Weekly Updates - March 5, 2012

From the Director

Well, the game was terrible, but fun still had by those able to get together to watch! Otherwise, a lot of great things to report this week.  We heard outstanding SAR talks from Dan Fox, Reshmi Srinath and Stacey Johnson, and were introduced to the residency program Quality Council, a new opportunity to get involved in QI.  Our night JARs at Duke continue to receive high praise from the gen med attendings, including a compliment to JAR Dale Okorodudu form Sue Woods. The remaining team includes Lisa Vann, Callie Coombs, Ivan Harnden, Anna Dolgner and Newton Wiggins.  This week was capped off with perhaps the most entertaining ( and educational) chairs conference to date, with SAR Jared Chiarchiaro taking us through a case of a 32 yo man found down at Nosh clutching a Nordstroms gift card and muttering "hey buddy!".  Happy Saumil Chudgar day to all, and thanks to Jared, JAR Jon Menachem and others for honoring one of our favorite attendings. The real case of chronic lithium toxicity was also stellar. Our new tradition of dominating the awards podium continued at Clinical Science Day! Congratulations to JAR Callie Coombs and Med Peds SAR Ann Marie Navar-Boggan for a second place tie for best poster. SAR John Roberts was also selected as a finalist.  Other presenters included Jared Chiarchiaro, Kristen Dicks, Michael Chenier, and Ryan Nipp. Congrats to you all for representing well and being this weeks pubmed from the program! [toggle title_open="Close Me" title_closed="Clinical Science Day Posters" hide="yes" border="yes" style="default" excerpt_length="0" read_more_text="Read More" read_less_text="Read Less" include_excerpt_html="no"]Long Term Outcomes Associated with Hospital Acquired Thrombocytopenia Among Patients with Acute Coronary Syndrome (ACS) Authors: Michael Chenier, MD, MPH; Phillip J. Schulte, MS, Eric D. Peterson, MD. MPH, Shaun Goodman, MD, MSc, Karen Pieper, MS, E. Marc Jolicoeur, MD, MSc, Renato D. Lopes, MD, PhD, Harvey White MB, CHB, DSc, Kenneth W. Mahaffey, MD, Tracy Y. Wang, MD, MHS, MSc Association of ICU admission with trajectories of well-being in patients with advanced chronic illness Authors: Jared Chiarchiaro MD1, Maren K. Olsen PhD, Karen E. Steinhauser PhD, James A. Tulsky MD Race as a Determinant of Disease Biology and Outcomes in Chronic Lymphocytic Leukemia Authors: C. Callie Coombs, Laura Rassenti, Sara S. Strom, Susan L. Slager, J. Brice Weinberg, Thomas J. Kipps,Mark C. Lanasa1 What the eyes don’t see, the heart doesn’t grieve over – Epidemiology and Risk Factors for Bloodstream Infections following Cardiac Catheterization Authors: Kristen Dicks, MD1; Russell Staheli, MPH; Deverick Anderson, MD, MPH; BeckyMiller, MD; Schuyler Jones, MD; Kevin Harrison, MD; Dan Sexton, MD, FIDSA; Rebekah Moehring, MD; Luke Chen, MBBS, MPH, CIC, FRACP Hypertension Control Among Patients Followed by Cardiologists Authors: Ann Marie Navar-Boggan, Joel C. Boggan, Judith A. Stafford, Lawrence H. Muhlbaier, Catherine McCarver, and Eric D. Peterson Role of Pain Medications, Consultants, and Other Services in the Improved Pain Control of Elderly Cancer Patients in Geriatric Evaluation and Management Units (GEMU’S) Authors: Ryan Nipp, MD1, Richard Sloane, MPH, Arati V. Rao, MD, Kenneth E. Schmader, MD, Harvey J. Cohen, MD Comparative Efficacy of Revascularization Procedures for Severe Coronary Artery Disease in Patients with Chronic Kidney Disease Authors: John K Roberts, Sunil V Rao, Linda K Shaw, Oscar C Marroquin, Uptal D Patel[/toggle] Have a great week. Aimee

What Did I Read This Week (by Larry Greenblatt, MD )

[box]   Bedtime dosing of antihypertensive medications reduces cardiovascular risk in CKD.  Hermida RC, Ayala DE, Mojón A, Fernández JR., J Am Soc Nephrol. 2011 Dec;22(12):2313-21. Epub 2011 Oct 24.  [/box] As a busy clinician, educator, and driver to numerous sports practices, I need to pick my journal articles carefully.  I want high quality and high impact.  This one is a beauty. What do I like about this article- so many things!  First-The title tells you the bottom line. If you are really lazy, stop here.  Second, it comes from the Bioengineering and Chronobiology Laboratories of a European University.  Doesn't that sound both sleek and nerdy at the same time? Why did I read this?  A number of my patients, often better informed than I, were asking me about taking some of their antihypertensives at night as they heard this was "better."  They are savvy but few are quoting relative risk reductions.  None can do ARR or NNT, or at least they are modest enough not to do this in my office. I'm all about improving care though I always want to temper my enthusiasm for improved outcomes with cost-conscious decision making. It was hard for me to get excited about Dabigatran reducing events by 0.6%/year when it costs $2800 per year or about $2704 (>28X) more than the next best medication. In this study of patients with generally early stage CKD (about half stage 2 or better, average GFR 65 or so), simply having patients take at least one of their blood pressure medications in the evening (vs all in the AM) reduced their composite endpoint by 4.8%/year.  Relative risk reduction was an astounding  65%!  What was in this composite outcome?  Major cardiac events (MI, death, new angina, revascularization), cerebrovascular events like stroke or TIA, HF, or occlusion of lower extremity arteries or retinal arteries.  Mostly, this is stuff that matters.  The cardiac events alone contributed 2% of the 4.8%.  Major events (Death, MI, or stroke) dropped 1% per year (p<0.001). Should we change our practice-Heck yeah!  No obvious harms and no cost.  What about patients at risk for CV events who don't have CKD?  Who knows?  We need a trial.  Any volunteers to organize this?

QI Corner

Thank you to Dr. Eric Peterson for his excellent discussion of quality in healthcare at our most recent Quality Improvement and Patient Safety Conference.  Please be sure to join us March 28th for our next conference when Dr. Bryan Sexton will be reviewing our program's SAQ RESULTS. As we announced, we are forming the Medicine Residency Program Quality Council.  We hope this to be a forum for faculty and residents to come together once monthly to discuss how our quality is measured as well as to discuss project opportunities.  The council will be open to all residents but we are asking each Stead Society to nominate 2 individuals to participate.  For any residents interested, please contact your Stead Team leader or Jon Bae. Also, be on the lookout for announcements from our new QI residency program sharepoint website.  This will ultimately be the Quality Improvement/Patient Safety home for the program.   It is in its earliest pilot phase but if you are interested to take a look.  The link is http://DOMcentral from any pin station or virtual pin. Lastly, we are beginning to put together performance metrics for our program.  Here is the data on patient satisfaction and hand hygiene we showed during conference. PATIENT SATISFACTION

	Program Performance    (7/11- 1/12)	Duke Hospital Gen Med          (7/11 - 1/12)	Target YTD
Press Ganey Overall Inpatient Score	87.5%	85.9%	86.8%
Press Ganey Discharge Process	86.2%	85.3%	None
HCAPHS Overall	78.6%	70.6%	72.6%
HCAPHS Communication with Physicians	83.7%	82%	None

HAND HYGIENE [divider]

From the Chief Residents

Grand Rounds

Date	Speaker	Division
3/9/12	Sunil Rao	Cardiology

Noon Conference

Day	Date	Topic	Lecturer	Time	Vendor
Monday	3/5	TTP	Gow Arepally	12:00	Jersey Mike's
Tuesday	3/6	SAR TALK	Priyesh Patel/Ashleigh Owen	12:00	Domino's
Wednesday	3/7	Obesity Hypoventilation Syndrome	Mark Powers	12:00	Chick-fil-A
Thursday	3/8	SAR TALK	Andrea Archibald/David Lofthus	12:00	Papa John's
Friday	3/9	Chair's Conference	Chiefs	12:00	Saladelia

Reminders

Charity Auction - Friday March 23rd at 7pm, at the Durham Arts Council Building. If you would like to support our cause, please contact Tian at tian.zhang2@duke.edu."  12th annual Charity Auction save the date Humanism in Medicine May 5, 2012 -  Please contact Chris Hostler if you're interested in either helping to organize this wonderful tradition or if you'd like to participate in the night's festivities.

Stead Society Projects

Habitat for Humanity Work Day Spring is here and it’s time to get back outdoors and shake off the doldrums of winter.  Come join Ben Powers, Gene Oddone and his “Pay It Forward” crew for a ½ day of work with Habitat for Humanity on Saturday afternoon, March 10^th at 1pm.  We are in the early stages of building a new home for (and with)the Bumphus family: Bernard and Karla and their children, Bryson (3) and Bryleigh (2).  The home is at 109 N Blacknall St. in Northeast Central Durham.  Absolutely no experience or equipment required.  Stead Society C will gladly sponsor a round of beers afterward for any who can join us.  Please contact Roxanne Hall at rhall@durhamhabitat.org to sign up. Thanks, Ben Powers, MD, MHS [divider]

From the Residency Office

Respiratory Fit Testing for March 2012

Fit Testing/ T-Dap Vaccination/ TB Skin Testing  will be available at Duke North for your employees in March. We apologize, but due to difficult staffing issues for March, we will only have three dates for fit testing at Duke North. Flu Shots will be available during these times.       Resp Fit Testing-T-Dap-TB Skin Testing FlyerMarch 2012

Re-Thinking Pain and Opiod Prescribing Forum,

March 15, 2012, at the Durham Marriott Convention Center. The forum intends to bring together a multi-disciplinary audience for a dialogue on new strategies to address non-malignant pain management.  Keynote speakers include Fred Wells Brason, II,  Project Lazarus (Wilkes County) and Dr. James Finch, NC Governor’s Institute on Addiction.  There is also an opportunity for agencies to display posters or have a resource table. Pain - Opioid Prescribing - Substance Abuse Flyer Please see the attached announcement for further details about the forum and feel free to forward it to others.   Please RSVP by March 9!

Dates to Add to Your Calendars

March 23 - Charity Auction May 5 - Humanism in Medicine June 2 - Annual SAR Dinner (invitations only) June 13 –Resident Research Event, 5-7pm

Other Dates

Medical Education Grand Rounds Session

"Making Presentations Even More Impactful" with Dr. Jonathan Mark, Chief of Anesthesia, VA Medical Center - will be held NEXT WEEK.

Monday, March 5th - 7am – 8am (DN2001)

Tuesday, March 6th - 12noon – 1pm (DN2001)

Wednesday, March 7th - 4pm – 5pm (DN2002)

If you would like to attend this session and have not yet registered, please do so by clicking the following link -  https://www.surveymonkey.com/s/MedEdGrandRoundsReg2012

Upcoming Medical Education Grand Rounds Sessions:

 April 3rd - "Legal Issues & Remediation" with Jamie Padmore and Kerry Richard, MedStar

Cardiovascular Symposium, Wednesday April 25 in Searle Lecture Hall 8:00am to 5:00pm.

This free event is available to everyone and provides 6.50  AMA PRA Category 1 Credit(s)^TM (all in one day!!).   Please register at http://cmetracker.net/DUKE/Courses.html The CV symposium is the one event during each year when all the groups/sub-divisions in Cardiology gathers to hear the best and most interesting research happening throughout the Division, from Clinical to Imaging to Translational to Basic.  This CME-sponsored event will include a keynote address by Jay Cohen, MD, FACC, Professor of Medicine, Director, Rasmussen Center for Cardiovascular Disease Prevention, University of Minnesota.  Duke faculty will give talks that cover a wide range of topics including heart failure, metabolism and hypertension, vascular biology and electrophysiology.  Three of Duke's talented young investigators will be giving short sessions highlighting their up and coming work. Please make an effort to attend at least part of the symposium.  Pre-register by April 9, 2012 to receive lunch.   Young Investigators Competition -  Poster Information There will also be a poster session to highlight the work of our talented students, post-doctoral fellows, and housestaff.  If you are interested in presenting your work as a poster, please email your abstract to c.ward@duke.edu by March 30, 2012.  All who submit abstracts will be given space to display their poster and will have an opportunity to discuss their work with symposium attendees. In addition, after reviewing the abstracts three finalists will be chosen to participate in a Young Investigators Competition and will present their work orally on the day of the symposium (they will be notified around April 9th in order to have time to prepare). A winner will be announced at the end of the day.

Opportunities

Dear Medical Resident:  My name is Neena Cassell and I am a doctoral student in the clinical psychology program at the University of Maryland, Baltimore County. I would like to ask for your participation in my dissertation, a study on Making Medical Treatment Decisions. You will be asked to read a brief medical summary and then complete several questionnaires. The survey should not take more than 20 minutes. In appreciation of the contribution of your time, you will be offered the opportunity to be enrolled in a raffle for $500 cash prize. By clicking on the following link, you will be redirected to a confidential online survey. https://seanacademic.qualtrics.com/SE/?SID=SV_eCInW3vM6pSny1m Note:  A particular part of the survey cannot be completed on a Mac. Your honest answers may provide valuable information to assist seasoned physicians, current residents, and future residents on how medical treatment decisions are made, as well as, guaranteeing the best care for each patient. Your participation is voluntary and will not affect your evaluations as a resident. The study can be performed entirely online and is 100% confidential. ***This study has been approved by the UMBC Institutional Review Board: Protocol Y12SB20079.

Useful links

• Main Internal Medicine Residency website
• Main Curriculum website
• Ambulatory curriculum wiki
• Confidential Comment Line Note: ALL submissions are strictly confidential unless you chose to complete the optional section requesting a response.
• Department of Medicine