Internal Medicine Residency News: January 12, 201

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From the Director

DUKE.RESEARCH.NIGHT.03 (1)"Hi everyone. It's been incredibly busy on all the services, so a big thank you for your ongoing excellent work. Lots of kudos this week - to Adam Banks for his gold star, to Andrea Sitlinger from Dr. Wilson and the GI team, to Lauren Porras from Mitch Black for great work covering on gen med and to both Jay Mast and Ben Lloyd for fantastic presentations at report and chairs conference. Murat Arcasoy sends kudos to Lindsay Anderson for a great case (legionella!) at DRH report and to Wendy Chan for getting the diagnosis. Audrey Metz and Kim Bryan brought us excellent SAR talks as well. Thanks to Lindsay Boole, Ryan Huey, Nick Rohrhoff, Joanne Wyrembak and Alan Erdmann for doing resident share and to all of our tour guides - I know Aaron Mitchell, Marcus Ruopp, Bobby Aertker, Sajal Tanna and Mandar Aras led tours, and that I am missing a thanks to several others!Malika - Madar Engagement Congrats to Mandar Aras and Mallika Dhawan on their engagement! And also to Andy Mumm and Azalea Kim on their engagement as well! Please be sure to join us at Humanities in medicine night on Wednesday. Whether you have talent or not ( I certainly don't!) come out and support your friends and enjoy music, dance and poetry." PubMed of the week goes to Lindsay Anderson, MD for her poster presentation at the American Heart Association meeting, in November 2013.   Direct Cath Lab Access Reduced Reperfusion Delays and Mortality for Transferred-in STEMI Patients: Insights From Mission: Lifeline.  (Lindsay Anderson, William French, Andrew Peng, Amit Vora, Timothy Henry, Matthew Roe, Michael Kontos, Christopher Granger, Eric Bates, Tracy Wang)  Mentor: Tracy Wang, MD Have a great week Aimee [box]

What Did I Read This Week?

"Submitted by David Butterly, MD“

Combined Angiotensin Inhibition for the Treatment of Diabetic Nephropathy, NEJM: 11/14/2013, 369: 1892-1903

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This article appeared in the NEJM in November and reports from the NEPHRON-D study group on the effect and safety of combination ACE-inhibitor and Angiotensin receptor antagonist therapy when used in patients with Diabetic Nephropathy. Diabetic Nephropathy is the single most common cause of ESRD in the US.  Roughly half of all patients entering 128907_butterly005the ESRD program have Diabetic Nephropathy with roughly 80% of these due to Type II Diabetes.  The mortality in those reaching ESRD remains high and the annual cost of caring for these patients exceeds $10 Billion in the US alone.  Once proteinuria is present, ESRD can be postponed but generally not prevented.  Obviously any therapy which could slow or prevent this progression to ESRD could have an enormous impact on quality of life and mortality for this group of patients.  Effective means which have been shown to slow progression in Diabetic Nephropathy have included: 1) Improved glycemic control (DCCT NEJM 1993), 2) ACE-Inhibitors (Lewis NEJM 1993) and 3) ARBs (Lewis NEJM 2001 and Brenner NEJM 2001). Although combination therapy with ACE and ARB has been demonstrated to reduce proteinuria, the safety and efficacy of the drugs when used in combination is uncertain.  This study reports on the results from the VA NEPHRON-D investigators which evaluated the effect of combined therapy in patients with Diabetic Nephropathy and CKD.  This is a multicenter, double-blind, randomized, placebo-controlled trial to evaluate the efficacy of the combination of Losartan with Lisinopril as compared to standard treatment with Losartan alone in slowing the progression of diabetic kidney disease. A total of 32 VA medical centers participated in the study.  Patients with Type 2 DM and Stage II or III CKD (GFR of 30-90 ml/min with protein excretion of greater than 300 mgs) were eligible to participate.  Patients entering the study were initiated on 50 mgs of Losartan which was titrated to 100mgs.  Once they were on this dose for 30 days, they were randomly assigned in 1:1 fashion to ARB plus ACE-I with versus ARB along with placebo.  Patients were seen every 2 weeks and lisinopril was titrated from 10 to 20 to a maximum of 40 mgs.  Once a patient was on maintenance dose, they were seen every 3 months throughout the remainder of the study.  BP meds were titrated for target SBP of 110-130 and DBP < 80 in both groups. A total of 1648 were enrolled and 1448 patients were randomized.  Baseline characteristics are shown in Table 1.  Average age was approximately 65 and roughly 70% enrolled were white.  Glycemic control was similar with HgbA1C in the groups at 7.8%.  Average GFR in each group was 53 ml/min with equal distribution of patients at each CKD stage.  Urine albumin excretion in each group averaged about 850 mgs and baseline UPC ratios averaged 1.6 to 2.1. Results: Blood pressure control was similar between the groups (within 2 mm Hg).  The primary endpoints followed were 1) a decline in GFR (absolute decrease of > 30 mls or a relative decrease of > 50%), 2) ESRD, and 3) death.  Secondary endpoints included cardiovascular outcomes (MI, CHF, Stroke) and change in albuminuria.  Safety outcomes included all-cause mortality, hyperkalemia, and Acute Kidney Injury. The study results are shown in Table 2.  There was no difference demonstrated in Primary or Secondary outcomes over the course of the study.  A total of 182 patients died or progressed to ESRD (60 patients in the monotherapy and 63 patients in the combination therapy died).  Progression to ESRD was lower in the combination group (27 vs 43) but did not reach statistical significance.  MI, CHF, and Stroke were similar between the groups.  Kaplan-Meier plots for the primary and secondary endpoints are shown on page 1899 and the curves are essentially superimposable. Adverse Events and Safety: Adverse events occurred at a much higher rate in the group assigned to combination therapy.  AKI occurred at nearly two-fold the rate (12.2 combination vs 6.7 ARB alone) RR of 1.7.  Hyperkalemia was more than twice as common 9.9% versus 4.4%, RR 2.8 in the combination group.  These data are shown in Table 3.  Figure 2 shows the Kaplan-Meier plots for AKI and hyperkalemia. Due to these concerns along with the failure to demonstrate clear benefit, the data monitoring and safety committee recommended that the study be stopped in October of 2012 and the study was thus halted.  Average duration of follow up for the patients enrolled was 2.2 years. Conclusion: Combination therapy with ACE-I and ARB in patients with Diabetic Kidney disease was associated with an increased risk of adverse events - AKI and Hyperkalemia.  Proteinuria did decrease however there was no demonstrable improvement in progression of CKD or Cardiovascular events and the study was therefore halted early.  These data are consistent with ONTARGET (NEJM 2008) and the ALTITUDE study (Parving NEJM 2012) which showed increased harm and no cardiovascular or renal benefit in combination therapy with drugs that block the renin-angiotensin system.  

QI Corner (submitted by Joel Boggan)

We Follow-Up Sharepoint Group Project Update For those of you who did not link to the file embedded last week, here's a summary of the first half of the year in the lab follow-up residency-wide JAR/SAR QI project.  We look forward to tracking everyone's progress in the second half of the year! Overall reporting of lab results within 14 days:  77% By clinic - DOC 71% Pickett 89% PRIME 84%  

From the Chief Residents

SAR Talks

SAR Talks: January 14, 2014 Malika Dhawan and Elizabeth Campbell

Grand Rounds

January 17, 2013:  Dr. Ebony Boulware – MRRC/MLK

Noon Conference

 
Date Topic Lecturer Time Vendor Room
1/13 INTERVIEW
1/14 SAR talks Mallika Dhawan / Elizabeth Campbell 12:00 Cosmic Cantina 2002
1/15 Between the Ferns with Armando and Chris Residency Council 12:00 Pita Pit 2002
1/16 Echo for the Internist Joe Sivak 12:00 Rudino's 2001
1/17 INTERVIEW
 

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From the Residency Office

Death Certificates - New Requirements

As some of you have noted, NC death certificates now have a box asking for the certifying doctor's license number, which presents a challenge for residents who have "RTL" during training. The recommendation at this time is to enter your RTL number in the required field.  If you do not know your training license number it can be found in MedHub on your demographics page under certifications.

Residents Take on the Disney Marathon (aka Cruella deVille and two of her Dalmatians:   Brian Miller, Carling Ursem, and Scott Evans)

Disney 2014

While most of us were staying inside to stay warm and avoid the cold - or simply doing all we could to ward off getting a cold - we had a few who were brave enough to head outside and stick to their training routines.  These three hardy residents were in Orlando this morning running the Disney World marathon.  This picture is from the start of the race, in the dark.  Times?  Three hours and 38 minutes for Brian and Carling, and a big thank you to Lauren Pouras from Brian for covering his gen med shift so that he could do the race.

 

 GME Research Training Series

This is a reminder of the GME Research Training Series for residents. The third series of workshop sessions will be offered in January & February of 2014. Learning objectives are attached. Trainees can register using the link below. Registration for this third series will close on Friday January 10th. The tentative agenda and learning objectives for the Blitz is also attached. We hope you will consider strongly encouraging (or requiring) your residents to participate. These sessions will help meet ACGME requirements, enhance resident QI and research experiences, and help ensure residents follow sound research principles and practices now and upon graduation. Registration Link:    https://www.surveymonkey.com/s/GME_Research_Training GME Fellow Blitz Learning Objectives for GME Resident Education Series DOCR/GME Research Training
Human Subjects Research at Duke/Research Data Collection and Security Plan
Date Time Location
Wednesday, January 15, 2014 12:00pm-2:00pm Duke South M224
Thursday, March 6, 2014 4:00pm-6:00pm Trent Semans Classroom 4
How to Ask and Answer Research Questions Using Library Resources/Ethics of Conducting Research
Date Time Location
Wednesday, January 22, 2014 12:00pm-2:00pm Duke South 3031
Thursday, March 13, 2014 4:00pm-6:00pm Trent Semans Classroom 4
IRB Overview, Informed Consent, Regulations and Best Practices
Date Time Location
Wednesday, January 29, 2014 12:00pm-2:00pm Duke South 3031
Thursday, March 20, 2014 4:00pm-6:00pm Trent Semans Classroom 4
Presentation and Dissemination of Data
Date Time Location
Wednesday, February 5, 2014 12:00pm-2:00pm Duke South 3031
Thursday, March 27, 2014 4:00pm-6:00pm Duke South 3031
BLITZ - Training in Advanced Research Principles and Practices
Date Time Location
Saturday, February 8, 2014 8:00am-12:30pm Duke South Amphitheatre
Saturday, April 26, 2014 8:00am-12:30pm Duke South Amphitheatre
 

Information/Opportunities

 Sutter Coast_W_Site Profile_FINALSound Business ModelPath to Partnership overview (4-11) MHC Internal Medicine Program Flyer 

Upcoming Dates and Events

  • Humanism and Voices in Medicine 

    Wednesday, January 15th at 7:30 PM Intrepid Life Coffee & Spirits 106 W. Parrish Street, Suite 1, Durham, NC

  • April 18th:  Charity Auction

Useful links

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