Weekly Updates - August 21, 2011 - Week 9

By heffe004@dhe.duke.edu
The Internal Medicine Residency newsletter is posted each week to share important news, announcements and updates about the residency program. Please contact Randy Heffelfinger or Emily Strollo with corrections, contributions and suggestions.

From the Director

Hi everyone! The year is now well underway, and we are about to start Block 3 of the schedule for JARs and SARs…amazing! And our family survived a crazy sleepover birthday party with 16 seven and eight year old boys – the house is still standing, which I take as a pretty good sign. This week, we started off with a town meeting for the residents to hear about the upcoming changes to the VA Gen Med schedule…again, huge hats off to Tony Gutierrez and Leon Cannizzaro for getting all the important “stakeholders” (attendings, residents, interns, clerkship directors, VA support staff) on board. It’s a bit complicated to explain in Weekly Updates, but ask us, and we’re happy to show you diagrams and flow charts! The main point is that we hope the new schedule keeps with our goals and objectives of the rotation (junior residents leading the team, interns admitting and following their patients, interns having night time cross cover experience in the hospital, students incorporated into the team, time for attending rounds and morning report – all in the background of outstanding patient care). In other news, a big THANKS to our outgoing ACRs – Tian Zhang (Duke), Leon Cannizzaro (VA) and Mike Durheim (DRH). You all did a fabulous job, and the incoming ACRs Krish Patel (Duke), Ed Coverstone (VA), and Mike Chenier (DRH) have big shoes to fill! Ed has started the Turkey Bowl trash talk in earnest – get ready everyone! We’ve seen some fantastic cases this week, worthy of chair’s conference, and got a chance to welcome our second year med students to the wards. Tian Zhang was spotted this weekend teaching some students how to present at the bedside, and there was some evidence of didactic teaching on the white boards in the workrooms! Ryan Nipp brought his patient to chair’s conference this week and reminded us that we should think of the three ways medications can cause trouble – drug-drug interactions, direct drug toxicity and drug side effects. Thanks again to our Stead attendings, and we welcome Ralph Corey, Mike Felker and James Tulsky to the wards for the next two weeks! As always, we want to recognize the academic accomplishments of our residents and GME faculty…keep on the lookout for this new feature “PUBMED from the PROGRAM”, featuring articles and abstracts published by our team! The only way I will know is if you email me about the articles and abstracts, so keep us in the loop of your accomplishments This week’s PUBMED from the PROGRAM featured authors are: Leon Cannizzaro (PGY3), Matt Summers (PGY1) and Michael Chenier (PGY3). [box]Cannizzaro LA, Piccini JP, Patel UD, Hernandez AF. Device therapy in heart failure patients with chronic kidney disease. J Am Coll Cardiol. 2011 Aug 23;58(9):889-96[/box] [box]Summers MR, Blauwet LA, Prasad A. Detection of myocardial bridging induced ischaemia during cardiac catheterization by dobutamine-stress electrocardiographic body surface mapping. Eur Heart J 2011 Jul 30 (epub)[/box] And an abstract was selected among the top 10% of abstracts at the AHA conferences this year! Congratulations to Mike Chenier and his mentor Tracy Wang on their abstract "Long-Term Outcomes Associated with Hospital-Acquired Thrombocytopenia Among Patients with Acute Coronary Syndrome". We look forward to seeing the article in print in the future! Have a great week! Aimee

What I Read This Week “WIRTW” (submitted by Eileen Maziarz)

[box] Lindsley MD, et al. “Evaluation of a Newly Developed Lateral Flow Immunoassay for the Diagnosis of Cryptococcosis.” Clin Infect Dis. 2011: 53 (4) 321-325. [/box] Why did I read this? Truthfully, because of a conversation I had with Dr. Perfect in the 8100 workroom this week. I wasn’t aware of the availability of this new assay and I wanted to learn more. (One can imagine how these point-of-care tests (POCTs) could dramatically change practice in our own clinics but especially in resource-limited settings, where the disease burden and mortality rates are concentrated.) Some background… - Best estimates indicate that up to 88% of cases and 90% of deaths from cryptococcal meningitis occur in sub-Saharan Africa or SE Asia. - Current diagnostic modalities include microscopy with India ink staining, culture and antigen testing of serum and other body fluids (performed either by latex agglutination or enzyme immunoassay). While culture remains the diagnostic gold standard modality, it has poor sensitivity, is often dependent upon the quantity of the sample, and requires things like electricity for refrigeration. The antigen-based tests take less time but require refrigeration and technical expertise to perform (and $$$). Consequently, both options are sub-optimal and impractical for the majority of settings where cryptococcosis is commonly seen. - POCTs have been used with good success in resource-limited settings for a variety of infectious diseases, including HIV, HBV, malaria, etc. A quick test for crypto that can be used as a POCT has not been widely available to date What did I learn from reading this? This article evaluates a POCT (lateral flow immunoassay or LFA) for the diagnosis of cryptococcal infection and compares it with our standard diagnostics to date (blood culture, EIA antigen testing). This test detects the capsular polysaccharide of Cryptococcus and can be read - with minimal laboratory infrastructure or technical expertise required – within 15 minutes. The authors collected blood and urine samples from over 700 HIV-infected patients hospitalized with acute respiratory illness over a 5-year period in Thailand. Blood cultures were drawn in 325 patients and stored sera in all patients were tested by EIA. All positive EIA samples (and a random selection of negative) were tested by LFA. For those cases that were EIA+/LFA+, urine was tested by LFA. Test characteristics for LFA were calculated using gold standard (+ve blood culture) as well as EIA on serum. Blood cultures were +ve in 18 of 325 cases, but sera were available for only 17 cases. Of these, 16 were +ve by EIA and 17 were +ve by LFA, yielding sensitivity of 94% and 100%, respectively. Of the 18 cases with +ve blood cultures, 13 underwent urine LFA testing, which was +ve in 12 cases (92% sensitive). The authors also compared EIA versus LFA alone to see how these compared. 92 of 704 patients tested +ve by EIA in serum. 82 of 91 of these patients (90.1%) were +ve by serum LFA testing at 5-min incubation, 87 of 91 (95.6%) were +ve by LFA at 15-min incubation time. Of the 612 neg EIA samples, a random selection of 373 serum samples were selected and tested using LFA. 371 of 373 were neg by LFA (99.5%). Calculated kappa statistic for agreement between these tests was 0.923 (95% CI, .877–.967), this was later increased to 0.959 when extended incubation time was factored into the calculation. This is excellent agreement (1.0 being perfect). Finally, they tested urine samples by LFA for a subset of pts that were +ve by serum EIA. Of 74 patients +ve by EIA in serum, 52 (70.3%) were +ve by LFA in urine at 5-min incubation. Bottom line Lateral flow immunoassay testing of serum samples is 100% sensitive compared with the gold standard (blood culture) for diagnosis of cryptococcal infection and there is a high level of agreement with standard EIA testing of serum. Sensitivity of urine based LFA was decent but not as high when compared to serum EIA+ve samples. Going forward, I think these findings argue for testing this new assay on the ground in resource-limited settings and seeing how it performs in real-time, both as a screening and diagnostic test. The reduced sensitivity of urine LFA needs to be investigated further and whether LFA testing of whole-blood (ie finger-stick) performs similarly would be important as well. What is most exciting is that the estimated cost of the test ($1.50 to $2.50) makes it a very real possibility for the places where it is most needed!

Global Health Residency:

Developing the next generation of globally educated, socially responsible healthcare professionals dedicated to improving the health of disadvantaged populations.

Now Accepting Applications for Global Health Elective Rotations

The Hubert-Yeargan Center for Global Health (HYC) is now accepting applications for Global Health Elective Rotations for July 2012 and March 2013. Application is open to residents from Departments of Medicine: Internal Medicine (PGY 2); Med-Peds (PGY 3) and Med-Psych (PGY 4).  Access the application form and FAQ at http://dukeglobalhealth.org/education-and-training/global-health-elective-rotation. Application deadline is September 23, 2011. Interviews will be held from September 26 to October 7. We encourage you to speak with past participants to get a better idea of what daily life is like on the wards of your top sites. For more information, contact Tara Pemble, Program Coordinator at tara.pemble@duke.edu or 668-8352. [divider]

From the Chief Residents

Grand Rounds - Friday, August 26, 2011

Date of Lecture:                     August 26, 2011 Learning Objectives:
Title of Lecture: “CT screening for lung cancer, review and update” 1. Review aspects of a screening test 2. Review background of imaging as a screen for lung cancer 3. Discuss latest NLST results 4. Discuss where screening stands now.
Speaker(s): Philip C Goodman, MD  

 Noon Conference

Day Date Topic Lecturer Time Vendor
Monday 8/22 Gallops Chiefs/ACR 12:00 Bullock's BBQ
Tuesday 8/23 Shock Joseph Govert 12:00 Dominos
Wednesday 8/24 Transplant ID Aimee Zaas 12:00 The Picnic Basket
Thursday 8/25 Liver Transplantation Alistar Smith 12:00 Rudinos
  Additions to our "Family On behalf of the Menachem's - it is our pleasure to post this announcement - The 'twins" have arrived !! Details:  Born August 15, 2011 - Violet and Matilda Robin (mom) and babies are doing GREAT, and to quote Jon -  "Dad is perhaps the happiest guy of all time." [divider]

Whole Foods to Benefit Senior PharmAssit (submit by David Karol)

"I’d just like to remind everybody that Senior PharmAssist will be the beneficiary of Whole Foods’ next 5% Day on August 23. Please help get the word out by telling your friends, and forwarding to any interested parties.  We are also still in need of volunteers to work at an information table from 8-9:30 am, 2:30 – 5:00, 5:00-7:30 and 7:30 – 10:00.  If you can help out, contact Lesley Williams at 682-4962.  Otherwise, come fill up your shopping cart on Tuesday!

From the Residency Office

MKSAP – 2011 Order - FINAL WEEK

This is the last week to complete the online request for MKSAP (Digital/CD-ROM only) if you wish to receive the training review material this year. Who:  JAR or above who have not received a set of MKSAP training materials. When/How:  We will collect requests for MKSAP on line through Sunday, August 28).  Please use the following link and complete all fields.  MKSAP ORDER FORM or  (https://www.surveymonkey.com/s/MKSAP_2011_Order)

Postings in MedHub:  Block 3 Schedules / Noon Conference Recordings

Schedules for block 3 have been posted to the "Resources/Documents" section in MedHub (Schedules - Block 3) We have also found a better way to upload links for the recordings of noon conference and grand rounds. Where?  Click on the "View My Calendar" option found on the left side of your MedHub home page.  Next, click on the conference you wish to view.  The link to the recordings and other resource documents  will be listed under "Conference Details".

Noon Conference - Grand Rounds Attendance

We encourage you to take advantage of all training opportunities offered by the program, including noon conference and grand rounds.  Lunch is provided for residents and medical students who are on medicine rotations attending noon conference. Please scan in ONLY if you are ACTUALLY ATTENDING conference.  Finally, please rember to clean up as you leave and remove everything that you carried into the room.

News from the GME Office - Transportation Options

The Duke Office of GME has identified transportation options for residents post call who are too fatigued to drive home safely. This includes a taxi service. The Duke Office of GME has reviewed the experience of the Duke Programs of Med Peds, Pediatrics and Internal Medicine. Our thanks to Drs. Woods, Staples and Zaas and their coordinators for sharing their expertise. Laminated cards are in the process of being made and will be distributed.  The following attachment summarizes the options available. Fatigue Ride Home Options (2)

Useful links

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