From the Director
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What Did I Read This Week?
submitted by: David Butterly, MD
JACC 63, 6 2014
[/box] Recently John Roberts reviewed this paper in our weekly Nephrology Journal Club. I think it brings up a very important clinical topic in our ESRD patients. I had not seen the paper when it was first published earlier this year and it gave me a chance to read and review it. Despite the many advances in Nephrology over the last years, the mortality in patients with ESRD remains substantial, approaching 15-20% annually. Death from cardiovascular disease is the leading culprit, accounting for roughly 50% of patient deaths each year, and CV mortality is 15-30 times higher than the age adjusted mortality in the general population. Traditional risk factors are certainly part of the problem with diabetes, hypertension, and hyperlipidemia all prevalent in the ESRD patient population. It has been hard, however, to demonstrate treatment of these traditional risk factors leads to improvement. Results of the 4D (2005), AURORA (2009), and SHARP (2011) trials failed to show a benefit in ESRD patients treated with statins and the FOSIDAL trial (2006) failed to show a reduction in CV morbidity or mortality in hemodialysis patients treated with an ACE-I. This paper tests the hypothesis that daily treatment with low dose spironolactone would reduce CCV mortality in patients with ESRD. This was a prospective, multicenter, randomized, controlled, open-labeled trial. Eligible patients were dialyzed at one of five centers in Japan, and received 4 hours, 3 times weekly treatments for at least 2 years. Patients had to have a serum potassium less than 6.5 and Urine output less than 500 ccs to qualify. Pre-enrollment ACE-I and ARBs and dialysis prescriptions were not altered. Baseline characteristics of study patients are shown in Table 1, page 531. A total of 309 patients were randomized: 157 to Spironolactone and 152 in Control group. Both groups contained patients who had already been on dialysis for a substantial time (99 vs 127 months). A little more than 30% of the patients in each group had diabetes as the cause of their kidney failure, which is a bit lower than seen in the US. ACE-I’s were used in 9-10% and ARB’s in 40% of each group. The primary outcome of the study was a composite of death or hospitalization from CCV events. These included CHF, arrhythmias, MI, angina, stroke, TIA, and sudden cardiac death. Secondary outcome was death from any cause. During the study, a total of 9 patients (5.7%) in the treatment group and 19 patients (12.5%) in the control group reached the primary outcome. Kaplan Meier curves (Figure 2A) show a lower event rate in Spironolactone treated patients. The unadjusted HR was 0.404 (CI of 0.2-0.8). There were 10 deaths in patients treated with Spironolactone compared to 30 in the control group (6.4 vs 19.7%) as shown in figure 2B. The unadjusted HR for death was 0.355 in the treatment group. Spironolactone appeared safe and did not significantly effect blood pressure or potassium. Only 3 patients over the course of the study discontinued due to hyperkalemia. Gynecomastia or breast pain was reported in 10%. The main limitations of the study are that it was not blinded and represents a small sample size. The patients included had already survived on dialysis for a long time (99 and 127 months) and the causes of renal failure in this population differ some from what we see. However, CV morbidity and mortality is a huge problem in our patients and I believe these data are compelling and you will be hearing more about Spironolactone use in ESRD in the future. [divider]
Clinic Corner
Last week’s Weekly Updates alerted residents to the activation of the Resident Identify Supervisor (RIS) tool in MedHub for use immediately following a scheduled Ambulatory Block, to enable residents to identify at least one (1) attending with whom they’ve worked with frequently in continuity clinic, for evaluation during that block. Attendings in the clinic will notice that this form is the same as the Summative Evaluation done three times a year. (Here is a link to the form .) This is intentional – through this identification process, residents who have an Ambulatory Block prior to when the Summative Evaluation would normally be due, get that Evaluation done by someone they have had frequent contact with over that concentrated period of time. It is also the same form as the Ambulatory Mini CEX – which makes it possible to use Mini CEX results, to which clinic site directors and advisors have access, to inform the Evaluations.
Speaking of Mini CEXs, what’s in it for y’all to complete at least three (3) Ambulatory Mini CEXs a year? Besides receiving pointers on how to get even better/faster in clinic, residents who complete at least this number and are rated to be at/above expectations for their stage of training, can be advanced in their level of autonomy in the clinic. (Here is a link to a one-pager describing the three “precepting levels.”) For interns, for example, this means being able to see patients without an attending following you into the room (after Medicare’s required six-month “waiting period” elapses). Incidentally, Duke was part of the first multi-center study piloting the milestone-based "promotion" of interns to seeing patients independently in clinic, which was published in Academic Medicine (Acad Med 2013(Aug);88(8):1142-8. doi: 10.1097/ACM.0b013e31829a3967).
So happy Mini CEXing!
Alex Cho, MD
QI Corner
We had a great QI-related grand rounds last week with Dr. Jolly Graham presenting on handoff safety. Let me know if this is a topic that interests you – Joel Boggan and I are currently writing up an observational study of handoffs that we did last year, and a new initiative to improve handoff quality may be in the works this year. I have continued to have residents come to me with more ideas on how to increase quality and reduce wasteful care within our program, especially as it relates to lab ordering. Keep them coming! And we can meet and get a plan in place soon – let’s keep the momentum going and make some change on this issue! Several people have been having technical problems with the Sharepoint website. Let me know if you do…we have been forwarding issues to one of our IT people which seems to be fixing things. And lastly, a correction of the information I sent out last week regarding the GME incentives program – while we will have 4 separate targets, each of which will be worth $200, the maximum total bonus is $600 rather than $800 at the end of the year. -Aaron [divider]From the Chief Residents
Grand Rounds
Friday, August 1 - Greenfield Visiting Lecturer, Dr. Marin Kollef, Washington University "Infections in Critically Ill"Noon Conference
Date | Topic | Lecturer | Time | Vendor |
7/28/14 | PE Week - Introduction/Cardiovascular Exam | Dr. Arcasoy / Dr. C. Patel | 12:15 | Picnic Basket |
7/29/14 | PE Week - Case Reviews | Dr. Hargett / Dr. Arcasoy | 12:15 | Saladelia |
7/30/14 | PE Week - Neurologic Exam | Dr. Morganlander | 12:15 | China King |
7/31/14 | PE Week - MSK Exam | Dr. Irene Whitt | 12:15 | Chick-Fil-A |
8/1/14 | PE Week - Inpatient Daily Exam / New Clinic Pt Exam | Dr. Zaas / Dr. Arcasoy | 12:00 | Rudinos |
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/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 ZaasNew Jackets/Fleeces for 2014!
Please come by the MedRes office during normal business hours to try on the new jackets! We are working on the new pricing structure, but Lynsey will be emailing additional details, with ordering instructions, directly to house staff and faculty this week! Many thanks to Sneha Vakamudi for taking the lead on these new jackets, which will replace the the fleece jackets we have ordered previously.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 RoadInformation/Opportunities
Hospitalists Practice Opportunity in PA 7-2014 Announcement Geriatrician Opportunity Elkin Hospitalist Elkin Internal Medicine Montana Hospitalist Summit Placement Service Washington State Opportunities Madison WI opportunities Community Health NetworkUpcoming Dates and Events
August 6th- Interview Skills Session August 17th- Kerby Society Hosting Durham Bulls Game GatheringUseful links
- July 14 Resp Fit Testing-T-Dap-TB Skin Testing Flyer2
- 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