Internal Medicine Residency News: February 3, 2014

By admin3

From the Director

DUKE.RESEARCH.NIGHT.03 (1)Hey Everyone! We survived snow-mageddon (term courtesy of Jon Bae) and should all pat ourselves on the back for being "essential". Thanks to Rajiv Agarwal for the essential snowman on my door.  In all seriousness, thanks everyone for staying in good communication and helping out as needed during the snow.  Hopefully this will be the last of the cold for this year. Kudos this week go to Wendy Chan, Nancy Lentz (last week), Tyler Black and Jodel Giraud for fantastic SAR talks.  Also to Eric Pollack for his gold star for outstanding patient care as well as Schell Bressler for her recognition by the DRH nurses for outstanding communication.  Huge thanks to our very busy teams throughout the hospital for maintaining great morale during the winter season.   Our other kudos double as pubmed from the program, so see below for why Lindsay Boole and Jenn Rymer deserve a big congratulations!  Also thank you to Stephen Bergin and the committee of residents and faculty who are working to reshape noon conference. The first MKSAP Monday (Rheum! Yikes!) was a big hit, and Stephen gave the first focused lecture (VAP) on Tuesday.  We look forward to continuing our new formats for conference, and will ask for your feedback throughout. Thanks to everyone who has filled out their GME survey – we are inching closer to the 70% requirement, and hope to reach 100% (last year we got to 84%, so at least let's top that!).  Survey closes Feb 16, and directions are in your email from Jen Averitt. Upcoming fun events include the following -- Fellowship Planning Meeting for JARs and SARs planning to apply in the AY2014-15 cycle — Feb 12 OR Feb 27 at 6:30 pm in the MED RES LIBRARY.  Join Bill Hargett and me for an overview of the fellowship match process, including how to get letters, what goes on your CV, why do I have to write ANOTHER personal statement, and more! -- The Warren Society Blood Drive and Trivia Bowl:  We would like to let you know of an upcoming blood drive by the Red Cross in the Searle Conference Center within the Seeley Mudd building (right out the back door of Duke North hospital) on Feb 13 from 9:30AM – 3PM.  Here is a chance to give back some of the blood you have drawn while here at Duke.  J  To stimulate participation, we will award 100 trivia points to the Stead Society with the highest level of participation.  We will ask each resident to notify his or her Stead group leader and Katie Broderick-Forsgren (Kathleen.broderick-forsgren@dm.duke.edu) by email after giving blood, so that we can keep a running tally of participation. -- On the evening of Wednesday, February 26, at 7PM, we will hold our next semi-annual Stead Trivia night at the Carolina Ale House (3911 Durham-Chapel Hill Blvd Durham, NC) with dinner on us at 7PM and trivia at 8PM.  The team with the most blood donors on Feb 13 will begin the Trivia Night on Feb 26 with a 100-point edge! -- Duke v UNC Basketball (yes, Emily Ray, we will let you join in the fun)..sponsored by the Duke Med Alumni at Tylers on Feb 12 at 8:30.  If you RSVP, there is complimentary appetizers and one drink ticket per person! Pubmed from the program this week goes to Lindsay Boole, Jenn Rymer, Jessie Seidelman for their prize winning submissions to the National ACP meeting.  Jenn will be honored as a young achiever and Lindsay gets this honor plus a platform presentation! Great work!! Jenn's poster (mentors include Jon Bae and George Cheely!)  Incentivizing Quality Improvement Among Housestaff: The Duke University Graduate Medical Incentive (GME) Task Force" Lindsay's poster (with Jessie as co-author! Mentor is Jon Bae)  "Residents finding their roots: Resident workshops to improve patient safety on the wards while teaching residents root cause analysis" Have a great week Aimee [box]

What Did I Read This Week?

"Submitted by Aimee Zaas, MD."

Daclatasvir plus Sofosbuvir for Previously Treated or Untreated Chronic HCV Infection;  Sulkowski, M, et al.  N Engl J Med 2014; 370:211-221

[/box] Why did I read this?  I was scanning the tables of contents of recent NEJM's and knew that I am not at all up to date in the rapidly changing treatment environment for HCV infection.  Thus, it seemed like a good idea to check out an article on two newer agents for this incredibly prevalent disease process.  Another fact – the lead author is a former Duke resident, although he hasn't been at Duke for a long time.   In addition to learning about 2 new drugs, I also learned a bit more about the epidemiology of HCV and refreshed some knowledge about the genotypes and their implications for treatment.   130312_zaas001 Background:  HCV is common (170 million cases worldwide).  HCV deaths now outnumber HIV deaths in the US.  Genotype 1a is most common in US.  THe old standard of Peg-IFN and ribavirin was a long and side effect laden treatment that obtained a sustained virologic response (SVR) in 40% of genotype 1 patients.  Adding the newer agents boceprivir or telaprivir (protease inhibitors that bind to the HCV serine protease NS3) increases SVR in genotype 1a patients but has side effects.  This treatment was not indicated for genotypes 2 and 3.  Also, if you fail this treatment, there were no other options.  So, more drugs are being developed to treat chronic HCV.  The two drugs in this study are daclatasvir (D) and sofosbuvir (S) .  Daclatasvir is a HCV NS5a replication complex inhibitor and sofosbuvir is a nucleotide NS5B polymerase inhibitor.  Both are oral once daily drugs. Study design:  Evaluated D +S in non cirrhotic/minimally fibroses (as measured by biopsy, serum Fibrotest or AST:plt index of <2) patients with HCV genotypes 1,2, or 3 and no prior treatment OR similar patients who had virology failure after treatment with telaprivir OR boceprivir + peg-IFN-ribavirin.  Exclusion was discontinuation of prior regimens due to adverse events, other types of chronic liver diseae or HIV or HBV confection. roup assignment was rather complex:  treatment arms were sofosbuvir x 1 week than S+D for 23 weeks (groups A and B), D+S for 24 weeks ( Groups C and D) and D+S+ribavirin for 24 weeks (Groups E and F).  Genotype 1 patients were in groups A, C or E and genotype 2 and 3 patients were in groups B, D or F.  Group sizes were designed to be equal.   The strange seeming one week lead in for S in groups A and B was a sub study to look at reduction in "D" resistance based on a lead in with S.   An amendment let in an additional set of patients to get either D+S or D+S+R, half were untreated prior and half had failed the protease inhibitors. The primary efficacy end point was the proportion of patients with a sustained virologic response (SVR, an HCV RNA level of less than 25 IU per milliliter) at week 12 after the end of treatment. Secondary efficacy end points included a sustained virologic response at 4 weeks after treatment and at 24 weeks after treatment. Safety end points included adverse events, discontinuation of a study drug due to adverse events, and grade 3 or 4 laboratory abnormalities.  Investigators also looked for virologic resistance by by sequence analysis of the NS5A, NS5B and NS3 regions of the virus in a subset of patients. Power calculations looked at both safety and efficacy.  With sample sizes of 14, 20 and 40 patients, and an assumed 10% rate of adverse events, the probability of observing one was .77, .88 or .99.  With the same sample sizes, the two sided 80% CI for SVR at week 12 ranged from 58-92%.  A modified ITT was used for efficacy end points.  Viral load was measured throughout the study at predefined times to look for response kinetics and breakthrough. Results:  That's a lot of groups for a relatively small study! 211 patients received treatment in the study — 44 with genotypes 2 or 3 and 167 with genotype 1 ( 126 untreated and 41 with lack of response to PI's).  91% of patients with genotypes 2 or 3 had SVR at 12 weeks and 93% at 24 weeks.  98% of genotype 1 patients had SVR at 12 weeks (prior treatment or not).  95% of previously untreated genotype 1 patients had SVR at 24 weeks.   Most common adverse events were headache, fatigue and nausea. Two discontinued due to AE (fibromyalgia and stroke).  Response rates were similar despite differences in race, prior treatment, genotype or the presence of the non CC IL28B genotype (a prior risk for poor response).   The use of ribavirin did not appear to enhance the effect of the D+S combination. Conclusions: This is a relatively small study but offers great promise for new treatments of HCV, particularly in those with difficult to treat genotypes of virus, and those with failure of prior regimens.  There are hints from this study that this may be a ribavirin sparing regimen, which is good for patients from the standpoint of side effects (anemia).  The next phases in our understanding of HCV treatment will include cost analyses, as these drugs are very expensive.  Importantly, these cost analyses should also look at time lost from work due to treatment, and the downstream costs of treatment failure (years of life lost, cost of transplant, etc). If you have made it this far, I highly encourage you to check out a VERY cool article in this week's NEJM Genetic PTX3 Deficiency and Aspergillosis in Stem-Cell Transplantation, as well as to definitely read the op-ed on CLER visits to GME programs by the head of the ACGME, Dr. Tom Nasca.  Much more on this to come…(article attached) Have a great week! Aimee

Ambulatory Clinics Report

We are adding a new section to Med Res News - highlighting the work that is ongoing in our ambulatory clinics.  The Duke Outpatient Clinic (DOC) is the first site, with the following submitted by Larry Greenblatt, MD: Congratulations to the DOC Team! Residents-you are likely aware of the multifaceted effort to improve the delivery of care to our medically and socially complex patients.  This effort has been implemented by our interdisciplinary leadership team, our nurses and staff, and importantly-our excellent and conscientious residents.  Your efforts-to follow up, GreenblattLarry08ensure comprehensive care, to communicate alternatives to the ED, etc. are making a difference. We not only try hard to improve what we do, we measure it.  We have set targets and are held accountable by the hospital leadership for meeting them.  I have the great pleasure of sharing some of our early and very impressive accomplishments.  Check this out:
  • ED Visits-10.5% reduction.  This is an enormous change.  Statewide, ED rates are climbing.
  • Doctor-patient continuity-up 8.3%
  • Residents scheduled with a same Stead Attending-88% (target >75%)
  • No show rates-down 15%
  • Hospital follow up within 14 days- up to 86% (14% over target)
  • ED Visits for our high utilizer (“Home Base”) patients-down 22%
  • Hospital days for our Home Base patients-down 31%
Take a minute to acknowledge the success of yourself, your colleagues, the nurses and staff, your DOC leadership, Natasha/Julia/Marigny/Jennifer (the all woman Home Base Team), Alex Cho, and Mark Dakkak (3rd year med student getting his Master’s and working on our project).  We plan to celebrate at clinic with cupcakes and other unhealthy treats.  

From the Chief Residents

SAR Talks

February 4, 2013:  Lindsay Boole;  Scharles Konadu

Grand Rounds

Dr Brice Weinberg;  Division of Hematology

Noon Conference

Date Topic Lecturer Time Vendor
2/3 MKSAP Mondays - Anticoagulation Chiefs 12:00 Subway
2/4 SAR TALKS Lindsay Boole / Scharles Konadu 12:00 Saladelia Salads
2/5 Essentials of Longterm Anticoagulation K Patel 12:00 Picnic Basket
2/6 Longterm Anticoagulation - Case Studies Causey/Smith/Bergin 12:00 Domino's
2/7 Chair's Conference Chiefs 12:00 Rudino's

image001

DukeMed Triangle Hoops Watch

Join local DukeMed alumni from the classes of 2004-13, current and recent house staff

to cheer the Blue Devils on to victory over our Tar Heel neighbors!

Duke Blue Devils vs. UNC Tar Heels

image002

Wednesday, February 12  |  8:30 pm  Tyler's Taproom 324 Blackwell St Durham, NC 27701 (919) 433-0345

Complimentary appetizers and one drink ticket per person provided.

[divider]

From the Residency Office

SAR Class Pictures

Please mark your calendars for Friday, February 14th immediately after Grand Rounds.  The group picture will be taken at 9:15am in the Duke Cancer Institute healing path (the lobby). Thankful to capture such a remarkable class!!  Erin

Duke Multidisciplinary Gastrointestinal Cancers Program is hosting its 1st Annual 5K Run/Walk

The Duke Multidisciplinary Gastrointestinal Cancers Program is hosting its 1st Annual 5K Run/Walk in honor and celebration of those whose lives have been touched by colorectal cancer. Together we can make a difference with your support and involvement.   Duke CRC 5K slide
  • Registration is open     DukeCRC5K.org
  • Race Date: Saturday, March 22, 2014
  • Time: Check-in begins at 7:00am. Race starts at 8:00am
  • Location: Al Buehler Trail, Duke Forest

Attendance At DoM Grand Rounds - ETHos

Just in case you may have not created an ETHos account - which is used to record attendance at Grand Rounds - the following attachement tells you how. How to register with Ethos

GME Fellows Research Blitz

Tbhe next research blitz is scheduled for Saturday, February 8th, 8:00am – 12:30pm in the Duke South Amphitheater. The Blitz will be repeated on Saturday April 26th. The agenda and learning objectives for the Blitz are attached. This is part of a GME-DOCR Collaboration to provide research education to residents and fellows across Duke. Additional information is attached. Registration Link:  https://www.surveymonkey.com/s/GME_Research_Training

MKSAP - Mid Year Opportunity

Last week to place orders for MKSAP -by using the following link https://www.surveymonkey.com/s/mksap2014
  • This offer is open to all  Categorical, Med Peds, and Med Psych trainees who have NOT previously received a copy of MKSAP
  • You are required to be a current ACP member to participate
  • You have the option to request the printed or digital version.  Should you want the complete set you have to cover the additional cost.
  • We do not place orders randomly at different times in the year.  This offer is for a limited time only – ending on February 9, 2014

Faculty Resident Research Grant applications are due on April 11, 2014.

Please use the following link to our website where the application instructions, forms and NIH format biosketch example can be downloaded . http://residency.medicine.duke.edu/duke-program/resident-research/research-funding Please feel free to email murat.arcasoy@dm.duke.edu with any questions

Resident/Fellow Survey Instructions

Program Scheduled: Duke University Hospital Program - 1403621320 Survey Timeframe: January 13, 2014 - February 16, 2014 Directions as to how to log in, complete the survey can be found on the following attachment:   ACGME Survey

Information/Opportunities

NEW Rheumatology Job OpeningOpportunities in the MidwestSpartanburg Regional Healthcare System  

Upcoming Dates and Events

  • Friday, February 14th :  SAR Class Pictures -  immediately after Grand Rounds
  • February 14:  SAR Class Pictures
  • March 21, 2014:  Match Day CELEBRATION !!
  • April 18th:  Charity Auction
  • June 3:  Annual Resident Reseach Conference
  • June 6:  SAR Dinner, Hope Valley CC

Useful links

Share