Internal Medicine Residency News - July 21, 2014

By residency1

From the Director

DUKE.RESEARCH.NIGHT.03 (1) Hi Everyone! Thank you for doing your new RL Solutions SRS training modules! The new reporting mechanism for patient safety events is more user friendly than before, and a great resource to use if you notice a "near miss" or other event as you are caring for patients. We had another great QI conference this week as well – Thanks to Lish Clark and Aaron Mitchell for running our first M and M of the year.  We continued to have outstanding SAR talks…Allyson Pishko, Adam Banks and Hal Boutte, as well as a rock star chair's conference by Gena Foster.  As heard by Dr. Corey "That was great!"  Titus N'geno got the diagnosis…nice work.  Other kudos go to Anubha Agarwal from Dr. Adrian Hernandez for making a great diagnosis on the Heart Txp service.  It's been great to hear all the compliments about what amazing work everyone is doing. We are looking forward to the Summer Celebration at Dr. Klotman's on Friday, and also the first JAR dinner on Tuesday.  This Friday, Dr. Aubrey Jolly-Graham from Hospital Medicine is doing Grand Rounds on Handoffs.  Please be sure to come out and support what is certain to be a fantastic talk. I'm looking forward to starting meetings with the interns — there is nothing to prepare, it's just a great chance to catch up on how the year is going, and show you how to keep your portfolio, use Medhub, interpret evaluations, etc. Are you interested in helping screen people for HIV? Join the VA in a great screening effort.  The ID section is planning to offer walk-in HIV testing on August 29, 2014 (Friday) as part of  HIV prevention effort. Details of the HIV testing event: Date: August 29, 2014 Location: 8B clinic (clinic rooms requested, awaiting approval) Walk-in HIV testing: Appointment or registration not required Providers' role:  Provide counseling, obtain verbal consent and order HIV test in CPRS.  You can also check out the new rational clinical exam article on acute HIV in this weeks JAMA! This weeks pubmed from the program goes to Aparna Swaminathan Lower Extremity Amputation in Peripheral Artery Disease: Improving Patient Outcomes, Swaminathan A, Vemulapalli S, Patel MR, Jones WS Published Date July 2014 Volume 2014:10 Pages 417 - 424 Have a great week! Aimee   [divider] [box]

What Did I Read This Week?hargett

submitted by: Charles Hargett, MD

Gottlieb DJ et al. CPAP versus oxygen in obstructive sleep apnea. N Engl J Med 2014 Jun 12; 370:2276. (http://dx.doi.org/10.1056/NEJMoa1306766)

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Background/Clinical Question: Obstructive sleep apnea (OSA) is a risk factor for hypertension, coronary heart disease, stroke, and death, and moderate-to-severe OSA is present in an estimated 4% and 9% of middle-aged women and men, respectively. Only about half of patients with OSA use the most effective therapy, continuous positive airway pressure (CPAP). For many patients declining CPAP, supplemental oxygen is employed in hopes of ameliorating nocturnal hypoxemia. However, although oxygen therapy improves arterial oxygen saturation during sleep, it increases the severity of apnea-hypopnea events. In the Heart Biomarker Evaluation in Apnea Treatment (HeartBEAT) study, the authors sought to determine the effectiveness of both CPAP and supplemental oxygen as compared with usual care for reducing markers of cardiovascular risk in patients with OSA recruited from cardiology practices. Reference: Gottlieb DJ et al. CPAP versus oxygen in obstructive sleep apnea. N Engl J Med 2014 Jun 12; 370:2276. (http://dx.doi.org/10.1056/NEJMoa1306766) Methods Design – Randomized (stratified permuted block design), parallel-group clinical trial Setting – Outpatient cardiology practices associated with 4 academic medical centers Patient Population – Patients aged 45 to 75 years with established coronary heart disease or multiple cardiovascular risk factors were screened for OSA. 5747 patients assessed for eligibility, 1034 eligible for home sleep testing (846 enrolled), 318 with moderate to severe OSA and known cardiovascular disease or multiple cardiovascular risk factors underwent randomization Intervention / Control – Participants were assigned to one of three interventions: healthy lifestyle and sleep education (HLSE) alone (control), CPAP with HLSE, or supplemental oxygen (2L via NC) with HLSE Blinding – Unblinded Analysis – ANCOVA model with adjustment for the baseline value and stratification variables (study site and the presence or absence of coronary artery disease). Due to outliers, a regression model was used to analyze values for C-reactive protein and N-terminal pro-BNP. A logistic-regression model was used to model the log-odds rate of non-dipping blood pressure at 12 weeks Outcomes –The primary outcome measure was 24-hour mean arterial blood pressure. Patients were also assessed for systemic inflammation, reactive hyperemia, fasting glycemia, and dyslipidemia, and adherence to therapy was compared across the active treatment groups Follow-up – Outcomes were measured at baseline and 12 weeks after randomization. 301 participants completedthe study, 281 (93%) underwent 24-hourblood-pressure monitoring at both baseline and 12 weeks  Validity Patients were randomized. Treatment groups generally similar at baseline. Patients accounted for at conclusion and analyzed in groups to which they were randomized. Again, patients and clinicians were not blinded. Groups were likely treated similarly outside of the intervention.  Results Both CPAP and nocturnal oxygen improved nighttime hypoxemia (had similar reductions in frequency of desaturation events and proportion of sleep time with oxygen saturation <90%). However, at 12 weeks, 24-hour MAP was significantly lower (by about 2.5 mm Hg) in the CPAP group than in the supplemental-oxygen or control groups.  Comments Even in a clinical setting in which cardiovascular risk factors (including blood pressure, average MAP 89 mm Hg at baseline), were well managed the present study shows that among patients with previously undiagnosed moderate-to-severe obstructive sleep apnea, treatment with CPAP resulted in reduced 24-hour mean arterial pressure. Though the reduction may seem modest, it’s certainly of a magnitude which has been associated with a meaningful reduction in cardiovascular risk. Of note, this was a unique population (not from sleep clinics but cardiology clinics) with a high risk for adverse consequences of OSA but who were not seeking treatment and he benefits were seen even in patients without daytime sleepiness. Additionally, there was no “threshold” for CPAP use, with a benefit from only 3.5 hours of use, and with a suggestion that each additional hour of use reduced BP by an additional 1 mm Hg systolic. There was also a suggestion of attenuation of relative nocturnal hypertension (aka “non-dipping” blood pressure), which has been shown to be more closely associated with target organ damage and worsened cardiovascular outcomes. From a physiologic POV, the reversal of intermittent hypoxemia doesn't fully explain the blood pressure–lowering effect of CPAP in patients with OSA. Future studies should be longer (e.g. 12 months) to assess sustainable changes and impact on clinical outcomes like MI. Also, these patients had relatively few symptoms and it would be interesting to see the effects on patients with worse sleep apnea and more poorly controlled variables (e.g. high BP) and who might perhaps have worsening surges in BP at night. Bottom Line: Continuous positive airway pressure, but not oxygen, lowered mean arterial blood pressure. [divider]

Clinic Corner

Welcome new interns.  Looking forward to a great year.  Please meet with your team and review your schedules and let your attending and team know who will be covering your CPRS alerts and any issues you see coming up with your schedule.  Remember communication is key. Also please remember to reach out to your new intern(s) on your team, please give any pointers, quick tips, time saving ideas that will help make their lives easier.  If anyone has any questions please remember we are here for you in PRIME. Just a couple of things to remind everyone:
  1.  Patients are scheduled at 15 and 45 on the hour for nurse check-in, residents are expected to see their patients on the hour and half hour, so for your am clinic, your first patient is scheduled for 8:45 for the nurse so that you can see the patient at 9am
  2. Remember, we now have walk-in PRIME psychiatry appointments at 11am and 3p every day EXCEPT Thursdays, please offer any patients that are having active psychiatric issues a same day appointment if you feel it would be beneficial
  3. The nurses wanted to remind everyone that they prioritize checking in patients before exit interviews, so remember to place the routing slips in the check –out bins and let patients know to sit in waiting room for exit interview, that way nurses can keep your clinic flowing
  4. Mini-CEX’s- please try to get them completed when clinic is not busy, this is a great way to receive feedback
  5. Don’t forget to huddle with your nurse when you arrive in clinic, they love chatting with you/getting to know you and also this is a great way for the nurses to get a heads up on any issues you foresee during your clinic
  6. Monday mornings we have a resident/staff meeting, this is the time for all of us to put our heads together to make PRIME great, if you are assigned to Monday morning continuity clinic please arrive by 8:45 for the meeting (your first appointment of the day should be blocked off)
Thank you for all that you do in taking care of our veterans and making PRIME all it can be. Sonal Patel, MD PRIME  Clinic Director Durham VA Medical Center  

QI Corner

We had a great kick-off meeting for the Patient Safety and Quality Council last week! Highlights of what we talked about that everyone should be aware of: First, the GME incentive program: our performance on 4 different measures is going to be tracked over the academic year, at the end of which we will get a $200 bonus in our paycheck for each measure where we hit our target! That’s up to $800 on the table! The four measures for the year are: Patient satisfaction score 30-day hospital readmission rate Time responding to admission consults from the ED Increased usage of SRS (Safety Reporting System) I’ll be updating from time to time to let you know how our progress towards the $800 is going. We also discussed the potential interest in getting personalized performance data for certain quality metrics. We already have the annual sharepoint ambulatory self-assessment tools, but would medicine housestaff like to see personalized feedback on an even higher level? Would you want to see readmission rates for the patients you took care of? Patient satisfaction scores? Use of DVT prophylaxis? If Maestro could be used to generate this feedback, would you find it useful? If you have more ideas, or want to get involved in making a program like this work, let us know! Another topic (as well as a treasure-trove of resident-led QI projects!) was the many areas of potential low hanging fruit to improve the quality of care at Duke by reducing the use of low-value tests and treatments. You will be learning more about this when the High-Value Cost-Conscious Care curriculum kicks of in September. But in the mean time, if you think Duke should be doing a better job by streamlining its biomarker testing for ACS, reducing inappropriate blood culturing, reducing routine daily lab ordering, or more judiciously treating asymptomatic hypertension (just a FEW of the ideas we’ve had thus far!), then let me know of your interest. Finally, grand rounds this week will be on a patient safety topic – Dr. Jolly-Graham will be presenting on handoff safety. See you there! -Aaron [divider]

From the Chief Residents

Grand Rounds

Friday, July 25th - General Medicine/Hospitalist, Dr. Aubrey Jolly-Graham "Consult Communication"

Noon Conference

Date Topic Lecturer Time Vendor
7/21/14 SAR Emergency Series: Hyperkalemia and Hypercalcemia Jay Mast 12:15 Subway
7/22/14 SAR Emergency Series: Acute Liver Failure Amit Bhaskar 12:15 Pita Pit
7/23/14 SAR Emergency Series: ICU Admission Indications Amera Rahmatullah 12:15 Cosmic Burritos
7/24/14 SAR Emergency Series: DNR Discussions Sajal Tanna 12:15 Sushi
7/25/14 Chair's Conference  Chiefs 12:00 Dominos
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From the Residency Office

Duke List

Duke List is a valuable online resource that is just like Craigslist but exclusively for Duke faculty, staff and students. You can buy tickets to local events, furniture, even cars and houses from fellow Duke employees. Another helpful resource is the Lost and Found section of Duke List. You can look for an item you may have misplaced or post one that you found. Please take a look at a very helpful website that the wonderful Duke community offers! http://dukelist.duke.edu/

Survival Guides and End of Year Gifts - Please Pick Up by 7/25/14!

The 2014 Survival Guides are in and they are awesome.  If you are a continuing Internal Medicine resident, please come by the MedRes office and pick up your copy during normal business hours.  We can only provide one copy per resident.  If you are interested in purchasing a copy, please contact Jen Averitt.  An electronic version of the guide is currently in development and we should have more information on when that will be available soon! For all continuing Internal Medicine residents, please also pick up your copy of “The Evidence – Classic and Influential Studies Every Medicine Resident Should Know” with the compliments of the program for a great year!

Ambulatory Evaluations - Resident Identify Supervisor

As of July 1, 2014, we have activated the Resident Identify Supervisor (RIS) tool in MedHub for use during all ambulatory rotations.  What this means is that 7 days before the end of your ambulatory block, you will receive a request, via email/MedHub to identify a minimum of one (1) supervisor for evaluation during that block.  This is intended only for your continuity clinic experiences during the block!  If you are unable to identify at least one attending from your continuity clinic time during the block, or have recently submitted an evaluation request for the same attending, please email Jen Averitt and she will remove the requirement for you for that particular block.  Our hope is to increase the consistency with which your clinic experiences are evaluated, as well as your clinic attendings are evaluated.  If you have questions about how this system will work, please feel free to contact the MedRes office.

Stead Resident Research Grants- Request for Proposals

For All Internal Medicine, Med-Peds, and Med-Psych Residents We are pleased to announce the Request for Proposals for the inaugural “Stead Resident Research Grant” applications. We are grateful to the leadership of the Stead Scholarship Society for their generosity to support resident research and our Stead Leaders for their mentorship and for promoting your scholarly activities ! The applications due on September 1, 2014 for a funding start date on October 1, 2014. Please find attached the Stead Resident Research Grant Instructions-2014, Stead Resident Research Grant Application Forms-2014, Human Subjects example,  and NIHSAMPLE Biosketch Form.   Please include your mentor’s NIH Biosketch and support letter with your application. Please see  link below for Biostatistical Support resources available to you for your projects and discuss with your mentor. http://residency.medicine.duke.edu/duke-program/resident-research/biostatistics-and-data-management-support Each proposal must have a Human subjects section that describes the protections of the patients and patient data, describe the consent procedure if applicable, status of IRB protocol (to be submitted, already submitted or already approved, as appropriate) etc. This section is required whether to not your project is a retrospective or prospective study, whether patient identifiers are exposed (or not) during data collection/analysis, whether consent is to be obtained or there is a waiver for consent. Please see attached example language that you can adapt to your own protocol after discussing with your research mentor who has already thought about the Human subjects issues. Wishing you continued success with your research projects ! Murat Arcasoy and Aimee Zaas  

Interview Skills

Whether you are going to interview for hospitalist position, primary care or attending position after fellowship, there are some skills to learn for the interview and essential questions to ask. Come to this session for dinner, sponsored by the North Carolina American College of Physicians, and get the answers you need before your job interview. Welcome to all medical students, residents, interns and fellows. Panelists: Dr. Jon Bae, Dr. Saumil Chudgar, Dr. David Simel, Dr. Pooh Setji, Dr. Poonam Sharma, Dr. Bruce Peyser, Dr. Sharon Rubin Location: Duke Internal Medicine Library, Durham, NC Date: Wednesday August 6, 2014 Time: 7:00 PM to 8:30 PM Please RSVP to Dr. Sharon Rubin by August 4, 2014 Sincerely, Sharon Rubin, MD, FACP Assistant Professor, Duke University Medical Center Residency Director at Pickett Road  

Information/Opportunities

Announcement Geriatrician Opportunity Elkin Hospitalist Elkin Internal Medicine Montana Hospitalist Summit Placement Service

Upcoming Dates and Events

July 25th- Summer Celebration at Dr. Klotman’s House August 6th- Interview Skills Session August 17th- Kerby Society Hosting Durham Bulls Game Gathering

Useful links

 

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