Internal Medicine Residency News: May 5, 2014

By admin3

From the Director

DUKE.RESEARCH.NIGHT.03 (1)Another busy week! Thank you to everyone who filled out the modified Learner's Perception Survey – this information about our clinics is very valuable as we work to make your ambulatory experience the best it can be for both you and your patients.  The VA does send out their own version (the longer version) and filling this out is important for national data, as well as for our VA.  You will be getting a several surveys in the next few weeks (it's that time of year!).  Please take the time to fill them out – it is one way we can learn how to improve the program.  This includes the program survey that was sent to you in Medhub this week.. It's anonymous! It's important! It's not that long! Fill it out! Our first kudos this week goes to APD Jon Bae. Jon started his role as APD in July 2011, and is our first APD for Quality Improvement and Patient Safety.  He has done an exemplary job integrating QI into our program, evidenced by the many projects, posters, presentations and papers that you all have worked on.  Jon's talents have been recognized by the health system, and in July he will be promoted to  Medical Director for DUHS for Quality and Mortality Review.  In this role, he will oversee the implementation of a standardized process to review mortality across the health system and assist with the identification of opportunities to reduce mortality and improve patient safety.  We are all very proud of Jon's accomplishments and look forward to continuing to keep him involved with the program. Our next kudos goes to Alicia Clark who has accepted the position as Associate Program Director for Quality Improvement and Patient Safety, starting in July.  Lisch came to Duke Hospital Medicine after completing her residency training at Beth Isreal Deaconness where she ultimately served as one of the Chief Residents.  In that role, and here at Duke, Dr. Clark has been extremely engaged in the education of our housestaff as well as with local quality  improvement efforts.  In the role of APD for QI, Dr. Clark will continue to guide the QI curriculum and QI and patient safety efforts of the medicine residency program.  Anyone who has worked with Lisch knows how fantastic she is as a physician and a role model, and we have already seen how well she leads noon conference (great HVCC conference this week!) and M and M.  Welcome to the team, Lisch! Kudos this week to the VA gen med teams – week 1 of the new schedule is "in the books" -- teams seem to be doing well, and the attendings tell me that SAR day floats Laura Caputo, Wendy Chan and Carter Davis were extremely helpful this week. Other kudos to Ben Peterson and Emily Ray for excellent work on 9300 (from Tony G). BB - ALLThe 10th Anniversary Faculty-Resident Basketball Game in Cameron was huge success.  Faculty (led by rookie sensation Steve Telloni, as well as veteran players Don Hegland, Tony G, Harvey Cohen and Adam Wachter) won on a shot in the final seconds.  Who knew that Kedar Kirtane rivaled Austin Rivers for 3 point shots, however?  Great showing by the chiefs as well as the residents.  Lynsey Michnowicz put in some quality minutes as well, and Ashley Bock represented the residency women.  We are looking forward to a few years from now when Alan Aertker takes the court.  Word has it that he signed a multi year contract (well, Medhub only lets you sign one year at a time) for 2039.  BB - Winners ST3!!! The Stead Tread was fantastic! Congratulations to Matt Crowley and the Kempner Society for planning such a great event.  Residents who took a lead role in planning include Marcus Ruopp, Jeremy Halbe, Kevin Shah, Marianna Papademetriou, Mike Woodworth and Dana Clifton.  Thank you to Kate Russell from pediatrics for helping as Mike worked in the ED!  Over 100 people signed up to run, and whether you were flying through the course (Meredith and Carter Clement, Eric Pollack, Jason Stout and kids) or schlepping a double stroller (Jane Trinh, Susanna Naggie), or a kid in a backpack (Jim and Zoe Lefler) we are so happy that you joined in.  Kudos to Zachary Stout as the "Fastest Runner Under 14" in the Stead Tread and Eric Pollack as Fastest Housestaff.  Faculty represented well…spotted running were Drs. Rob Califf, Sharon Rubin (who also was quite FAST!), Chuck Gerardo, David Simel, Peter Kussin, Paul Rosenberg and Cary Ward.  We were also excited to see several 4th year med students/future interns…Lauren Ring, Fumiko Chino, Eric Black-Maier and Jenna McNeill.  Word has it that the Stead Tread Team raised over $6000 to benefit Lincoln Clinic.  Donations still being accepted..contact Matt Crowley or visit www.steadtread.org. ST Set Up   ST Team   This week's Pubmed from the Program goes to Nina Beri for her upcoming ASCO oral presentation  "Breast Cancer Screening in Younger Women" with mentor Jeffery Peppercorn! Way to go Nina. Have a great week Aimee   [box]

What Did I Read This Week?

Diagnosis of Childhood Tuberculosis and Host RNA Expression in Africa

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1303657

Submitted by Aimee Zaas, MD

[/box]

Why Did I Read This:  Went to check out the NEJM table of contents to find a good article for WIRTW.  The review article on LYME DISEASE in this week's issue is worth reading as well (it's finally spring! Everyone thinks they had a tick bite! Do I give them doxy?).  However, I really wanted to see this article where they use host expression for diagnosis of infectious diseases, as this has been a huge area of focus here at Duke for the past several years. What is the Reason to Evaluate Host Expression for Diagnosis of Infectious Diseases? :  In the situation presented by the authors, (childhood Tb in Africa), it is a COMMON (500,000-1 million cases diagnosed annually) disease that is difficult to diagnose as many children with Tb are smear/culture negative,  and since the clinical symptoms overlap with many other common diseases of childhood in the developing world, both over and under diagnosis are common.  IGRA's don't distinguish latent versus active disease, and can be unreliable in compromised hosts. Therefore, a new diagnostic method is imperative.   This theme is the same for many infections – either finding the pathogen is hard, our clinical definitions are hazy or we can't tell the difference between colonization and infection.  Evaluating host response is one way of getting past the limits of pathogen based diagnostics. What Did the Authors Do?  After getting approval from all the relevant IRBs, they recruited African children from 3 countries with a high burden of Tb.  They formed a "discovery" cohort of children from Malawi and S Africa and a validation cohort in Kenya.  Discovery and validation cohorts are a standard procedure in genomic studies like this one, so that you can show that your data can be replicated in a new set of patients.  To be considered for the study, you had to be under age 15 and meet certain clinical criteria: cough/fever/wt loss lasting > 2 weeks, pneumonia not responsive to antibacterials or "suggestive clinical findings" or close contact with an adult who had active Tb. CXR, sputum and other clinically relevant body fluid specimens were obtained for Mtb smear/culture; IGRA was performed as was CRP and HIV testing.  Follow up at 3 months determined if those without Tb remained disease free and also the response to therapy in those with Tb.  Cases were defined as "definite Tb" for culture positive subjects, and for culture negative subjects, they were defined as "highly probable", "probable" or "possible" Tb.  A positive IGRA indicated "latent" disease and "no Tb" was the label for subjects who remained Tb free at 3 months without antiTb therapy.1356 children were screened for the discovery cohort, with ultimately 364 included.  114 had culture confirmed Tb, 157 had diseases other than Tb and 57 had latent Tb. The authors did not evaluate children with culture negative but clinically likely Tb (the "highly probable" "probable" "possible" group) for the discovery cohort.  For the validation cohort, 1599 children were screened and 157 selected for the study.  In this group, 64 had no Tb, 35 had culture + Tb, 9 had latent Tb and 44 had culture negative Tb (8 "highly probable" 19 "probable" 17 "possible").   How did they test RNA: RNA Paxgene tubes were drawn on each subject.  These are special blood draw tubes that have a means of "freezing" cellular expression so that when you extract RNA, you know exactly what the cell was doing at the time you drew the sample.  The samples later had the RNA extracted and hybridized to Illumina microarrays.   They then looked for genes having differential expression (eitherlog2 of 0.5 up or down) between Tb and no Tb – and whittled this list down to the minimum number of genes possible using an algorithm called an elastic net.  This gene list became used for their "risk of Tb" score, calculated by evaluating the difference in the total intensity of up regulated genes minus intensity of down regulated genes. What did they find?  In the training set (comprising 80% of samples from the discovery cohort), they  identified 409 transcripts that were differentially expressed between tuberculosis and other diseases and 3434 transcripts that were differentially expressed between tuberculosis and latent infection. Using variable selection to identify the smallest number of transcripts that distinguished each group, they found that 51 transcripts distinguished tuberculosis from other diseases and 42 distinguished tuberculosis from latent infection.  These transcript sets were used to generate a risk score for each patient in the test set (comprising the remaining 20% of samples from the discovery cohort) that distinguished tuberculosis from other diseases (sensitivity of 78% and specificity of 74%) and that distinguished tuberculosis from latent infection (sensitivity of 96% and specificity of 91%)  In the validation cohort,  The risk score discriminated culture-confirmed tuberculosis from other diseases in patients with or without HIV infection with a sensitivity of 82.9%and a specificity of 83.6%.   Among patientswith negative cultures who were treated for tuberculosis, the risk score identified 62.5% of those in whom tuberculosis was highly probable, 42.1% of those in whom it was probable, and 35.3% of those in whom it was possible.  The risk score did better than the pathogen based GeneXpert MTb test performed on respiratory samples (this is a gene probe test to identify presence of MTb).  They then performed a sensitivity analysis, estimating how the gene score would perform in groups with 10%, 30% and 50% pretest probability of having MTb.  As expected, the test performs better for finding Tb when there is a higher pretest probability. Overall, however, this test had better NEGATIVE predictive value than POSITIVE predictive value, so perhaps has a more defined role in "ruling out" disease.  Limitations include the cost, and a much cheaper way of processing RNA needs to be developed before this could be used in resource limited settings.  When looking at the gene list, they do not make any attempt or any claims to say that the genes they found have biologic plausibility to be related to Tb, although 3 defensins and one IFN related gene are represented. What can we conclude:  This is a strong "proof of concept" study using solid methodology to look for novel ways to diagnose Tb in a setting where our traditional diagnostics are limited.  It is certainly not ready for "prime time" both because it needs to be validated again in a prospective manner and also because cost is a huge factor and this test would not be practical until we can easily and cheaply measure RNA expression. How does this apply to your practice?  Well, immediately it does not apply to your practice, even if you are headed to a Tb endemic area next year for a global health elective. However, the concept of host based diagnostics for infectious diseases is growing (think of procalcitonin in the simplest scenario).  As expression arrays and other 'omics technologies become cheaper and more automated, we will see these kinds of tests in clinical practice and will need to be able to interpret the results. WDITTW Graph

The "Clinic Corner"

(submitted by  Alex Cho, MD )

This week’s Clinic Corner is pretty simple – just an announcement of something to look forward to:  The spring Ambulatory Town Hall meetings are coming up in a few weeks, scheduled for Tuesday May 27 over the noon hour.  Come and catch up on the latest in your continuity clinic, and share your thoughts and suggestions. DOC and PRIME will be in DN 2002/3, and Pickett Rd in the MedRes Library.  Don’t miss it! And thanks to everyone who completed the inaugural Learner Perception Survey (LPS) Snapshot clinic survey that Duke IM grad and first-year GIM fellow Denise Duan-Porter developed with help from the VA’s national LPS group.  (Congrats to the Kerby Stead Society for raising $250 for Senior PharmAssist/DOC Patient Fund by having the highest completion rate!)  The results have been shared with the clinic leaders and will help inform ongoing work at the clinics to improve patient care as well as the resident experience [divider]

From the Chief Residents

Grand Rounds

Dr. Souha Kanj – Greenfield Visiting – Infectious  Diseases Topic: Infections in the Middle East

Noon Conference

Date Topic Lecturer Time Vendor Room
5/5 MKSAP Mondays Chiefs 12:00 China King Med Res Library / 8262
5/6 Clinical Reasoning I Hargett 12:00 Pita Pit 2002
5/7 IM-ED Combined Conference - COPD Kussin 12:00 Subway 2002
5/8 Clinical Reasoning II Hargett 12:00 Domino's 2001
5/9 Chair's Conference Chiefs 12:00 Chick-fil-A Med Res Library
 [divider]

From the Residency Office

 

SAFETY ATTITUDES QUESITONNAIRE ABOUT TO START!

What is it:  Culture of Safety Survey, second full cycle for DUHS When is it:  Survey runs May 5-May 30. Who does it:  All ACGME program members will be included (if at least 8 members);  other clinical departments throughout the health system also doing survey How is it done:  Participants will get an email from support@pascalmetrics.com, with subject “DUHS Safety Culture Survey from Pascal Metrics”;  in the body of the email, the target/referent for the survey is listed.  For GME it is the GME Program (e.g. GME-Medicine-Internal Medicine). Last cycle, GME participation rate was 71%.  We are looking for at least 80% response rate from each program!  Your input is very important.

Residency Program Evaluation by Residents 

All Internal Medicine residents have been assigned, via MedHub, an evaluation of the residency program.  Please complete the evaluation no later than May 23rd.  Your feedback is extremely important to us and the information that we are able to gather via this evaluation will help tremendously as we continue to investigate ways to improve in all areas. In response to the results we received from our 2012-13 ACGME Residents Survey, we would like for you to pay particular attention to the questions concerning duty hour  violations, as we continue to examine how to improve these issues within specific services. Thank you in advance for your time and attention to this! Please feel free to contact Jen Averitt if you have any questions.

Duke Hospital Medicine Social

If you are considering a career within Hospital Medicine, the following is an opportunity to meet with our hospitalist team to discuss opportunities in greater detail.
  • What:  Hospital Medicine Interest Meeting
  • Date:   May 19, 2014
  • Location: Nosh Café Trent Semans Center
  • Time:  5:00pm
For more information feel free to touch base with Jeffrey White, Hospital Medicine Physician Recruiter Jeffrey.white@duke.edu

Information/Opportunities

  Hospitalist Practice Opportunity 5-2014

Upcoming Dates and Events

  • May 24:  Housestaff Party - Elodie Farms
  • May 30: Program pictures, Trent Semans West Steps, 9:15
  • May 31: SAR Dinner, Hope Valley CC
  • June 3: Annual Resident Research Conference
  • June 6: Serve dinner at the Ronald McDonald House

Useful links

Share