Internal Medicine Residency News, October 13, 2014

October 13, 2014

By residency1

From the Director

Hello everyone! Lots of great GME news this week…..first of all….the cafeteria is re-opening at night! We learned on Wednesday at the ICGME meeting that starting in November, the Duke North cafeteria will have nighttime hours, with both hot food and "grab-and-go" items. Many thanks to the GME reps, Dr. Kuhn and Carolyn Carpenter (DUHS) for making this happen. Also, the ACGME-sponsored iCOMPARE duty hours study has been approved and we are one of the sites, along with 57 other IM programs nationwide. We will hear more in the coming weeks which arm we are randomized to for next year, so we will keep you all posted on what to expect. As a reminder, the study is a one-year randomized trial of current duty hours rules versus duty hours flexibility (keeping the 80 hour work week, no more frequent call than q3 and also 1 day off in 7). Once we know more, I look forward to thoughtful discussions with you all regarding what changes we would make in the schedule. Kudos this week go to our global health presenters Dan Pugmire, Iris Vance, Joe Brogan for presenting at Global Health Gallops, and to Adrienne Belasco for a great chair's conference. Other kudos to Kahli Zietlow, overheard teaching her medical student on gen med, and from Alicia Clarke to our night float team of Ryan Jessee, Brian Sullivan, Kristen Glisinski, Matt Turrissini and Eric Yoder for great work on a busy night, also to Brian Sullivan from Steve Telloni for a fantastic transfer note. Kudos also to Jenny Van Kirk from the 7100 and 7300 teams for great patient care and communication! And, kudos to Winn Seay from Devi Desai on 9300 for excellent work with the prm team! It's getting seriously close to Turkey Bowl….thank you to Jay Mast for continuing to organize practices. The game will be at the Githens Field again this year, we look forward to having a great game and a big supporting crowd in the "stands". Doctoberfest continues as well. Congrats to Myles Nickolich as our "Go Green" winner last week. Also congratulations to our conference attendance winners for the first quarter….stop by the office for your prizes. Grand rounds attendance: Pascale Khairallah and David Kopin-- 8 each Marc Samsky-- 7 Michael Woodworth-- 5 Noon Conference attendance (ACRs don't count!) : Michael Dorry—42!!!! WOW! Amy Jones—21 Carli Lehr—25 This week's pubmed from the program goes to MSIV and current sub-I Allison Webb for her article in Academic Medicine! A First Step Toward Understanding Best Practices in Leadership Training in Undergraduate Medical Education: A Systematic Review Allison M.B. Webb, MAT, Nicholas E. Tsipis, Taylor R. McClellan, Michael J. McNeil, MengMeng Xu, Joseph Doty, PhD, and Dean Taylor, MD [divider] [box]

What Did I Read This Week?

Submitted by: Aimee Zaas, MD

Clinical Management of Staphylococcus aureus Bacteremia

by Tom Holland, Chris Arnold and Vance Fowler. This article was published in JAMA 2014;312(13)1330-41.

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What I Read This Week: I read “Clinical Management of Staphylococcus aureus Bacteremia” by our very own Tom Holland, Chris Arnold and Vance Fowler. This article was published in JAMA 2014;312(13)1330-41. Why did I read this? A number of reasons….we see A LOT of S. aureus bacteremia here, the attributable mortality is high, it is a required ID consult and in support of our colleagues who wrote a very high impact article. What Did the Authors Do? This is a review article, performed in a rigorous manner. To find appropriate articles, the authors did two literature searches: 1) Pubmed 1968-May 2014, to find studies addressing the fundamental question of “What is the role of echocardiography in the management of SAB?” and 2) Pubmed, EMBASE and Cochrane Library to address the question of “What is the optimal treatment of SAB?” They then used the well accepted Grades of Recommendation, Assessment, Development and Evaluation system, with two authors needing to form a consensus opinion on the quality of evidence. What Did They Find? Background: The annual incidence of SAB is 4.3-38.2 per 100000 person years. 30 day all cause mortality is 20%. It is well established that all patients with SAB should undergo the following

thorough history and physical exam, with attention to finding metastatic foci of infection
obtaining follow up bcx to document clearance of infection
“source control” – drain abscess and remove infected prosthetic material

The role of Transthoracic (TTE) vs transesophageal (TEE) echocardiography is more nuanced. Infective endocarditis (IE) is a serious complication of SAB that affects treatment and prognosis, however can be difficult to distinguish clinically from uncomplicated SAB. In all patients with SAB, you should ask the question “Does my patient have IE?” To address the question regarding TTE vs TEE, 79 publications were identified, with 9 (totaling 4050 patients) met the predefined inclusion criteria. Despite this, the 9 studies were rated as being low or very low quality, as they were observational and limited by sampling bias (patients who undergo TEE have a higher pretest probability of IE than those who don’t). Nonetheless, among the 6 studies that used both TTE and TEE, TEE identified IE in 14-28% of patients compared to TTE (2-15%). Two single center studies (rated as low quality) showed that TEE reclassified patients with negative TTE approximately 15-19% of the time. Importantly, low risk criteria for having IE (and thus avoiding TEE if TTE is negative) were shown in 5 studies. These factors are lack of intracardiac device (pacer, ICD), sterile follow up bcx 4 days after initial set, not on HD, nosocomial acquisition of SAB, absence of secondary foci of infection and no clinical signs of IE. NPV for these ranged from 93-100%. SO…what is the role of echocardiography in SAB? All patients should get some type of echo (TEE vs TTE). Choice of TTE instead of TEE may be made if your patient falls in the low risk category. Additionally, if other factors (osteo, abscess) dictate longer therapy AND bacteremia is resolved, perhaps TEE is not necessary as well. To address the question of therapy for MRSA IE, 81 of 1876 studies found met inclusion criteria. Again, evidence quality was not great, with 1 study as high quality, 3 moderate, 22 low and 55 very low. The high quality trial was the NEJM comparison of vancomycin versus daptomycin for SAB and right sided IE. In this study, vancomycin plus short course low dose gentamicin was compared to either antistaphyloccal PCN + gent (MSSA) or daptomycin. Treatment with daptomycin was deemed noninferior (44% vs 42% success rate) to the other therapies. Authors did not find evidence to support the idea that daptomycin (standard or high dose) was superior to vancomycin for SAB with higher vancomycin MICs. Linezolid has also been studied and was noninferior to vancomycin in open label study of suspected catheter related BSI. However, there is a black box warning for empiric use of linezolid in catheter related BSI if gram negatives are suspected due to a higher overall death rate in the linezolid arm. There is limited low quality data for use of TMP SMX, telavancin, ceftaroline and dalbavancin. Evidence suggests that vancomycin or daptomycin are first line therapy for MRSA BSI. Duration of treatment for uncomplicated SAB (no ID, no devices, follow up bcx are negative at 2-4 days, defervesce at 72 hours and no metastatic infection) can likely be treated for 14 days past the last positive blood culture. Complicated SAB should have 4-6 weeks of treatment. Other pearls: for MRSA, you do not need to add gent or rifampin. For MSSA, while the quality of evidence is low to suggest that anti-staph beta lactams are better than vanc, however if your patient reports PCN allergy, you may consider skin testing as a cost effective alternative to vancomycin treatment. Overall, this article provides well-written and clear guidance for workup and treatment of SAB, answering (to the best of the current evidence), the status quo for SAB. It is interesting to note that the articles we quote regularly around here regarding diagnosis and management of SAB, while they are the best we have, often do not meet the GRADE criteria for high or moderate quality evidence. As they say in most papers, more studies are needed!

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Clinic Corner

Remember to wear pink this month for Breast Cancer awareness!

Pickett road has had some additions! Christine Mitchell has moved from the front desk as a PSA to the CMA position. Kelly Sullivan will start as our new LPN in Triage in November. There will a shuffle of attendings in March 2015. We welcome Dr. Audrey Metz to Wednesday morning, Dr. Boinapally to Tuesday morning, Dr. Brown to Thursday afternoon. Pickett Road has been piloting Lunch Topics this past month. We have discussed vaccines, the new indications for pneumovax 13/Prevnar, What to do with abnormal Paps and next week will be the complicated topic of chronic narcotics. October is Mini CEX is month. We are doing well and most residents are on their 2nd mini cex. We always can be better with our style and this is a good way to get feedback. Interns- this is so in January you need 3 in order to see patients alone. Jars and SARs this is for multiple sign out. Beaker transition has been as expected, an adjustment. I forwarded 7 POC orders from Marie, our Super User. Not much has changed other than the printing process is a work in progress for the rooming nurses- have patience with them! Ask Marie or Valencia if there are questions. Have a great weekend and see you next week! Sincerely Sharon

QI Corner

[caption id="attachment_16361" align="aligncenter" width="141"]

Aaron Mitchell, MD[/caption] Thanks to everyone who came to last week’s PSQC meeting! We were able to identify the three areas of care that residents felt are the best “low hanging fruit” to go after to reduce wasteful care within Duke Internal Medicine. Those three areas are:

Excessive ordering of daily labs
Unnecessary telemetry
Reflexive “FFWU” leading to low-yield testing

Each of these projects has a team of residents that will be working on it. We are going to be meeting again this week, 5:30pm on Wednesday, to divide into teams and get the projects moving. If you would like to get involved in one of these initiatives from the beginning and haven’t already signed up, let me know or come join us on Wednesday.

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From the Chief Residents

Grand Rounds

Fri., Oct. 17: Stead Speaker/Alumni Weekend, Dr. John B. Simpson (Avinger)

Noon Conference

Date	Topic	Lecturer	Time	Vendor
10/13/14	MKSAP Mondays: Benign Hematology: Anemia/Thrombocytopenia	A. Mitchell	12:15	Nosh
10/14/14	Review of Peripheral Blood Films	M. Arcasoy	12:15	Domino's
10/15/14	Approach to Anemia	A. Mitchell	12:15	We Care Wednesday
10/16/14	Approach to Thrombocytopenia	A. Mitchell/Metjian	12:00	Sushi
10/17/14	Chair's Conference	Chiefs	12:00	Chick-Fil-A

From the Residency Office

A BIG "Thank You" from Dr. Arcasoy to Lynsey Michnowicz in the Med Res office for her help in putting together a comprehensive mentorship database for the residency program!

Doctoberfest is off to a great start!

DOCTOBERFEST IS HERE! “This is OUR Community” October 1-31, 2014

Join the Internal Medicine Residency Program in our 3^rd annual Doctoberfest celebration! This year our continued focus will be on building and strengthening our community – both locally and on a global scale!

October 1, 2014 will mark the start of our Doctoberfest celebration with “We Care Wednesdays.” A special treat will be provided during Noon Conference to kick things off!

How Do YOU Go Green? – Ride a bike to work? Use a recyclable water bottle? We want to hear how YOU Go Green both at home and at work! Please feel free to come by the MedRes office and post your ideas on our Go Green wall, or submit them online using the link below. All submissions will be entered in our weekly drawings for gifts and prizes and all of the ideas will be compiled and shared at the end of the month. Bleed Blue/Live Green!!

https://duke.qualtrics.com/SE/?SID=SV_9TBHGku53op13uJ

October 15 A special German beer garden-style treat!

October 21 Join us for a special lunch to honor our house staff. Eat, relax and re-connect with your friends and colleagues! More details to follow!

October 31 As Doctoberfest 2014 draws to a close, enjoy some Halloween treats of donuts and cider as we welcome our first group of applicants on our 1^st official recruiting day!

Flu Vaccination Update

**Please Note: There has been an issue with the EOHW reporting system not showing compliance even if you got your shot at a Duke facility. If you have gotten your flu shot but are still showing as non-compliant, please contact the MedRes office. If you have not yet gotten your shot, please see the information below for locations where you can have it done. If you have any questions, please call EOHW 684-3136

A schedule of vaccination clinics is posted on the employee intranet at https://intranet.dm.duke.edu/influenza/Lists/Calendar/calendar.aspx. This list will be updated throughout the flu season. Vaccination is also available at Employee Occupational Health and Wellness (EOHW) during business hours.

If you have questions about the flu vaccine or its availability, please visit the DUHS Influenza Resource Guide or duke.edu/flu, ask your manager or contact EOHW.

Together, we can stop the flu. Thank you for your commitment to keeping our patients, and our community, safe and healthy.

The VA PRIME Clinic 20th Anniversary Celebration

Please join us for the celebration, Friday, October 17th, from 11:30am - 1:00 pm. Please the flyer for more details!

Register Now for BLS Blitz - November 10-14, 2014

Use the Swank system to register for BLS classes. If you do not have an account in Swank contact the DHTS Service Desk 919-684-2243 to establish an account. You may register for one session. Detailed Registration Instructions and Informational Flyer When you attend class, arrive 15 minutes before session begins and you must have your:

Class Registration Confirmation
Duke ID Badge
AHA BLS Healthcare Provider Manual 2010

All sessions are held at Hock Plaza - G07 Auditorium. Parking is not available at Hock Plaza. No one will be admitted to the session after it starts or if you do not have your AHA BLS manual.

Women In Medicine Event

The Duke Medical Alumni Association invites you to join us for the inaugural Women in Medicine Luncheon and Program Friday, October 17, 2014 | 11:45am-1:45pm Great Hall, Trent Semans Center for Health Education The luncheon program features a panel discussion of Duke Medicine alumnae followed by roundtable conversations on issues specific to women in medicine.

ETHOS for Noon Conference Attendance Tracking!

You MUST have your Duke Unique ID entered in to you ETHOS account in order for the system to work properly! Please make sure that you enter your Duke Unique ID and NOT your Net ID! If your unique ID is entered incorrectly, you will not get credit for attending the conference!