From the Director
It's been a historic week....official Maestro go-live. So proud to say that the DOC and Pickett (and the Med Peds clinic) were ready! A lot of background hard work by clinic leadership and residents to make this happen. Kudos to all who were "heroes of maestro" by providing outstanding patient care while figuring out the new system. Extra kudos go to intern
Ben Lloyd who helped the attendings at Pickett, and JAR
Matt Summers, and SARs
Ryan Nipp, Jen Chen and
Blake Cameron who were especially helpful at the DOC.
Noon conference was also amazing this week....thanks to SAR
Jon Menachem for inviting a special guest to talk to us on Tuesday.
JAR
Aaron Mitchell gave a great chairs conference on a case of disseminated Cunninghamella infection in a patient with AML - thanks to
John Perfect for an inspiring discussion and to Aaron for pointing out that being a JAR means giving a talk on a subject to your peers when a world expert is watching. We also learned about hepatorenal syndrome from intern
Veronica Jarido and continued our theme of drug reactions with SAR
Sima Hodavances presentation on NMS and JAR
Josh Thadenon Thrombocytopenia induced by IFN. Also, thanks to SAR
Krishn Sharma for an outstanding VA med surg conference. VA Chief Jason Webb thought Krishn did a fantastic review of perioperative risk assessment. Great work!
Be sure to come to physical exam week at noon this week, and congratulations to med peds JAR
Tim Mercer on his wedding!
See you Friday at our "Summer Celebration"!
Aimee
Pub Med:
Today's pubmed from the program was discovered when Duke Chief Jeff Clarke was doing a lit search for his ASCO committee...he found this article by intern
Allyson Pishko!Anticoagulation in ambulatory cancer patients with no indication for prophylactic or therapeutic anticoagulation. A cost-effectiveness analysis from a U.S. perspective. Pishko AM, Smith KJ, and MV.
Thromb Haemost. 2012 May 25;108(2).
QI Corner (by Jon Bae, MD)
Thanks to all who attended our first Quality Improvement and Patient Safety noon conference of the year. For more details on the GME Trainee Performance Incentive Program, please see George Cheely or Jon Bae. And be on the lookout for updates on our performance in weekly updates.
Thank you to all who have completed their Sharepoint Individual Performance Improvement Modules. We will start publishing in weekly updates program performance in foot exams so stay tuned.
And special congratulations to VA Incident Commander Ryan Schulteis for bringing air conditioning back to our vets. Patient Safety and Quality Improvement in action!
What Did I Read This Week (by Aimee Zaas MD)
[box] "Genetically Distinct Subsets within ANCA-Associated Vasculitis" by Lyons, et al in this weeks NEJM (
N Engl J Med 2012; 367:214-223) [/box]
Why did I read this? After all the discussion of ANCA-Associated Vasculitis in report and chair's, who could resist reading this? Besides, this falls under the umbrella of "personalized medicine", which is a topic of growing importance in how we care for patients. It also serves as a lead-in for me to introduce a new opportunity for
RESIDENTS, MED STUDENTS and ATTENDINGS to take a course offered by the School of Nursing on personalized medicine (see below)
Why Was this Study Done? Investigators were interested in further determining the genetic basis for ANCA associated vasculitides (Granulomatosis with Polyangiitis, Microscopic Polyangiitis and Churg Strauss), and to uncover whether GPA and MPA were the same disease with different clinical manifestations or two distinct entities. To do this, they did a genome wide association study of patients with proven GPA or MPA. Key points are that they had a WELL DEFINED PHENOTYPE (no ambiguous vasculitidies, please!), a hereditarily similar (Northern European) population, and a separate DISCOVERY and VALIDATION cohort. You can't trust a GWAS that has poor phenotyping, the possibility of population heterogeneity leading to your effect or only a single cohort.
What did they Find? 4 single nucleotide polymorphisms (SNPs) exceeded the threshold of significance for association with ANCA vasculitis. HLADRP-1 was related to the MHC locus, whereas SERPINA1 and PRTN3 were not. While it appeared that these were more associated with GPA, further analysis showed an even more interesting finding. When stratifying patients by their ANCA type (PR3 vs MPO), it turns out that these SNPs were associated with PR3 ANCA, regardless of whether the clinical syndrome was phenotyped as GPA or MPA. This is termed "antigen specific autoimmunity" and is relevant as we consider inclusion of patients in trials (you want to have the same disease being tested, so perhaps lumping GPA and MPA together, as was done in some of the major therapeutic trials for ANCA vasculitis, is not a good idea). Two other diseases where this occurs are IDDM and membranous glomerulonephritis with PLAR1 antibody
How does this Help You Clinically? Well, probably not so much at this point, but it is worth remembering that any disease we need to classify by meeting a set of clinical criteria likely will be reclassified as our molecular diagnostics improve. Also, it is always helpful to review vasculitis and autoimmune diseases for the boards. Finally, we know that physicians have a relatively low literacy when it comes to genetics and personalized medicine. No IM programs across the country teach residents formally to deal with the types of genetic questions your patients will come to you with. So, if this is interesting to you, please consider the following opportunity. When else can you get a 23andMe genome scan?
Personalized Medicine
"Faculty in the Duke School of Nursing and the Center for Personalized Medicine have developed a distinctive course on genomics and personalized medicine that is tailored to the needs of health professionals and includes a personal genome test option as a learning experience. The course is
N562, Genomics and Personalized Medicine in Clinical Care, and we would like to invite your students, faculty, and/or health professionals to enroll in or audit the course this Fall semester."
Fall 2012: N562: Genomics and Personalized Medicine in Clinical Care (2 credits) *available for audit.
FLYER_21Jun12_GenomicsCourse
The course is appropriate for nursing, medicine, PA, and other allied health students. The syllabus encompasses a range of topics around interpretation of genomic information, ethical and policy issues in genomics, clinical risk assessment, and current/emerging genomic applications. Students will have the opportunity to explore their personal genome as an applied learning exercise.
Here's our Website (containing a link to FAQs):
Genomics Courses | Duke School of Nursing and Center for Personalized Medicine And a brief video about the course:
future_genomics_take_2_-_Flash_(Medium)_-_20120628_03.43.20PM"
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From the Chief Residents
Grand Rounds
| Date |
Division |
Speaker |
Title |
| 27-Jul-12 |
Hematology |
Dr. Ortel |
Bleeding |
Noon Conference - Physical Exam Conference Series
| Date |
Topic |
Lecturer |
Time |
Vendor |
| 7/23 |
Physical Exam Week- Neuro Exam |
Arcasoy/Morgenlander |
12:00 |
Chick-fil-A |
| 7/24 |
Physical Exam Week- Cardiovascular Exam |
Chetan Patel |
12:00 |
Dominos |
| 7/25 |
Physical Exam Week- MSK, Thoracic/Resp Exam |
Criscione/Hargett |
12:00 |
Sushi |
| 7/26 |
Physical Exam Week-Abdomen/HEENT |
Peyser/Simel |
12:00 |
Meelos |
| 7/27 |
Physical Exam Week-MICU, inpatient, clinic exams |
Hargett/Zaas/Arcasoy |
12:00 |
Rudinos |
Step 3
This is something to think about for interns, something to be actively working on for JARs & something SARs should have completed.
In order to be promoted to PGY 3, Duke requires you to pass Step 3. A test date before March 2013 guarantees your result before June 2013. Dr. Zaas and the chiefs can't do anything about this rule, so take step 3 before March!
You need to schedule this for either an ambulatory or consult rotation.
You CANNOT schedule this during the inservice training exam (from 10/5-10/15 2012). Please notify Nicole of the date of your exam. 60 days notice is preferable but 30 days is absolutely necessary to re-arrange your clinic schedule.
[divider]
From the Residency Office
Moonlighting Opportunity
Current SARs - there is a new moonlighting opportunity for weekend days on CAD. The shifts are from 7 am to approximately 1 pm. To be eligible, you need to have an approved TSMA on file in medhub, and also keep within duty hours while moonlighting. Typically, sign ups will be on the 5th of each month for the following month (e.g. Aug 5 for September shifts). There are some openings for August, so please email Shelley Thompson if interested (and approved). More details will be forthcoming in a separate email from Erin.
Office Updates
Noon Conference and Lunch: Thanks to all for helping to clean up at the end of noon conference - we have really gotten off to a great start this year. Lunch is provided for those who are attending noon conference, and leftovers are brought back to the library at approximately 12:30 and are available on a first come basis.
Survival Guides - if you have not all ready picked up your new "yellow" survival guide, please do so before the end of the month.
Maestro Countdown! We are LIVE!! (from Drs Bowlby and Phelps!!)
Maestro went LIVE last week - and THANKS to all who helped to make the launch a success.
DOC - "We had a very successful golive week with Maestro! I can’t say enough how proud I am of the DOC staff and residents of our first 3 days of Maestro! There certainly were some challenges—ask
Matt Summers or Bobby Aertker about being kicked out of Maestro in the middle of a note—but everyone worked together, figured out solutions and did a fantastic job. We did a great job taking care of the patients without any prolonged waits.
Teamwork was the key—we couldn’t have done it without everyone helping and learning from each other!
We will be continuing the learning process with Maestro with every PCC 12:30-1 in the consult room to share tips and tricks. Every day we will improve and we will see the many benefits of an integrated, comprehensive system. Thanks for all of your hard work, and we are ready for day #4, week 2!"
Pickett - "Our residents did an incredible job with launching EPIC at our clinic. I am happy to report that the first three days went very smoothly. Our new intern
Ben Lyold deserves recogntition for being our
"superuser." He helped his attendings and colleagues with their EPIC notes."
Look for future "TIPS" to be posted here as we all learn how to take advantage of the tools built into Maestro.
Faculty Club - Opportunities to Join
"The DFC (as it is more affectionately known) is a swim and tennis club tucked into the beautiful wooded Duke Forest just south of West Campus. Aside from our wonderful pools, tennis courts, and fitness room, we have an abundance of activities, camps, socials, and year-round programs for most all ages and interests. Our
website and
newsletter will give you a great idea of all the programs and facilities we have to offer, and be sure to check out the
DFC Facebook page for the latest snapshots of summer activity
We recognize that many of our House Staff and Fellows have a relatively short stay at Duke, therefore we defer all initiation fees and only require the yearly membership dues to join. You can find additional information on
Membership at our website."
Dates to Add to Your Calendars
July 27 Residency Program Summer Celebration at the Zaas's
Useful links
