From the Director
Doctoberfest continues! Remember, our theme is
"Building Our Community" and we are working to recognize the fantastic nursing staff that partner with us to take care of patients in the hospital and in the clinics. Donuts and cider were delivered to the nursing stations on Monday, as well as the clinics. Send us a note about a nurse (or nurses) who have been particularly outstanding, and we will recognize them on our Wall of Fame in the Med Res office. Look for more Doctoberfest trivia, as well as the opportunity to see the chiefs and I do something ridiculous (sumo wrestling?!?!) You can make that happen by donating to our community cause…we are trying to raise money to buy a portable wheelchair ramp for the North Street Community. Collection buckets are in the med res office, and will also show up at noon conference.
We are FLU SHOT SUPERSTARS! When I left town on Wednesday night, we were at 96% overall for the house staff, with
Martin Society edging out the win (Warren had 100% "in country" members get a flu shot first) and Orgain coming in 3rd. It's possible we are at 100% by now! Either way — what a tremendous effort and thanks to our
Stead Leaders, to
Jen Averitt for tracking and reporting (and reminding!) and to all of you for keeping our patients safe. If we are not at 100%, and you are part of the few holdouts, GO GET YOUR SHOT!
Kudos this week go to SAR
Lindsay Boole for helping out a colleague, to
Jessie Seidelman for a great intern report (strong participation by the entire audience!), and to
Fola Babatunde (from Murat Arcasoy) for presenting an amazing diagnosis that she made at the DOC during DRH morning report! More kudos to
APD Bill Hargett for the milestones video!
Bill, Murat and I presented a seminar on faculty development at the program directors meeting in New Orleans this weekend, and one of our participants said that watching the video was "worth the price of admission to the whole meeting!". It's on medhub, so watch it if you haven't seen it yet! Also at the meeting were
Jane Gagliardi, Saumil Chudgar, Diana McNeill and Mary Klotman!
Turkey Bowl preparation continues, and we are very excited that the recruitment season is about to begin. Look for recruitment dinner sign ups, and also for Erin to be asking you to help out with tours, talking to the applicants and for any other ideas you have to make our recruitment season successful!
This week's Pubmed from the Program goes to
Marc Samsky! Note the Duke Med Res alums
Jake Jentzer and Ashleigh Owen as co-authors! Ten Year Experience with Extended Criteria Cardiac Transplantation, Marc Samsky, Chetan B. Patel, Ashleigh Owen, Phillip J. Schulte, Jacob Jentzer, Paul B. Rosenberg, G. Michael Felker, Carmelo A. Milano, Adrian F. Hernandez, and Joseph G. Rogers, Circ Heart Fail. Originally published October 2, 2013. doi: 10.1161/CIRCHEARTFAILURE.113.000296
http://circheartfailure.ahajournals.org/content/early/2013/10/02/CIRCHEARTFAILURE.113.000296.abstract.html
Have a great week! Aimee
QI Corner
Patient Safety and Quality Council
Our next meeting will be this Wednesday at 5:30 pm in the Med Res Library - come and bring some nifty recipes for quality . . .
Flu Vaccination Campaign
Thanks to everyone who has been vaccinated - Martin Society was the first to hit 100% and that we're only THREE residents short of 100% compliance! Strong work everyone!
Our Thanks
If the Baldrige site visitors came and spoke to you this week, many thanks for your participation - we'll let you know when we hear more.
We will be sending you the September handwashing information in the next week or two - keep foaming!
Follow Us on Twitter
- @DukeMarines - Duke Chief Resident Updates - @JonBae01 - QI and Patient Safety (general news and program updates) - @DukeDOMQuality - Duke DOM Quality Updates - @bcg4duke - Maestrocare and health informatics
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What Did I Read This Week
Submitted by David Butterly, MD
Efficacy of Remission-Induction Regimens for ANCA-Associated Vasculitis
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I read this article after seeing a patient this past month in clinic with John Roberts.
The patient is a 63 yo woman referred for a second opinion on treatment for ANCA associated vasculitis. She reports a 2-3 year history of microscopic hematuria noted on routine yearly physicals. Urology evaluation including CT and cysto were normal. This spring she developed constitutional symptoms with weight loss, low grade fever and polyarthralgias. Lab exam showed continued microscopic hematuria along with low grade proteinuria and creatinine now elevated at 1.8. Serologies done were notable for P-ANCA positive at 1:640 and kidney biopsy revealed a pauci immune necrtotizing GN consistent with GPA vs MPA. She was started on 60 mg of Prednisone and referred in for a second opinion regarding further therapy.
This study appeared in the
NEJM 8/1/2013 and details longer term follow up from the
RAVE trial evaluating the efficacy of Rituximab in patients with ANCA-associated
vasculitis. Earlier results from this trial were published in the
NEJM in 2010. Of note, Bill St. Clair and Nancy Allen of our Rheumatology Division at Duke are co-authors in this study.
Granulomatosis with polyangitits (formerly termed Wegener's Granulomatosis) along with Micrscopic polyangitis are both ANCA-accociated vasculitidies because they are frequently associated with antibodies against PR3 or MPO. For nearly 40 years now standard therapy for induction has been corticosteroids and Cytoxan. In the early results of the RAVE trial published in 2010, a 4 week course of Rituximab was shown to be equally efficacious to Cytoxan followed by Azathioprine. The current study reports on longer term results in this same patient group.
This study is a multicenter, randomized, double blind, placebo controlled study comparing 4 weeks of Rituximab (375 mg per square meter) with Cytoxan/Azathioprine given for 12-15 months. Patients enrolled had severe ANCA associated vasculitis (AAV) with antibodies positive for PR3 or MPO along with Birmingham Vasculitis Activity scores for Wegener's (BVAS/WG) of 3 or more. Patients were randomized 1:1. Prednisone was tapered in both groups over 5.5 months. Ritux was given weekly for 4 weeks. Patients in the Cytoxan group received CTX at 2 mg/kg for 3-6 months followed by Azathiopine (2mg/kg) for remaining 18 months.
A total of 197 patients were randomized. 99 received Rituximab and 98 were treated with CTX/AZA. Figure 1 gives details on randomization and follow-up. Complete remission was defined as a BVAS/WG score of 0. 64 % of patients in the Rituxan group had complete remission at 6 months with 48% and 39% retaining the remission at 12 and 18 months. This compared to 53% , 39%, and 33% in the CTX-AZA group. Rituximab thus met criteria for non-inferiorority, but not criterion for superiority.
As shown in Figure 2, relapse was common in both groups (2A). As has been demonstrated previously, PR3 ANCA along with history of relapsing disease were strong predictors of relapse. However increases in ANCA titer did not predict relapse in either treatment group. There was no difference demonstrated between treatment groups in PR3 vs MPO ANCA patients (2C). There was also no difference in adverse events between the groups with the exception of increased risk of leukopenia and pneumonia in the group receiving CTX-AZA.
So in conclusion, Riuximab given weekly for 4 weeks was found to be equally efficacious to 18 months of continued immune suppression with CTX-AZA. Relapses were not uncommon in both groups, particularly in the group with PR3 antibodies.
Based on these results we elected to treat our patient with Rituximab. She is now 3 weeks into her treatment course. She has tolerated it well thus far with no problems with the infusions and a creatinine which has improved form 1.8 to 1.4.
Thanks for reading.
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From the Chief Residents
Grand Rounds
Each year, as part of Duke Medical Alumni Weekend, the Department of Medicine hosts the
Eugene A. Stead Jr., MD Lecture at Medicine Grand Rounds.
Please plan to join us at
8 a.m. on Fri., Oct. 18 in the Great Hall of the Trent Semans Center.
This year, the Stead Lecture will be presented by
Ralph Snyderman, MD, James B. Duke Professor of Medicine and Chancellor Emeritus, to honor
Robert Lefkowitz, MD, professor of medicine (Cardiology), and Nobel Laureate.
Dr. Snyderman's talk, “From the Bronx to Stockholm via Duke: Bob Lefkowitz’s Journey,” will honor his friend and colleague.
Please save the date and note the special location. A continental breakfast will be served beginning at 7:30 a.m.
Noon Conference
| Date |
Topic |
Lecturer |
Time |
Vendor |
Room |
| 10/7 |
Resident's Townhall - "Coffee Talk with Armando and Chris" |
Residency Council |
12:00 |
Saladelia Sandwiches |
2002 |
| 10/8 |
Adrenal Insufficiency |
Lillian Lien |
12:00 |
Bullock's BBQ |
2002 |
| 10/9 |
COPD |
Peter Kussin |
12:00 |
Moe's Burritos |
2002 |
| 10/10 |
Global Health Gallops |
Global Health Residents |
12:00 |
Sushi |
2001 |
| 10/11 |
Chair's Conference |
Chiefs |
12:00 |
Rudino's |
MEDRES |
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From the Residency Office
DOCTOBERFEST IS HERE !
"Building Our Community" October 1-31, 2013
We hope everyone enjoyed the cider and donuts that were delivered to the clinics, gen med services, and program office to kick off the month. Hats off to Jen and Lauren who trucked in 18 dozen donuts and gallons of cider.
So, what's next?
The fund raiser is up and going - and on behalf of
Erin and the Friendship House and Jubilee House here in Durham, thanks for the support. A lot has all ready been done - here are just two pictures of the before renovation and after renovation to show what can ba accomplished.
Thus far we have raised $126 towards our goal of $1,200 - with Summo Wrestling by the Chiefs and Dr Zaas leading the way.
Recognition of our nurses are coming in and posted to the wall of fame in the program office. Keep them coming - using the following link:
https://www.surveymonkey.com/s/doctoberfest2013_greatnurses
October 15 Join us at noon conference for a traditional “beer” garden treat!
October 31 Halloween Tricks and Treats! Join us at Noon Conference for some Halloween goodies and for the announcement of our fundraiser’s “winning” Chief!
We look forward to celebrating with and honoring our incredible Duke Medicine community all month long!
Fit Testing - T-Dap- TB - Flu Shots
Take note of the schedule posted below for easy access to these services in Duke N, or check out where to find them elsewhere using the following link:
http://www.hr.duke.edu/about/departments/eohw/
October 2013 Resp Fit Testing-T-Dap-TB Skin Testing Flyer
New BLS Challenge Class Available
New BLS Challenge class has been added on a trial basis. Class will be on Nov. 5
th. This course will offer the Healthcare provider the opportunity to renew their BLS (CPR) skills according to American Heart Association Standards and receive the AHA card valid for 2 years. Pre-Work/skills necessary for participation See
attached flyer for more information. Questions, contact 919-684-4293.
BLS Blitz Schedule
BLS Blitz is scheduled for November 18-21, 2013. See instructions in
flyer to register for classes. Remember absolutely no participant will be allowed in class after the session begins or if the participant does not have their manual with them.
BLS Blitz flyer 11-2013 BLS Challengeflyer
How do You Ask Patients About Their Code Status
(Tufts Medical Center)
"How do residents ask patients about code status? Do they think this discussion is the responsibility of a resident or an attending? We ask these and other questions in a nation-wide survey of Internal Medicine residents on how they approach discussions of code status with patients with advanced cancer. I am writing to ask your permission to distribute a brief online survey to your residents. This project has been reviewed by the Tufts Medical Center IRB. There is a lottery for prizes for participants, including $10 and $25 Amazon and iTunes gift certificates."
https://bostonu.qualtrics.com/SE/?SID=SV_afnZ9hvaidkjvFz
Sincerely, David Einstein, MD (PGY-3, Internal Medicine, Tufts Medical Center)
Kraft Fellowship in Community Health
The Kraft Fellowship is a two-year, multidisciplinary program providing formal academic training in Community Health leadership while immersing fellows in community health center practice. It is open to graduates of residency training in primary care/internal medicine, pediatrics, family medicine, obstetrics/gynecology and psychiatry. More details are available below and at:
http://www.kraftcommunityhealth.org/Participate/Physician-Fellowship-Program/Default.aspx
Information/Opportunities
Raleigh Medical Group, PA part-time MD letter 2014
Raleigh Medical Group, PA part-time MD position 2014
Hospitalist - Georgia
Upcoming Dates and Events
- October 18: SoM Clinical Science Day
- October 28: Annual Recruitment Kickoff
- November 13: Networking Event at Dr. Klotman’s! (An opportunity for JAR’s, fellowship directors, and division chiefs to connect!)
- November 28: Annual "Turkey Bowl"
- December 4: "Voices in Medicine"
Useful links
