From the Director
We are halfway through July! Great work by all on the inpatient teams and in the clinics. Special thanks to Jenny Van Kirk for presenting our first chair's conference of the year, with great discussion lead by Dr. Corey, great participation by all and the diagnosis made by Adva Eisenberg.
This week is the week that fellowship applications get uploaded, so please let me know if you have any last questions before you hit the "send" button. I am enjoying having meetings with all of the interns. For JARs and SARs, don't forget to check in with your advisor about meeting sometime in August or September. Next week also starts my annual meetings with the division chiefs, and I will be bringing highlights of last year's rotation evaluations to your attention just before noon conference starts.
Speaking of noon conference... GREAT attendance! We will be looking at bringing in more chairs to avoid that "standing room only" back line. Thank you to Julia Cupp, Jason Zhu, Kristen Glisinski, and Jesse Tucker for outstanding talks. Look for their slides on medhub coming up soon. Other kudos this week to the Duke Night Float team of Zach Wegermann, Taylor Bazemore, Kara Johnson, and Ryan Orgel for their leadership overnight - Zach was spotted rounding at the bedside with his day team as the interns presented their overnight admissions. I know lots of good work is happening all over, so please send me a quick email about your colleagues who you want to recognize. Another thanks to Cory Miller and Rob Harrison (and Jenn and Armando for covering the ICUs) for providing hands-on code training to our JARs in the MICU and CCU last week. We will be scheduling this training for all JARs as they enter their first ICU rotation of the year, so be on the lookout for an email as you approach your ICU rotation. Cara O'Brien and Nilesh Patel led their first ultrasound sim session for the interns last week, which I hear was a great success as well.
Looking forward to dinner with JARs this week, as well as the upcoming Kerby Society Durham Bulls Game and Warren Society Trivia Night!
This week’s pubmed from the program goes to Dinushika Mohottige for her article in JAMA, "Tools to Promote Shared Decision Making in Serious Illness: A Systematic Review" Austin CA, Mohottige D, Sudore RL, Smith AK, Hanson LC. JAMA Intern Med. 2015 Jul 1;175(7):1213-21. doi: 10.1001/jamainternmed.2015.1679. PMID: 25985438
Have a great week!
Aimee
What did I read this week?
Submitted by Lynn Bowlby, MD
Advanced Dementia
N Engl J Med 2015, 372:2533-2540 June 25, 2015
Dementia, both early and advanced , is very common in outpatient and inpatient medicine.
This recent review caught my eye, particularly as I am about to round again, where I am acutely aware of the many challenging issues with dementia.
This review begins with a common case scenario, 89 yr old NH resident with fever and severe dementia.
Dementia, commonly classified as Alzheimer's and/or vascular dementia, affects millions, estimated 5 million last year, with it being the 6th leading cause of death in the US.
Median survival after diagnosis is 6 - 12 years. It is a progessive and incurable illness, but quite variable in individuals. In advanced dementia, the final year of life is marked by severe disability, stage 7 on the Global Deterioration Scale.
The CASCADE study followed 323 Nursing home residents for 18 mos, and showed that eating problems and infection were the major clinical issues. the Median survival was 1.3 years.
Estimating life expectancy is difficult, which then makes it challenging to know the appropriate time frame for Hospice referral. Pts need to have an estimated survival of < 6 months and be stage 7c on the Functional Assessment Staging tool and have one of 6 complications in the past year for Medicare Hospice referral.
Advanced care planning is a cornerstone of treatment. Decision support and education , particularly around issues such as the option for a do-not-hospitalize order are key. I am always suprised when I round how few families are aware of this option. Alignment with the patients prior goals is very important. In prospective studies > 90% of proxies said that comfort was the main goal.
Eating problems are the most common complication in advanced dementia. Oral and pharngeal dysphagia are very common. Reversible issues such as dentures and continued hand feeding help with these issues. There is some evidence that high calorie supplementation can help with weight gain. A 2009 Cochrane review showed that there is no evidence to support the benefits of tube feeding. Procedural complications and continued aspiration of oral secretions make tube feedings not indicated in this population.
A randomized NC study with 256 NH residents showed that a decision - making aid for families can help reduce the challenges they face in the decsions they are making for their family member. Eating is such a basic need and it is very challenging for families to watch the struggle that can occur with this issue.
Infections are very common in advanced dementia. The SPREAD trial showed that urine or respiratory track are the most common sites, and about half of the pts receive a diagnosis of pneumonia in the last 2 weeks of life.
Asymptomatic bacteriuria should not be treated, but it can be very challenging to determine what asymptomatic is in this population.
There is little evidence on the rate of survival or symptom relief with use of antibiotics, and rates of death did not differ with IV, IM or po administration.
15 % of pts who die with dementia, die in the hospital.
75% of hospitalizations may be medically unnecessary, often again due to families not even knowing that do-not hospitalize is an option.
Palliative care is an underutilized option, and often in the last weeks of life, dyspnea, agitation or aspiration are issues.
Inappropriate medications are often prescribed, the major ones being cholinesterase inhibitors, memantine and statins. Clinical trials of cholineserase inh and memantine do not include severe dementia, thos at stage 7 on the Global Deterioration Scale.
There remain many challenges in the area of severe dementia. Patient care as well as better education of families as what to expect are important.
Clinic Corner
Submitted by: Sharon Rubin, MD
We have lots of new faces here at Pickett!
First is our new new LPN Iesha Drayton, LPN and George Booth our PSA.
Then new Attendings Dr. Dave Halpern and Dr Meredith and soon to be attending Dr. Claire Kappa!
We welcome the new interns and proud of the advancement of the JARS and SARs.
We are still proceeding with Transforming Primary Care. Rooming nurses are helping to put in health maintenance orders and associating diagnosis to help assist the doctors.
Fun things planned for the clinic is a Step Challenge starting July 20, 2015. Get your podometers and FitBits ready. We are going to see who walks the most in clinic. This is getting us ready for the Triangle Walk Sunday September 27, 2015. Pickett Road will have a team to walk for heart disease and all residents are welcome to join!
Thanks!
Sharon
QI CORNER
Dr. Lindsay Boole, VA QI Chief Resident
Please join us for the first meeting of the Patient Safety and Quality Council (PSQC)!
This Thursday, July 16th at 7:00pm
Six Plates Wine Bar
(Just down Erwin Rd from the hospital)
This is a resident committee with resident-driven goals and projects. It's YOUR chance to get involved! We will meet monthly, usually luring you with food. As a group, we'll select projects at the beginning of the year, and then work together to follow them through.
At this first meeting, we'll eat, drink, and brainstorm project ideas. We'll also ask your input on the best time for a standing monthly meeting. So if you want to be involved but you can't make it to the Six Plates kick-off, email lindsay.boole@duke.edu or alicia.clark@duke.edu with your scheduling preferences.
From the Chief Residents
Grand Rounds
Friday, July 17th- Dr. Andrew Muir, Hep C Update (Gastroenterology)
Noon Conference
| Date | Topic | Lecturer | Time | Vendor |
| 7/13/15 | SAR Emergency Series: Acute/Decompensated Heart Failure |
Amanda Verma |
12:00/MedRes | Mediterra |
| 7/14/15 | SAR Emergency Series: GIB |
Bassem Matta |
12:00/MedRes | Domino's |
| 7/15/15 | SAR Emergency Series: End of Life/Comfort Care |
Andy Mumm |
12:00/MedRes | China King |
| 7/16/15 | SAR Emergency Series: Inpatient Approach to the Anemic Patient |
Emily Ray |
12:00/MedRes | Chick-Fil-A |
| 7/17/15 | Chair's Conference | Chiefs | 12:00/MedRes | Picnic Basket |
From the Residency Office
Get Involved 2015!
As we start another academic year, we remind you of all of the opportunities the program and Duke Medicine offer for you to get involved and give back to to our community. Please see the brochure linked at the end of this post for more information!
Duke Partners Club
We are a group of significant others (spouses/fiancés/partners, etc) of residents and fellows in the many different specialties at Duke. Our group offers several monthly activities such as book club, dinners, movies, playgroup, and most simply, a community for those sharing similar experiences during this exciting time in our partners' careers.
This year, GME invited us to participate in orientation with a info-table allowing us to share details about our group. Knowing that information received at orientation doesn't always make it home, please see the information available for download at the end of this post!
Certification in Language Translation Services
If you speak a language other than English fluently and would like to be certified as a medical translator in order to inform/consent patients, please contact The Duke International Patient Center (919) 681-3007
First Annual Summerfest
The Duke Medical Alumni Association is delighted to host this year’s First Annual Summerfest, an event for all Duke residents and their families. We want to welcome Duke’s newest house staff and celebrate with all residents that they are part of the Duke medical alumni family.
SARs
Please know there is an excellent opportunity to hone your interviewing skills. Dr. Kathryn Pollak who is a communication coach and faculty member in the SoM will provide 4 1-hour sessions from which you can choose. In the session, Dr. Pollak will cover tips to finesse interviewing skills as well and give some a chance to role play. She also will be available for practice for their interviews in September and October.
The four sessions will be held the following dates and times:
Monday, August 17th: 12:00 noon to 1:00pm
Tuesday, August 18th: 4:00 to 5:00pm
Wednesday, August 26th: 12:00 to 12:00pm
Thursday, August 27th: 4:00 to 5:00pm
Each session will be 10 people or less, that way it’s more personalized. Please let me know as soon as possible which session you would like to sign up for. This is a very valuable tool being offered!
Upcoming Dates and Events
August 21 - Housestaff Welcome Event
September 12 - Stead Tread
Useful links
https://intranet.dm.duke.edu/influenza/SitePages/Home.aspx
http://duke.exitcareoncall.com/.
Main Internal Medicine Residency website
Main Curriculum website
Ambulatory curriculum wiki
Department of Medicine
Confidential Comment Line Note: ALL submissions are strictly confidential unless you chose to complete the optional section requesting a response
Opportunities
http://www.ad001.info/blasts/CKS/CKS15_05431/CKS15_05431.html
CAH Primary Care Bulletin 2014.pdf
Decatur Primary Care CHIC Bulletin.pdf
PC Beardstown Bulletin.pdf