From the Director
"It's the first Med Res News of 2014! Welcome back everyone - lots to do in the new year!
Recruitment continues in full force - look for applicants on rounds and at lunch. Erin will be reminding you about tours and resident share. You guys are the reason we will have an amazing class of new interns in July!
Kudos this week to
Lindsay Anderson from Alex Cho for fantastic work in a busy ACC, to
Marcus Ruopp from Aaron Mitchell for some VA CCU heroics, to
Aaron Loochtan and Emily Ray from the CAD nurses for outstanding work and to
Amy Jones from Krish Patel for her gracious covering on the pull list.
This week's pubmed from the program goes to
Katie Broderick Fosgren who will be presenting her work on the photo business cards at ICGME on Wednesday!"
Happy new Year!
Aimee
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What Did I Read This Week?
"Submitted by Vaishali Patel, MD“
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Why did I read it? CNN reports that weight loss is once again the nation’s number one New Year resolution (it beat “spending time with family” and “spend less, save more” by a mile). And yet, in spite of the promotions and deals offered by gyms every January, according to Time magazine, “60% of gym memberships go unused and attendance is usually back to normal by mid-February.” I suppose you have to give some credit to America for realizing that much of the bur
den of obesity (no pun intended) does, in fact, fall on the individual. The release of the guideline by the ACC/AHA/TOS Task Force in November 2013 is somewhat timely in helping physicians tackle the post-holiday overweight or obese patient who is ready to make some changes.
How are society guidelines created? The National Heart, Lung, and Blood Institute (NHLBI) expert panels first develop critical questions (CQs). Recommendations are devised for each CQ based on rigorous systematic review of randomized trials, meta-analyses, and observational studies. Most existing guidelines have not considered evidence beyond 2011, and so many will be updated by the societies in 2014. See below for a summary of levels of evidence and classifications of recommendations (I always have to remind myself of the details of these). Data that are included in the review may or may not provide adequate information about the efficacy of a certain intervention in different subpopulations. Level of Evidence B or C does not necessarily mean that the recommendation is weak – rather, you have to interpret the data available in the right clinical context. Many pertinent clinical questions that are addressed by guidelines are not easy to investigate in a clinical trial; some may lend themselves to a clear clinical consensus without evidence from a randomized trial.
What do these guidelines cover? The panel’s goal was to create recommendations to assist primary care clinicians for 5 CQs. These guidelines address the expected health benefits of weight loss (CQ1), the appropriateness of the current BMI cutoffs, CV-related risk, hypertension risk, impact on lipid profiles, risk of diabetes (CQ2), dietary composition and interventions (how to create reduced dietary energy intake and pattern of weight loss over time with dietary intervention, CQ3), physical activity and efficacy of lifestyle interventions (CQ4) and interventions for weight loss maintenance (a hot topic since many studies have shown high rates of recidivism and poor weight loss maintenance), and lastly the efficacy and complications of surgical weight loss interventions (CQ5). They also propose a model or treatment algorithm for the management of obesity as a chronic disease.
What are the summary recommendations for overweight or obese adults that you can share with your patients? Height, weight and BMI should be calculated at annual visits (Grade E). The BMI cutoff for overweight is 25kg/m
2 (these patients have an elevated CV risk), and for obesity it is 30kg/m
2 (these adults have elevated risk of CV disease, diabetes and all-cause mortality) as it has been in the past (Grade A). A larger waist circumference, is associated with a greater risk of CVD, diabetes and all-cause mortality (Grade E). Sustained weight loss of 3-5% produces clinically meaningful health benefits in lipids, A1c, and risk of developing diabetes; greater weight loss reduces the risk of hypertension, diabetes, and all-cause mortality. The initial goal should be weight loss of 5-10% of baseline weight within 6 months (Grade A). Prescribe a 1200-1500 kcal/day diet for women and 1500-1800 kcal/day for men as part of a comprehensive lifestyle intervention (participation in a high intensity activity program for >6 months). An energy deficit of 500-750 kcal/day should be recommended to those who would benefit from weight loss (Grade A). Weight loss maintenance requires participation in a comprehensive program for >1 year. Patients with BMI >=40 or >=35 with obesity-related comorbidities who have not responded to diet and exercise may be appropriate for bariatric surgery referral.
1) Applying Classifications of Recommendation
- Class I – benefit outweighs risk (procedure/treatment should be done).
- Class IIa – benefit outweighs risk but additional studies needed, or there may be some conflicting evidence (it is reasonable to do procedure/treatment).
- Class IIb – benefit outweighs risk but additional studies with broad objectives are needed, or there is greater conflicting evidence from RCTs or meta-analyses. Procedure/treatment may be considered.
- Class III – no benefit or harm. Procedure/treatment may be harmful/not useful and should be avoided.
2) Applying Level of Evidence
- Level A – multiple populations evaluated, multiple RCTs or meta-analyses.
- Level B – limited populations evaluated, single RCT or nonrandomized trial.
- Level C – very limited populations evaluated, only consensus opinion of experts, case studies, or “standard of care.”
3) NHLBI Grades of the Strength of Recommendation
- Grade A – strong recommendation/high certainty based on evidence that net benefit is substantial.
- Grade B – moderate recommendation/moderate certainty that net benefit is moderate to substantial, or high certainty that the net benefit is moderate.
- Grade C – weak recommendation/moderate certainty based on evidence that there is a small net benefit.
- Grade D – recommendation against /moderate certainty based on evidence that it has no net benefit or that risks outweigh benefits.
- Grade E – expert opinion / net benefit unclear, insufficient evidence to determine balance of benefits and harms, but the panel thought it was important to provide clinical guidance and make a recommendation.
- Grade N – no recommendation for or against / net benefit is unclear and panel thought there was insufficient evidence to make a recommendation. Further research is recommended in this area.
QI Corner (submitted by Joel Boggan)
Welcome back
Welcome back, everyone! Thanks for all your hard work during a great first half of the year.
Updates on projects
Below you'll see updates on our Hand Hygiene compliance and the results of the We Follow-Up Sharepoint campaign for our JARs/SARs. Our hand hygiene performance seems to have plateaued, but we still have five months to bring the average up to our goal of > 90%.
Hand Hygiene
| Ward |
Compliant |
Total Observations |
| 7100 |
9 |
11 |
| 7300 |
7 |
8 |
| 7800 |
9 |
10 |
| 8100 |
19 |
20 |
| 8300 |
4 |
5 |
| 9100 |
16 |
20 |
| 9300 |
8 |
8 |
| Overall |
72 |
82 |
Overall rate of compliance for December: 87.8%
Rate of compliance Aug-Dec: 87.9%
Lab Follow-Up Rates (attached)
Follow up # 2
From the Chief Residents
SAR Talks
SAR talks: January 9th, 2014
Audrey Metz and Kim Bryan
Grand Rounds
Dr. Kim Huffman – Rheumatology
Noon Conference
| Date |
Topic |
Lecturer |
Time |
Vendor |
Room |
| 1/6 |
INTERVIEW |
|
|
|
|
| 1/7 |
MED PEDS INTERVIEW |
|
|
|
|
| 1/8 |
Schwartz Rounds |
Lynn O'Neill, Lynn Bowlby |
12:00 |
Jersey Mike's |
2002 |
| 1/9 |
SAR talks |
Audrey Metz / Kim Bryan |
12:00 |
Domino's |
2001 |
| 1/10 |
INTERVIEW |
|
|
|
|
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From the Residency Office
SAR Talk Survey (submittedy by Kim Bryan)
Please take a moment to complete a simple, quick, anonymous survey regarding physician and nurse communication.
Your help is greatly appreciated !
https://www.surveymonkey.com/s/TMZHSB2
Kimberly Bryan, MD
Duke University
Internal Medicine, PGY 3
Ambulatory Care Leadership Track Event
When: Wednesday, January 8th
Where: Alivia's, 900 West Main street Durham, NC 919-682-8978
The Ambulatory care leadership team would like to hold a Get to know the Ambulatory Care Leadership Track (ACLT) on Wednesday January 8, 2014 7pm at Alivia's. This event is for any resident who is interested in the ACLT and who would like to speak to the current ACLT residents about the program. We hope the Med psyche residents will join the ACLT residents and discuss their experiences.
So far ACLT resident RSVP's include: Alexandra Clark, Lauren Porras, Claire Kappa and Jennifer Chung
Please RSVP to Dr. Sharon Rubin
sharon.rubin@dm.duke.edu by Wednesday January 8, 2014.
Rising JAR - SAR Preferences
FINAL REMINDER: rising JAR / SAR schedule preferences for FY 15 are to be submitted no later than Wednesday, January 8, 2014. Access to the survey monkey link locks down on January 9th.
Information/Opportunities
Resp Fit Test - T-DAP-TB Skin Test schedule for January, 2014
January 14 Resp Fit Testing-T-Dap-TB Skin Testing Flyer
Upcoming Dates and Events
- January 8th: ACLT Meet and Greet
- January 15th: "Voices in Medicine"
- April 18th: Charity Auction
Useful links
