Internal Medicine Residency News: June 30, 2014

By admin3

From the Director

DUKE.RESEARCH.NIGHT.03 (1) It's here! Shadow day for the new interns is Monday, and first day on the rotation is Tuesday! A final congratulations and thank you to our graduating SARs and to the entire GME group for an amazing year.  We are really excited to get started, and Nilesh, Coral, Bonike and Aaron kicked off the year with their first week as chiefs! Not enough thanks can go to Jen Averitt, and the rest of our phenomenal team (Randy, Lynsey, Erin and Lauren) for a smoothly run and very informative orientation week.  Amazing work!! We had a lot of fun at the new intern party at the Pit, and a great "rising JARBQ" at our house on Saturday night. Kudos this week go to many of you….to Matt Atkins for receiving a gold star, to Gena Foster and Alan Erdmann from Myles Nickolich for covering while he presented at a national meeting, to Nick Rohrhoff for an incredible Tom Holland lecture, to Joe Brogan from Vaishali for outstanding patient care, kudos love back and forth between Vaishali and Amera Ramatullah (Amera for stepping up for extra coverage and to Vaishali from Amera for generally being awesome all year), also from Vaishali to Chris Merrick, Jesse Tucker and Brian Kincaid for coverage at the VA, and to Carli Lehr from Ryan Schulteis for team leadership at the VA.  More kudos to Matt Atkins and Myles Nickolich for leading the effort on revising the Intern Survival Guide (and to all who wrote/revised the chapters), and to Sarah Goldstein, Joanne Wyrembak, Ryan Jessee, Jonathan Hansen, Paul St. Romain, Jon Buggey and Alan Erdmann for running a fabulous intern practicum. We kick off our new SAR talks this week with the SARs leading the intern emergency lecture series.  Please make every effort to attend and support your colleagues and to GET YOUR INTERNS TO NOON CONFERENCE! Our new equipment is almost ready for use! Fellowship application due dates are rapidly approaching! I promise to have all of your letters ready before July 15th! Please let me know if you have any questions about the process.  ERAS registration seems to be going smoothly for everyone, and applications can be opened by fellowships on July 15th. A special thank you to Randy Heffelfinger for his work on "Med Res News" (aka Weekly Updates). What started as a group email has grown into a great way to get information out to everyone in the program.  Starting in July, look for the news at a NEW TIME of Monday morning.   Keep sending us your kudos, your publications and your announcements! This week's pubmed from the program goes to Kevin Trulock for his upcoming publication with Jonathan Piccini in JACC.  Rhythm Control in Heart Failure patients with Atrial Fibrillation: Contemporary Challenges including the role of Ablation.  Trulock, KM, MD, Narayan, SM, MD, PhD, Piccini, JP, MD, MHS. Have a great FIRST WEEK OF JULY!!! Aimee [divider] [box]

What Did I Read This Week?

submitted by: Vaishali Patel, MD

Wunderink RG, Waterer GW.  Clinical Practice: Community-Acquired Pneumonia.  N Engl J Med 2014; 370:543-551.

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Why did I read it?  Even thought I’m going back to being a GI fellow next week, whether I’m seeing patients on Gen Med, in clinic, or moonlighting in the good ol’ VA ED (!!), community-acquired pneumonia (CAP) is EVERYWHERE!!  This article is a few months old, but nicely delineates why we do what we do for CAP (and a great review for the start of internship!).  Because of the economic cost and mortality associated with CAP, the Joint Commission and Center for Medicaid and Medicare services (CMS) have pushed for CAP-related QI measures, institutional reporting of outcomes, and pay-for-performance initiatives.  It is important, therefore, to review the data-driven VAISHALI_PATEL__1interventions that reduce both mortality and cost.  This article is consistent with the most recent IDSA-ATS 2007 guidelines for CAP, with the exception of criteria/risk factors and antibiotic recommendations for HCAP and MDR pneumonia, which are driven by newer data.  Refer to the article for very helpful tables and figures.
  • CAP needs coverage of Streptococcus pneumoniae and atypicals (mycoplasma, chlamydophila, and legionella).  Atypical coverage is especially important for outpatients and young adults (macrolides, fluoroquinolones and doxycycline).
  • For inpatients, patients with comorbidities, or antibiotic use in the previous 90 days (use a different antibiotic class), use a respiratory fluoroquinolone (moxifloxacin or levofloxacin) or a combination of a second or third-generation cephalosporin and a macrolide (reduced mortality and decreased length-of-stay with these regiments).  S. pneumoniae is the most common cause of severe CAP requiring ICU admission (treat with combination cephalosporin with either fluoroquinolone or macrolide).
  • Retrospective data from Medicare databases suggests decreased mortality if the first dose of antibiotics is given within 4 hours of presentation to the ED; however, efforts to meet this quality metric has resulted in inappropriate antibiotic use and adverse events such as C diff infections.  The main point is that antibiotics should be given as soon as possible following the diagnosis of CAP; for patients in shock, antibiotics should ideally be given within an hour of onset of hypotension.
  • The recommended duration of antibiotic therapy is 5 to 7 days (no evidence that longer courses have better outcomes, even in severely ill patients, unless immunocompromised).
  • Patients at risk for health-care associated pneumonia (HCAP), MRSA and multi-drug resistant (MDR) gram-negative pathogens need broad-spectrum coverage (see Table 2 of article). However, there is now increasing recognition that using all of the original criteria as indications for broad-spectrum coverage has led to overtreatment (use of broad-spectrum treatment in up to half of the patients with CAP in some centers).  Studies of HCAP patients show low rates of MDR pathogens, and high rates of negative cultures.  While there may be some selection bias as an explanation for this, several multi-center studies have showed increased adverse events and even increased mortality in patients given broad-spectrum therapy compared to those who received standard CAP therapy.
  • Another group of patients not included in the original criteria that is at risk for drug-resistant pathogens are those with structural lung disease (bronchiectasis) or severe COPD who have received multiple outpatient courses of antibiotics.
  • A prospective, observational, multicenter Japanese study (Shindo et al. Am J Resp Crit Care Med, 2013) identified 6 pneumonia-specific risk factors that can be used to determine risk for MDR pathogens (hospitalization >=2 days or antibiotic use during previous 90 days, non-ambulatory status, tube feedings, immunocompromised status, and use of gastric acid suppressive agents).   Using these criteria, a patient who is from a nursing home but does not have one of these risk factors would not get broad-spectrum therapy.  The presence of one MRSA risk factor (prior MRSA infection or colonization, long-term hemodialysis, heart failure) warrants MRSA coverage.
  • There is increasing recognition of exotoxin-mediated pneumonia caused by community-acquired MRSA in previously healthy patients (see Table 3); combination of vancomycin and linezolid or clindamycin (suppress toxin production) has shown decreased mortality.
  • Influenza testing should be done in the appropriate season.
  • You can use the Pneumonia Severity Index to predict short-term mortality and help make admission decisions to reduce admissions of healthier patients; however, it requires the use of an online calculator.  The CURB-65 score (1 point each for confusion, BUN>20, RR>30, SBP<90, and age >65, with a score >=2 as a cutoff for possible admission) can also be used, though is not as well validated as the PSI.
  • The presence of three or more of nine IDSA-ATS minor criteria should prompt ICU evaluation (see Table 5).  Increased attention given to these patients in the ED results in decreased mortality and fewer floor-to-ICU transfers.
Welcome to the new interns!  Have a great year! [divider]

From the Chief Residents

Grand Rounds

No grand rounds this week - Holiday

Noon Conference

Date Topic Lecturer Time Vendor
6/30/2014 Chief's Intro Chiefs 12:15 Picnic Basket
7/1/2014 SAR Emergency Series: Rheumatologic Emergencies Fola Babetunde 12:15 Saladelia Wraps
7/2/2014 Emergency Series: Micro Lab Essentials Aimee Zaas 12:15 China King
7/3/2014 SAR Emergency Series: Hyper and hyponatremia Benjamin Llyod 12:15 Chick-Fil-A
7/4/2014 HOLIDAY - No Conference Domino's
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From the Residency Office

Survival Guides and End of Year Gifts

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! Change in Parking Location (continuing trainees) Trainees who entered Duke in 2013-14 and are currently parking in the Research Drive lot, are being relocated to PG2 (across from Duke North),  effective July 1.  Continuing trainees currently in PG2 will remain in the PG2 Garage.  Parking Decals are in the mail and, per the parking office, should arrive at your home soon (to the address listed in duke at work).  Your current decal will remain active until July 11th  which will allow plenty of time for you to receive the new decal.  Exceptions to this are the departments of Dermatology (assigned to and remain in PG1)  and the departments of Ophthalmology and Nephrology (all trainees are assigned to and remain in Research Drive).

Information/Opportunities

 

Upcoming Dates and Events

November 8:  Clinical Science Day

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