From the Director
Happy March!
Ryan Kelly's on fire, less than 2 weeks till match day, and we kicked off mini cex madness!
Kevin Trulock,
in perhaps a preview of how Indiana will do in the tourney, secured himself as the "#1 seed" as the only resident to have 6 minicex for the year. For those who are wondering why we are making such a big deal out of this...read
Atul Gawandes article on coaching. (
http://m.newyorker.com/reporting/2011/10/03/111003fa_fact_gawande).
We had great attendance at our fellowship planning meetings. Info to follow. If you are planning a career in primary care, look for information soon about a get together hosted by our ambulatory attendings. If you are planning a career in hospital medicine, please get in touch w
Dr. Gallagher.
Compliments this week go to
Monica Tang for a great chairs conference and to
Matt Hitchcock for quickly preparing an excellent Duke intern report. Also from
Lynn Bowlby to Jason Rose and Newton Wiggins for great work at the DOC with some challenging issues. Also to
Shereen Katrak and Lisa Vann for excellent SAR talks. Congrats to
Carling Ursem who will represent us at the Southeastern Geriatrics Summit!
Thanks also to
Aaron Mitchell for keeping us updated on the current issues in health care - if you don't read his weekly emails, check them out!
There are also some very worthy updates to the choosing wisely lists
(choosing wisely.org) that deserve some time to look over. High value, cost conscious care is an important topic and our QI team looks forward to bringing this curriculum to you in 2013-14!
This week's pubmed from the program goes to
Shereen Katrak who will be presenting her abstract at the upcoming CROI meeting.
Have a great week!
Aimee
QI Corner (Submitted by Jon Bae, MD)
Quality Improvement and Patient Safety Noon Conference
Thank you to
Mamata Yanamadala and her presentation this past week at QI and PS noon conference on Patient Safety.
Save the Date for Wednesday, March 27th when
Dr. Eric Peterson will present a national perspective on quality improvement.
Quality Champions
Please join us in congratulating this month's
Quality Champions:
Mandar Aras, Jeremy Halbe, Adia Ross, Hany Elmariah, Bonike Oloruntoba, Aaron Mitchell, Kevin Shah
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What Did I Read This Week
(submitted by Jennifer Rymer, MD)
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I found this article after signing up for
Evidence Updates through BMJ, which was
recommended by Dr. Greenblatt. I highly recommend doing this, as I get daily emails with a few articles, rated highly for relevance and newsworthiness. Additionally, this article was interesting to me as a few of us currently in the MICU have gotten recent exposure to high-frequency oscillatory ventilation (HFOV) over the last several weeks.
As a brief reminder, Acute Respiratory Distress Syndrome (ARDS) is diagnosed when the following criteria are present: bilateral pulmonary infiltrates present on imaging, respiratory failure not explained by a cardiogenic cause, PaO2/FiO2 ratio of less than or equal to 200 mmHg (in moderate ARDS), and patient presentation with worsening symptoms usually over a one week period of time. The literature suggests that the inflammatory processes at play in a patient with ARDS can be worsened by repetitive stretching and collapse of the lung during ventilation. Because of these findings, we know that the utilization of low tidal volumes and higher levels of PEEP in these patients is paramount. HFOV functions by allowing the delivery of small tidal volumes to be delivered by high frequencies (3-15 Hz) via an oscillatory pump. A 2010 BMJ meta-analysis of 8 RCTs concluded that use of HFOV in children and adults with ARDS improved survival and was, at least, unlikely to cause harm (Sud et al., BMJ 2010; 340: c2327).
In the recent highlighted study, there were over 500 patients from 39 centers (5 countries) randomized to receive either HFOV or conventional ventilation (pressure control, tidal volume target 6 ml/kg, plateau airway pressure less than or equal to 35 cm of water). Patients were eligible for inclusion if they had had an onset of respiratory failure within the previous 2 weeks, had undergone intubation, had hypoxemia (defined as [Pao2] to [Fio2] of ≤200, with an Fio2 of ≥0.5), and had bilateral opacities on chest imaging. Upon enrollment, patients were initiated on conventional ventilation (pressure control, TV 6 ml/kg, FiO2 0.60, PEEP 10). After 30 minutes, if the Pao2:Fio2 ratio remained at 200 or lower, patients underwent randomization to either HFOV or conventional ventilation. Physicians were allowed to prescribe vasopressors, sedatives, NM blockers, and fluids at their discretion.
After enrolling only 548 of the over 1,200 planned patients, the study was terminated out of concern for increased mortality in the HFOV group, though the threshold p-value for termination had not been reached. Baseline characteristics of the two groups were similar. 129 patients (47%) in the HFOV group, as compared with 96 patients (35%) in the control group, died in the hospital (relative risk of death with HFOV, 1.33; 95% CI [1.09 to 1.64]; P = 0.005). There was significantly greater utilization of vasopressors, sedatives, and NM blockers within the first 4 hours of initiation of HFOV when compared to conventional ventilation.
This study highlights several interesting points, including the effects of early termination and the fallacies of prior RCTs, which perhaps made HFOV appear less harmful when compared to conventional ventilation. Early termination typically overestimates the magnitude of harmful (or beneficial) effect. The authors propose that prior RCTs, demonstrating potential benefits of HFOV, utilized control ventilation settings that are now known to be harmful. Other theories behind increased mortality in patients randomized to HFOV included increasing sedative usage (compromising hemodynamics) and increasing mean airway pressure. Despite early termination, this study at least raises the question of whether HFOV is appropriate during early presentations of ARDS, and contradicts prior RCTs.
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From the Chief Residents
Grand Rounds
| Date |
Division |
Speaker |
Title |
| 3/8 |
Nephrology |
Dr. Ogebe |
HTN |
Noon Conference
| Date |
Topic |
Lecturer |
Time |
Vendor |
| 3/4 |
Stead Society Noon Conference 2002, 8253, 8262, 4275, 2270 |
Stead Leaders |
12:00 |
The Picnic Basket |
| 3/5 |
Inpatient Insulin Management |
Lillian Lien |
12:00 |
Sushi |
| 3/6 |
IM-ED Combined Conference |
|
12:00 |
Rudinos |
| 3/7 |
SAR talks |
Leah Rosenberg, Carrie Horney |
12:00 |
Dominos |
| 3/8 |
Chair's Conference |
Chiefs |
12:00 |
Chick-fil-A |
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From the Residency Office
Scholarly Activity and Research Opportunities
Dr. Arcasoy will hold OPEN OFFICE hours for those of you who would like to discuss Scholarly Activity and Research Opportunities throughout residency. Please sign up for a 30 minute time slot by contacting Erin Payne.
March 5 @ 9:30 am - 11:30 am and 1:30 pm - 4:30 pm
March 8 @ 1:30 pm – 4:30 pm
March 12 @ 9:30 am – 11:30 am and 1:30 pm – 4:30 pm
Contact Information/Opportunities
Upcoming Dates and Events
- March 12 & 19: Duke Medical Oncology fellowship discussions, 4:00, Med Res Library
- March 15: MATCH DAY CELEBRATION at Dr. Klotman’s!
- March 25-28: BLS Blitz (registration: blsblitz )
- March 29: Faculty Resident Research Grant Application Deadline
- April 19: Residency Program Pictures (rain date May 10)
- April 28: 2nd Annual Stead Tread
- June 4: Resident Research Conference, Searle Center
- June 8: SAR Dinner, Hope Valley Country Club
Useful links
