From the Director
So, I am officially a Med Res News slacker and a Fun-bruary slacker. Better late than never for today however. And congratulations to Amy Lee’s gen med team for winning the “why we deserve lattes” contest last week. I think the whole team is back today, so find me for your Starbucks trip. More trivia to follow ASAP.
We are really looking forward to representing at the ACP meeting this weekend. Many thanks to Jenn Rymer for working out the schedules, and to Tia and Lynsey for working on the posters and to Murat for helping everyone be motivated to show off your great work. I hope to see you all that evening after a day of rounding on Gen Med!
Other kudos this week go to our gold star recipients Shai Posner, Meghan Steiner, Alana Lewis and Jeremy Cypen! A gold star is awarded when a patient specifically mentions you in their comments about great care at Duke. Way to go! Other kudos to Stephanie Li (kudos x 2) - for outstanding patient care at the VA from colleague Bill McManigle and also for presenting a fantastic chair’s conference on Friday.
SARs … the deadline for ‘early’ registration for the ABIM exam has passed. Please don’t forget to register before the final deadline. Boards are always offered in AUGUST and you get a better choice of site and date the earlier you register. Also, we are HAPPY to fill out any end of the year paperwork (there is always a lot), so please send whatever you need to Tia and me.
This week’s pubmed from the program goes to Laura Musselwhite for her recently accepted abstract to the:
GLOBAL CANCER: OCCURANCE, CAUSES, AND AVENUES TO PREVENTION Conference
RISK FACTORS FOR INTERVAL ADVANCED COLORECTAL NEOPLASIA AFTER SCREENING COLONOSCOPY: 10-YEAR FOLLOW-UP OF A PROSPECTIVE, MULTI-CENTER COHORT IN THE UNITED STATES Musselwhite, L.W., Abbott, D., O’Leary, M.C., Hauser, E.R., McNeil, R.B., Weiss, D., Lieberman, D., and Provenzale, D.
Have a great week
Aimee
What Did I Read This Week?
Submitted by Lynn Bowlby, MD
Management of Grave’s Disease: A Review
JAMA December 15, 2015 Vol 314, No. 23 PP 2544-2552
Henry S. Burch MD and David S. Cooper MD
We see a lot of thyroid disease at the DOC, mostly hypothyroidism of course, but even with on site Endocrinology we manage a lot of hyperthyroidism. We recently have seen several pts with Grave’s disease, and this review caught my eye.
The 2 authors, endocrinologists from Walter Reed and Johns Hopkins , selected the articles—13 randomized trials, 5 systematic reviews and 52 obs. Studies were included.
The major points—
Most pts with Grave’s disease have overt hyperthyroidism with palpitations, tremulousness, heat intolerance, weight loss, and anxiety.
Physical findings include tachycardia, proptosis, thyroid enlargement and tremor.
Older pts are less symptomatic.
AF is common in the older pts.
Possible lab findings include leukopenia, hypercalcemia, increased alk phos, mild to mod trans aminase elevation.
Diagnosis—not the focus of this review,
Includes elevated T4, T3 and very low TSH,
Can test for TSH receptor antibodies (TRAb), RAI uptake or thyroid US to confirm the dx
Ddx also includes multi nod goiter, painless thyroiditis, drug induced thyroiditis
Pathogenesis-immunoglobulins that stimulate TSH receptor on thyrocytes
Management—
1. Antithyroid drugs--
Methimazole and PTU, remission in 40-50% of pts treated for 12-18 mos
In US second line choice after RAI
Inhibit thyroid hormone synthesis by interfering with TPO.
PTU blocks T4 to T3 conversion
Can normalize TRAb levels over time, leading to long term remissions
Methimazole is first line, as primary treatment or pretreatment prior to RAI or surgery.
Starting dose 10-30 mg/day, qd, max usually 40 mg/day
Retest 2-6 weeks to check for improvement with T4 and/or T3
TSH remains low for 1-2 mos
Then test q 2-3 mos and lower methimazoe dose to 5-10 mg/day after 6 mos
Treat for 12-18 mos, if TRAb normal, drug can be tapered off
Relapse rates 20-30% over 3-5 yrs
Adverse effects—pruritic rash and arthralgias in 5% of pts
Can switch to PTU, but may occur with this drug as well
Agranulocytosis occurs in about 1 in 500 pts, in the first 90 days, high fever and sore throat are the sx.
Stop med, may need IP hospitalization, antibiotics
Controversial if WBC should be monitored.
PTU is second line med (except in pregnancy when preferred) due to risk of hepatocellular injury with hepatic failure, usu. in first 90 days.
This also may occur with methimazole.
Not clear if monitoring LFTs helps.
ANCA vasculitis with PTU is risk, can occur after years of therapy.
B Blockers –relieve many symptoms, ie. Palpitations
Start with propranolol 40-160 mg/day
Use carefully with asthma, COPD, CHR
Ca chanel blockers can be used in these pts
2. RAI (radioactive iodine)—most cost effective option
RAI incorporated into thyroid hormone with gradual destruction of the gland occurring
Pt will be hypothyroid 2-3 mos after a single Rx
Repeat not considered before 6 mos
Pretreatment with antithyroid meds may reduce the hormone levels that can be very high post treatment
RAI treatment is assoc with new or worsening orbitopathy, esp if pts are smokers
Orbitopathy—25 % of pts with Graves, can be ocular inflammation, periorbital edema, proptosis, extraocular ms enlargement,, optic neuropathy and lacrimal gland dysfunction
Corticosteroids may reduce this risk
3. Surgery-in some centers uses over RAI as the definitive treatment , esp in lower SES pts
Most helpful in pts with very large goiter, or those who plan to become pregnant with in the next 6 mos
Antithyroid meds for 1-3 mos prior to surgery used.
4. Pot. Iodide therapy for those allergic to anti thyroid meds-
Very interesting to me, I have never seen this used.
Recent studies from Japan, remission in pts similar to methimazole.
QI CORNER
Lot's of exciting opportunities currently happening in the QI World:
1) The PSQC is progressing with our paging improvement project, and 4300 is our first trial ground. For those of you on gen med, you should have been oriented to the new paging template already. For those who aren't aware however, the nurses have been encouraged to follow a page template that includes name/room/team/issue/urgency/call-back number (non-HUC). The urgency codes are as follows:
Routine -requires return phone call or other communication (including order entry) within 60 minutes
Urgent - requires return call or communication within 15 minutes
STAT - requires return call or trip to bedside within 5 mins (Charge RN is also to be alerted)
Please let Lindsay, Lish Clark, Matt Atkins, or any other PSQC member know if you have any questions or suggestions. As always, the PSQC meets the second Thursday of every month and all residents are invited to attend. Great opportunity to get involved!
2) Have you ever been in clinic and wanted to calculate your patient's ASCVD risk score and thought "there's gotta be a better way than having to go to clincalc.com then click back and forth what seems like a hundred times between the internet browser and your patient's labs, vitals, and demographics?" Now there is. The .ASCVDRISK dot phrase calculator is now up and running (see below for example). Stay tuned in the upcoming weeks for details about an effort at the DOC to use this calculator to increase appropriate use of statins for primary prevention of ASCVD.
The 10-year ASCVD risk score (Goff DC Jr, et al, 2013) is: 12.5%
Values used to calculate the score:
Age: 58 years
Sex: Female
Is an African American: Yes
Diabetic: No
Tobacco smoker: No
Systolic Blood Pressure: 157 mmHg
Prescribed Anti-hypertensives: Yes
HDL Cholesterol: 47 mg/dL
Total Cholesterol: 201 mg/dL
Thanks!
Matt
R. Matthew Atkins, MD
PGY-3, Duke Internal Medicine
CLINIC CORNER
by Sonal Patel, VA PRIME
Hello PRIME
I wanted to take a moment and review the staff changes in clinic. Please take a moment and introduce yourself to all of the new faces in PRIME. Welcome to Christy Lucero (on left) and Carmen Hurst (on right) who will be on PRIME team 1.
Team 1
Carmen Hurst- RN
Christy Lucero- LPN
Jonathan Parrish- MSA
Team 2
Marie Currin- RN
Jill Caudillo- LPN
Paul Granchukoff- MSA
Team 3
Denna Kellum - RN
Lori White-Johnson- LPN
Tyson Williams- MSA
Also please look out for VA PRIME business cards in your inboxes. Please provide a card to each of your patients and explain that you would like to see them in clinic and for them to try to make an appointment with you if possible. We are really hoping this will help with continuity. In addition please be on the look-out for your block schedule for the rest of the year color coded to clinic availability and request patients to return to clinic when you are more likely to be in PRIME clinic.
Lastly I am sure each of you have met Leigh Wynkoop our Clinic Coordinator. Please continue to reach out to her with any day to day issues that come up in clinic and please send her an email updating her after your complete COMP or Admin time.
Thanks for reading
Sonal Patel
PRIME Clinic Director
From the Chief Residents
Grand Rounds
Friday, February 26 - Endocrine, Jennifer Perkins
Noon Conference
| Date | Topic | Lecturer | Time | Vendor |
| 2/22/16 |
MKSAP GI |
|
12:00 | Cosmic |
| 2/23/16 |
Pancreatitis |
Vaishali Patel |
12:00 | Domino's |
| 2/24/16 |
ACGME Survey |
Chiefs |
12:00 | China King |
| 2/25/16 |
Residency Council Townhall |
Dinushika and Jesse |
12:00/DN 2001 |
Chick Fil A |
| 2/26/16 | Research | 12:00 | Panera |
From the Residency Office
Fellowship Program Info Sessions
Gastroenterology Fellowship Program
Monday, March 7th at 5:00pm in the Tyor Conference Room located in the GI Administrative Suite.
Hem-Onc Fellowship Program
March 1, 2016 4:00-5:00 PM. Room 405 Mudd (Conference Room). Pizza and drinks will be provided.
General Internal Medicine Career Night
General Internal Medicine Career Night
Interested in a career in General Internal Medicine?
Thinking about primary care medicine or hospitalist medicine?
Envision working in academics, research, Quality Improvement
or a combination?
Come to Gen Med Career Night
Tuesday March 15, 2016
6:30-8:30pm
Gen Med Resident Library
Dinner from Nosh
Come ask questions for our panelists about their path and journey:
Kevin Shah, Claire Kappa, Bruce Peyser, Sharon Rubin, David Edelman, Sonal Patel, Lance Teagen, Gene Odone, David Gallagher and Daniella Zipkin
Please RSVP to Sharon.rubin@dm.duke.edu by March 11, 2016
Teaching and Leading EBM: A Workshop for Educators and Champions of Evidence-Based-Medicine
Registration is now open!
Teaching and Leading EBM: A Workshop for Educators and Champions of Evidence-Based-Medicine
Duke Medicine, Durham NC
April 12-15, 2016
http://sites.duke.edu/ebmworkshop
This workshop focuses not only on learning EBM skills, but also on teaching EBM. Previous participants have included rising chief residents, faculty charged with developing an EBM curriculum, librarians, and other clinicians and faculty passionate about applying the best evidence to patient care. The program includes large group sessions in the morning, then supportive, small group, learner-driven sessions for the rest of the day.
The workshop will take place on the Duke Medicine campus in the new Trent Semans Center for Health Education and the Duke Medicine Pavilion.
Workshop Objectives:
Train leaders in medicine to facilitate evidence-based clinical practice in their teaching and practice settings.
Practice the skills involved in evidence-based medicine including clinical question formation and acquisition of medical evidence from the literature.
Review and develop critical appraisal skills and application of available evidence to patient care and medical education.
Develop skills in teaching EBM in both large and small group settings.
Provide interactive experience with a variety of evidence-based resources guided by faculty with expertise in evidence-based practice.
Please contact Megan von Isenburg (megan.vonisenburg@duke.edu) or Laura Huffman (laura.huffman@dm.duke.edu) with any questions.
11th Annual Duke Health Patient Safety and Quality Conference
REGISTRATION NOW OPEN: 11th Annual Duke Health Patient Safety and Quality Conference
11th Annual Duke Health Patient Safety and Quality Conference
Thursday, March 10, 2016
Durham Convention Center
301 West Morgan Street, Durham, NC
Onsite registration/check-in begins at 7:00 AM
Conference program is from 8:00 AM-4:30 PM
Register online today!
Book Club Survey
If you haven't been to one of our events yet, please support the Dept of Medicine book club project by taking a quick moment to fill out the survey below! Your participation is totally voluntary and anonymous, and the questions only takes ~2 minutes. You may remember filling this out before -- if you have, try to use the same identifier you used last time (if you can't find it, just make up a new one).
Here's the link: https://duke.qualtrics.com/SE/?SID=SV_bfJqGFkA6HScRq5
Feel free to email Laura.Caputo@duke.edu if you have any questions. Thanks so much for your participation!
Teaching and Leading EBM Scholarships
Three scholarships are available for the nationally-recognized “Teaching and Leading EBM” Workshop, which will be held at Duke Medicine from April 12 – 15, 2016. These scholarships are funded by a GME Innovations project and are reserved for residents, fellows and junior faculty who can bring EBM back to Duke residency programs. The workshop focuses not only on practicing EBM, but also on teaching EBM, making it an ideal educational opportunity for rising chief residents or others involved in teaching and the education of your residents.
We invite you to apply or to identify a member of your program to attend the workshop.
Scholarship recipients will be expected to create an educational deliverable on EBM for their programs. Deliverables could be a live session or physical / online materials. After completion of the workshop and deliverable, recipients will be required to complete a short report detailing their contribution to their programs.
Selection will be based, in part, on how participants will use the skills gained in the workshop to foster EBM in your program.
Read more about the Duke EBM Workshop here - http://sites.duke.edu/ebmworkshop/. Please contact Megan von Isenburg at megan.vonisenburg@duke.edu or 919.660.1131 with any questions.
Apply online at http://tinyurl.com/dukeebm2016
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/
Upcoming Dates and Events
March 2 - JAR Networking Event
March 5 - UNC vs Duke
March 18 - Match Day Celebration
April 29 -Charity Auction
Useful links
GME Mistreatment Reporting Site
https://intranet.dm.duke.edu/influenza/SitePages/Home.aspx
http://duke.exitcareoncall.com/
Main Internal Medicine Residency website
Main Curriculum website
Department of Medicine
Confidential Comment Line Note: ALL submissions are strictly confidential unless you chose to complete the optional section requesting a response
Opportunities
www.bidmc.org/CentersandDepartments/Departments/BIDHC
http://www.careermd.com/employers/latestbulletins.aspx