From the Director
Hello everyone! Thanks to Randy, Jen and the chiefs for holding down the fort during my vacation! I heard some kudos throughout the week, including a rockstar job as VA Gen Med JARs by
Lindsay Boole and Mandar Aras (from attending
Brian Schneider, who remarked that he would have thought they were end of year JARs, not July JARs), a big help from JAR
Scharles Konadu at the DOC, and a Stead good deed by SAR
Shereen Katrak who set up a big sib program for the Kerby Society! The Smith Society is making great progress with the City of Medicine Academy mentoring program (thanks again to recent grad and renal fellow
Jon Roberts as well as recent grad
Priyesh Patel for their leadership here!)..looking forward to hearing more about this tremendous accomplishment.
SARs….keep letting us know about your fellowship interviews. Its great to hear your successes, and we want to make sure you are able to figure out the coverage plans. We are all committed to getting you to where you need to be. Also, don't forget to register with the NRMP (
http://www.nrmp.org/fellow/faq.html#4) so that you are able to enter a rank list when the time comes.
The
ACLT team is meeting
Monday night at Larry Greenblatt's house….if you are interested in primary care, please email Larry about attending! You don't have to be an ACLT member to attend.
QI module and sharepoint participation was outstanding this past two weeks! The Sharepoint results are fantastic — if you haven't seen them, log in and check it out!
This week's pubmed from the program goes to SAR Hassan Dakik….Dig Dis Sci. 2012 Jun 26.
Management of Occluded Metal Stents in Malignant Biliary Obstruction: Similar Outcomes with Second Metal Stents Compared to Plastic Stents. Shah T, Desai S, Haque M, Dakik H, Fisher D. [hr]
Have a great week! Aimee
What Did I Read This Week (Sarah Rivelli, MD)
[box] John W. Devlin, PharmD et al, Efficacy and safety of quetiapine in critically ill patients with delirium: A prospective, multicenter, randomized, double blind, placebo-controlled pilot study. Crit Care Med, February 2010, Vol. 38, No.2, 419 - 427 [/box]
How should we treat delirium?
This question comes up all the time whether I am rounding on medicine or psychiatry. The truth is, it depends, and there is no real pharmacological treatment for delirium per se. You may be surprised to learn that there are
virtually no placebo-controlled trials for antipsychotics to treat delirium despite their wide use and being recommended as standard treatments in guidelines. Here is one of the two very small placebo-controlled trials comparing quetiapine (Seroquel) to placebo for delirium, in this instance in the ICU.
This randomized, double-blind, placebo controlled trial took place in 3 academic medical centers. The study screened 258 patients and excluded 222 patients due to prior antipsychotic use within 30 days, primary neurological condition, advanced liver disease, alcohol withdrawal, dementia, inability to obtain informed consent, irreversible brain disease, among others. Only 36 patients, about 14% of those screened, were included, with 18 patients in each arm. Patients had been in the ICU for about 6 days prior to enrollment and about 80% were intubated.
Intervention:
Quetiapine, starting at 50mg VT or PO q12h, versus placebo added on to as needed haloperidol IV.
Patients could received anywhere from 1-10mg of haloperidol IV for “symptoms related to delirium” prescribed by the intensivist as part of usual care and not as part of the study protocol. Those patients that received more than one dose of haloperidol prn in the last 24hrs had their study drug (quetiapine or placebo) increased by 50mg to a maximum of 200mg q12h. The exact trigger for giving haloperidol was a clinical decision, and it was likely given for agitation, which would lead to a bias towards treating only hyperactive delirium more aggressively with quetiapine. The study drug was continued until delirium resolution, therapy lasting >10 days or ICU discharge.
Patients received on average 1.9 and 4.5mg of as-needed haloperidol IV in the quetiapine versus placebo arms, respectively. The maximum median total daily dose of quetiapine in the active medication arm was 200 mg.
Outcomes:
The primary outcome, time to first resolution of delirium, was significantly decreased among patients randomized to quetiapine versus placebo, 1 vs 4.5 days (p<0.001). Patients on quetiapine also spent fewer hours in delirium, 36 hrs vs 120 hrs (p=0.006) and required shorter duration of drug therapy, 102 hours vs 186 hrs, and also fewer hours of agitation, 6 vs 36 hrs. Duration of mechanical ventilation, length of ICU and hospital stay, hospital mortality did not differ between groups. However, patients on quetiapine were more likely to be discharged from hospital to either home or rehabilitation facility as opposed to being transferred to a chronic care facility or dying, 89 vs 56%.
Patients randomized to placebo received significantly higher doses of fentanyl than those on quetiapine.
QTc prolongation >500 msec was actually more common in placebo subjects (28% vs. 22%), though this difference was not statistically significant (p=1.0). There were no adverse events thought to be associated with quetiapine.
Comment:
The major limitation of this study was that only 14% patients screened to actually be enrolled, leading to concern for poor generalizability. The study examined only short-term quetiapine treatment and it is not known if quetiapine would have been effective without add-on haloperidol being used as well. Quetiapine did appear to shorten the time of delirium and agitation compared to placebo and was associated with less need for fentanyl and haloperidol prn.
One might think that quetiapine is simply doing the same work as haloperidol and a straightforward replacement for it, but at the low doses used in this study, quetiapine is more of an antihistamine than an antipsychotic, raising the question of how much we really need dopamine blockade (ie haloperidol) in delirium, versus medications that promote calming and sleep.
[hr]
From the Chief Residents
Grand Rounds
| Date |
Division |
Speaker |
| 17-Aug-12 |
Rheumatoloy |
Dr. Megan Clowse |
Noon Conference
| Date |
Topic |
Lecturer |
Time |
Vendor |
| 8/13 |
Library Session- interns med res, JARs/SARS 2002 |
Connie Schardt, Megan Vonisenberg |
12:00 |
Moe's |
| 8/14 |
Approach to Anemia |
Murat Arcasoy |
12:00 |
Bullock's BBQ |
| 8/15 |
Lung Transplantation |
Laurie Snyder |
12:00 |
Jersey Mike's |
| 8/16 |
Inpatient Management of CHF |
Chet Patel |
12:00 |
Papa John's |
| 8/17 |
Chair's Conference |
Chiefs |
12:00 |
Rudinos |
Stead Society News: Kerby (submitted by Heather Whitson, MD)
We (Kerby Society) would like to thank
Richard Riedel and
Ralph Corey who are both conducting mock interviews with JARs…I greatly appreciate their time and willingness to do this and I’m confident that after an hour of Corey/Riedel-style grilling, our JARs will be prepared for anything they encounter on the interview trail.
Other updates... a BIG thank you to Shereen Katrak for stepping up to the plate to organize a big sib/little sib program for Kerby Society
[divider]
From the Residency Office
MKSAP - LAST CHANCE
If you are planning to order MKSAP, and have not all ready submitted your request, you only have until Wednesday of this week to do so. The online request forms close on
Wednesday, August 15. This opportuinty is open to all Internal Medicine, Med Peds, and Med Psych residents (Intern, JAR, and SAR classes). You can submit your request as shown below:
- First, you need to become a member of the ACP
Associate membership costs $109/yr
https://www.acponline.org/membership/dues/new_us.htm
Please make note to record your ACP # - you will need it to complete our online request form
- Which MKSAP format to you want?
The cost for Digital MKSAP 16 is covered by the program – simply complete the order blank using the following link. The updated digital version will be released in January, 2013.
https://www.surveymonkey.com/s/MKSAP_16_Request_Form
If however you request MKSAP 16 Print (hard copy), or the complete set, you will need to cover the additional cost. The printed copies are released in two phases. Part A is available now – Part B will be released at the end of the yr.
Cost:
MKSAP 16 Digital - $339 for members (paid for by the program)
MKSAP 16 Print - $389 for members (your cost $50)
MKSAP 16 Complete - $629 for members (your cost $290) includes Digital and Print copies
Summary:
- This offer is open to all Categorical, Med Peds, and Med Psych trainees who have NOT previously received a copy of MKSAP
- We cover the cost of the MKSAP 16 Digital release
- You are required to be a current ACP member to participate
- You have the option to request the printed version or complete set – but you will need to cover the additional cost
- We do not place orders randomly at different times in the year.
Duty Hours - Two Weeks in a Row
Last week we hit a new milestone. This week now makes it two in a row with 100% duty hours recorded. Way to go !!
Rule Change: Prescribing Controlled Substances to Self, Family Prohibited
The NC Rules Review Commission in July gave final approval to administrative rule changes that prohibit physicians and physician assistants from prescribing controlled substances to themselves or to members of their immediate families. These changes came out of the Board’s review in 2011 of the NCMB Position Statement now entitled, “Self-treatment and treatment of family members.” A task force convened by the Board, which included representatives from stakeholder groups representing physicians, PAs, health insurance companies, malpractice insurance carriers, pharmacists and others, agreed by consensus that prescribing controlled substances to oneself or to immediate family members was unacceptable.
Underlined text represents new language
21 NCAC 32B .1001 AUTHORITY TO PRESCRIBE
- A license to practice medicine issued under this Subchapter allows the physician to prescribe medications, including controlled substances, so long as the physician complies with all state and federal laws and regulations governing the writing and issuance of prescriptions.
- A physician must possess a valid United States Drug Enforcement Administration ("DEA") registration in order for the physician to supervise any other health professional (physician assistant, nurse practitioner, clinical pharmacist practitioner) with prescriptive authority for controlled substances. The DEA registration of the supervising physician must include the same schedule(s) of controlled substances as the supervised health professional's DEA registration.
- A physician shall not prescribe controlled substances, as defined by the state and federal Controlled Substance Acts, for the physician’s own use or that of a member of the physician’s immediate family, which shall mean a spouse, parent, child, sibling, parent-in-law, son-in-law or daughter-in-law, brother-in-14 law or sister-in-law, step-parent, step-child, step-sibling, or any other person living in the same residence as the licensee, or anyone with whom the physician is having a sexual relationship.
Respiratory Fit Testing Schedule for August 2012
Fit Testing/ T-Dap Vaccination/ TB Skin Testing will be available at Duke North Room 4000C. (Forth Floor beside service elevator)
Resp Fit Testing-T-Dap-TB Skin Testing Flyer August 2012
Maestro Tips (submitted by Kathleen Kiernan, MD and Ivan Harnden, MD)
submitted by Kathleen Kiernan, MD
- When you login to virtual pin from home, one the screen that you would usually choose Virtual Pin Desktop, scroll down and double click on Maestro and then open Maestro Care from home to check your in-basket, update problem lists, prepare for clinic etc.
- When you refill meds, click "mark as long term" which will allow you to refill it in the future without re-typing in the dosage, instructions, # to dispense, and # refills. It auto populates the same info in the future which you can change if needed..
submitted by Ivan Harnden, MD
- I have one more tip: for almost any new med you can type the name or category in the field for patient instructions and a great overview will print out for the patient on their AVS. I recently used this for OCP initiation and for sertraline. Can save time while explaining how to use the meds (especially complex things like OCPs, insulin or warfarin).
Annual Duke Medicine Patient Safety & Quality Conference
Attached is the “Final Early Call for Abstracts" for the 8
th Annual Duke Medicine Patient Safety & Quality Conference scheduled for March 14, 2013.
Final Early Call for Abstracts_March 14_2013
Cindy Gordon, RN; Administrative Director; Patient Safety Office, Duke University Health System
Dates to Add to Your Calendars /Contact Information
Useful links
