line in the Maestro encounter note.

Jan Dillard MSW

From your DOC team! Lynn, Larry, Jan et al!!

From the Chief Residents

Grand Rounds

Friday, December 11 - M&M, Dr. Lindsay Boole

Noon Conference

Date	Topic	Lecturer	Time	Vendor
12/7/15	Recruitment day-Lunch w/ Applicants		12:00	Panera
12/8/15	MedPeds Recruitment-Lunch with Applicants		12:00	Saladelia
12/9/15	ECG Interpretation	Jenn Rymer	12:00	Domino's
12/10/15	Wellness	Jim Lefler and Jake Feigal	1:45	Mediterra
12/11/15	Chair's Conference -11:30 Lunch with Applicants follows	Chiefs	12:15	Bull STreet

From the Residency Office

Annual Toys for Tots Holiday Toy Drive

As is becoming a holiday tradition, the Department of Medicine and Internal Medicine Residency Program will be sponsoring a Toys for Tots Campaign Drive.

All toys will be donated to the 2015 Marine Corps Reserve Toys for Tots Campaign! A donation to Toys for Tots would give toys to needy families in the local area just in time for Christmas. You can drop off your toy in the Medical Resident's Office between now and December 13th (all toys have to be collected and returned to the Marine Corps by December 14th). In addition, there will be donation boxes at the entrance to the DOM Holiday Party on December 12, 2015!

Details:

- Unwrapped

- New/Unused

- No guns

- Accepting toys for all ages including stuffed animals (really need toys for ages 6-8 and 9-13)

Did you know? One in five Durham residents live in poverty while 65 percent of children attending Durham Public Schools qualify for free or reduced-price lunches. That's more than 21,000 kids whose contemplation of the future is led by concern for food and shelter instead of the periodic table and book reports.

The U.S. Marine Corps Reserve Toys for Tots program collects messages of hope for these young people in the form of new, unwrapped toys for the holiday season. So please - if you can – donate today!

Thank you and Happy Holidays!

Stead Event

Pre-Holiday Stead Event next Tuesday 12/8/15 at Ponysaurus Brewery

All Stead groups are welcome and encouraged to join us!

http://ponysaurusbrewing.com/taproom/

The chirba chirba food truck will be there for anyone who needs dinner.

Thanks so much! Hope to see many of you there!!!

Eileen and Ryan

Deadline for ordering your 2015 Labcoat – December 31, 2015

All trainees that have continued in their current training programs for academic year 2015-16 (currently in 2nd year of the same program or above) are able to order one new GME provided labcoat per year. If you have not ordered your new coat this year, the deadline for ordering is quickly approaching (December, 31, 2015). To order, you will need your email address (exactly as listed in MedHub). Go to https://shopgmeuniforms.dukestores.duke.edu to place your order.

NOTE: If you are a first time user OR don’t know your password, click on the “Attention First Time Users“ link and you will receive one. If you have any trouble logging into the system, please contact the GME Office at dukegme@dm.duke.edu.

ALL LABCOAT ORDERS MUST BE PLACED BEFORE DECEMBER 31, 2015.

Hematology Division Newsletter

Please note that we will now include a copy of the Hematology Division Newsletter, published monthly, at the end of this post - check it out!

ACLT Applications Now Being Accepted!

Ambulatory Care Leadership Track (ACLT) Applications Due December 31, 2015:

Calling all interns who may be interested in either general internal medicine or a subspecialty where your focus will be ambulatory medicine, please consider applying to the ACLT. It’s a foundation for careers in general medicine leadership, primary care, academic ambulatory subspecialties, research, or education. Program highlights:

Three blocks of ambulatory medicine throughout JAR and SAR years, with dedicated didactic time following four key themes:
Clinical: Expanded clinical options in fields inside and outside of medicine: sports medicine, ENT, ophtho, dermatology, obesity medicine, as well as all medicine subspecialties. Maximum 4 weeks in any one medicine subspecialty (plus subspecialty continuity clinic), minimum 4 weeks general medicine ambulatory, over a total of 24 weeks.
Teaching: Curricula in teaching and opportunities to teach in small group as a SAR
Scholarship: Support for preparing and presenting scholarship, ambulatory journal club
Advocacy and health policy: seminars given by faculty in government relations and health policy throughout the year, and an advocacy trip in the spring to both Washington DC and Raleigh, NC, alternating year.

Please fill out the application linked at the end of this post and submit to Armando Bedoya and Dani Zipkin before the end of the year!

Duke Narrative Writing Project

Dear Medical Trainees,

We invite you to participate in the inaugural Duke Narrative Medicine Project.
This initiative includes a special Medicine Grand Rounds by invited speaker Anna Reisman, MD from Yale School of Medicine (Director of Yale Internal Medicine Residency Writers' Workshop) as well as a one-day workshop focused on honing the craft of writing.

Duke medical students, residents, and fellows across all departments are invited to submit narrative or reflective writing samples in advance of a one-day workshop in which participants will engage in critical and constructive feedback of each other's writing.
The writing workshop will be moderated by Dr. Anna Reisman as well as Duke faculty members who will work with you to prepare your narrative writing pieces for publication.

Please see the attached flyer as well as the application link below for additional details.

Duke Narrative Medicine Project: Writing Workshop
Saturday, February 6th 2016
Duke Medicine Pavilion
Pre-workshop dinner February 5th, 2016
Application details:
https://duke.qualtrics.com/SE/?SID=SV_2fUx5jKrPKf9ZhH

Application deadline:
Rolling submissions until January 15th 2016

Please contact DukeNarrativeMedicine@duke.edu with any questions!

Sincerely,
Duke Narrative Medicine Project Team
Amy L Jones, Dinushika Mohottige, Lakshmi Krishnan, Anubha Agarwal

NC ACP Call for Poster Abstracts

The North Carolina Chapter is excited to announce the Call for Poster Abstracts for the 2016 Chapter Scientific Session, taking place February 26-27 at the Grandover Resort in Greensboro, NC. As always, registration fees for the Scientific Session are waived for all Residents, Fellows and Students.

The poster competition is open only to Resident/Fellow and Medical Student members of the ACP North Carolina Chapter. First authors must be Medical Students or Resident/Fellow-level members of ACP or have made official application for membership in order to enter this competition. There will be no exceptions to this requirement. If you have not joined ACP (medical students join for free; Residents/Fellows should contact their residency program directors), please visit ACP Online to find out more and apply.

Each abstract will undergo careful review and will be ranked for scientific merit, originality, proper presentation, and clinical application. To view ACP's guidelines and tips on preparing an abstract, click here.

We will accept as many posters for display and judging as time and space permit.

The deadline for submitting entries is Friday, December 11, 2015, at midnight.

Abstracts can only be submitted electronically online. To electronically submit an abstract, go to http://www.acponline.org/about_acp/chapters/nc/abstract15.htm.

Why Submit?

Educational opportunity to showcase your work.
Best Clinical or Basic Research, Clinical Vignette, Quality Improvement, High Value Care, and Student Poster will each receive a cash award of $300 and reimbursement of travel expenses to the 2016 ACP Internal Medicine Meeting to present their poster.
Best Overall Poster will receive an additional cash award and reimbursement of travel expenses to the 2016 ACP Internal Medicine Meeting to present the winning poster.

For questions concerning this poster competition or the Scientific Session, please contact Nancy Lowe, CMP, Associate Director of the North Carolina Chapter, at nlowe@ncmedsoc.org.

Thank you,

Peter Lichstein, MD, FACP
ACP Governor, North Carolina Chapter

General Medicine Health Services Research Fellowship at Duke (Attention SARS!)

Health services research (HSR) is multi-disciplinary and focuses on the impact of systems of care, access, cost, quality, behavior and other factors on health care outcomes. We have a very robust network of support and outstanding faculty in HSR at Duke. Here is an introduction to our fellowship, courtesy of David Edelman. The application cycle begins in January!

The Division of General Internal Medicine collaborates with the Center for Health Services Research in Primary Care in the Durham VA Medical Center to offer fellowships for MD and PhD scholars with an interest in training in clinical or health services research. The fellowship is ordinarily a two year program, though three year fellowships may be available to certain candidates. Training grants are funded by the VA Office of Academic Affairs (OAA). We have trained more than 100 fellows in our 30-year history, including many leaders in Health Services Research and many of our core faculty in General Internal Medicine.

The primary goal of the post-doctoral fellowships is for fellows to perform high-quality, mentored clinical or health services research working closely with a mentor from the Division of General Internal Medicine. MD fellows ordinarily obtain a Masters in Clinical Research from Duke’s CRTP program, with tuition paid by the fellowship. All fellows also participate in a Faculty/Fellow Development Seminar Series, a set of weekly, one-hour discussions addressing a variety of career development topics. Stipend is at the appropriate PGY level.

Senior Residents wishing to apply for July 2016 should contact Dr. David Edelman, Fellowship Director (David.Edelman@duke.edu) no later than Friday, January 9 to express interest. Written application will be due February 1 with interviews competed by the 3rd week in February and applicants notified of their status by March 1.

Click the link for more info:

http://www.durham.hsrd.research.va.gov/MD_fellowship.asp.

Or, contact David Edelman, MD, Fellowship Director (david.edelman@duke.edu).

Annual Call for New Ideas

The Journal of Graduate Medical Education is seeking brief articles on novel ideas in curricula, teaching, assessment, quality and safety, program evaluation, or other topics relevant to graduate medical education. Selected papers will be published in the July 2016 issue.

Criteria

New Ideas must describe an intervention that is novel.
The intervention must have been implemented at least once; longer implementation is preferable. While outcomes data may be preliminary; feasibility (effort, costs) and acceptability (to subjects) must be discussed.
Preliminary evidence should suggest the intervention is successful.
The intervention can be replicated in other specialties.

New Ideas manuscripts must

Follow required manuscript format

No more than 650 words
Organized into 3 parts:

Setting and Problem
Intervention (the “New Idea”)
Outcomes to Date

May include 1 figure or table
Descriptions should not include a literature review or references

Be submitted via the online editorial management system by 8:00 am CT, Monday, November 16, 2015.

Acceptance decisions will be communicated by January 31, 2016.

NOTES:

Due to the brevity of these submissions, manuscripts that are not accepted will not receive editor comments.

Manuscripts not following the required submission format and/or submission deadline will not be considered.

If you have additional questions, please contact the Journal office.

Opportunities for Wellness

Feeling down? Need to talk to someone?
All trainees at Duke have FREE access to Personal Assistance Services (PAS), which is the faculty/employee assistance program of Duke University. The staff of licensed professionals offer confidential assessment, short-term counseling, and referrals to help resolve a range of personal, work, and family problems. PAS services are available free of charge to Duke faculty and staff, and their immediate family members. An appointment to meet with a PAS counselor may be arranged by calling the PAS office at 919-416-1PAS (919-416-1727), Monday through Friday between 8:00 A.M. and 5:00 P.M. For assistance after hours, residents and fellows can call the Blood and Body Fluid Hotline (115 inside DUH, 919-684-1115 outside) for referral to behavioral health resources. Another resource is Duke Outpatient Psychiatry Referrals at (919) 684-0100 or 1-888-ASK-DUKE.

https://www.hr.duke.edu/pas/