Clinical Research fellowship in Pediatric Endocrinology, Growth and Diabetes

Preamble:

The need for a training program in Pediatric Endocrinology:

Knowledge in the field of pediatrics is now very vast. With the increase in knowledge and concomitant increase in investigative modalities and therapeutic avenues, specialization has become necessary to maintain excellence in health care. Specialist in specific areas of need have now become necessary to fulfill, the need of increased demand of subspecialty training. 

Pediatrics has lagged behind in the development of specialties. Pediatric specialists so far have either been trained abroad or have been trained by mentors in the corresponding adult specialty. As a result the country now has in place only a handful of pediatric specialists in teaching institutions, who can now function as the mentors. Among the pediatric specialties, pediatric endocrinology is one of the youngest in India. There are scarcely 12 to 14 pediatricians in the whole country who are trained pediatric endocrinologists. 

Pediatric endocrinology encompasses areas such as growth and puberty, the very child development and pediatrics.  Even the appreciation of the normal in these aspects of pediatrics is inadequately taught in general pediatric training.  Proper management of disorders such as diabetes mellitus, growth retardation, metabolic bone disease, disorders of sexual differentiation, and other hormonal abnormalities requires specialized training and exposure than is available in a typical pediatrics training program. Relatively newer problems such as childhood obesity, type 1 and 2 diabetes have now become commonplace in routine pediatric practice.  To ensure good care of children with these and other disorders in India, there is an urgent need to augment the numbers of trained manpower in the field.

Aims and objectives of the program:

1.    Early recognition of pediatric endocrine and growth disorders, improvement in the care of children and adolescents with pediatric endocrine disorders

2.    To train postgraduates in pediatrics with sufficient knowledge and skill to recognize and manage growth and pediatric endocrine disorders at peripheral centers in India. 

3.    To provide an alternative to similar super specialty training programme abroad which are often beyond the reach of a typical pediatric post-graduate in India. 

4.    To provide a viable alternative to much longer DNB of DM courses in endocrinology which are only available as super specialty of adult medicine. The course will aim at emphasizing a similar curriculum in a concise manner in the stipulated one-year period.

Proposed eligibility and selection of trainee:

Eligibility: Pediatrician holding MD or DNB degree in pediatrics

Number of candidates: One per year. 

Selection: Interview (Final decision at the discretion of HCJMRI Management)

Training period: 6 months to 1 year

Terms and conditions:

1.    The faculty shall include individuals with sufficient post MD or DNB experience in pediatric endocrinology/overseas training/long standing experience in pediatric endocrinology as a teacher

2.    The course duration is of 12 months where the candidate will work in HCJMRI and Jehangir Hospital Pediatric endocrine unit

3.    The candidates work will involve substantial research responsibilities.

4.    There would be an examination at the end of fellowship.  It is mandatory to pass this examination to acquire fellowship certificate.

Faculty:
Dr. Vaman Khadilkar MD, MRCP Consultant Pediatric Endocrinologist

Dr. Anuradha Khadilkar MD, DCH Deputy Director HCJMRI

Course design:

Postings:

The trainee will spend a year in clinical pediatric and adolescent endocrinology / diabetes and pediatric endocrine research the laboratory training.  He/she will complete at least one paper acceptable for publication in a peer reviewed journal, and participate in the teaching programs in the department (case presentations, seminar, journal club, radiology/nuclear medicine meetings and pathology/mortality/research project presentation/combined endocrinology surgery meeting).

He/she will be responsible for caring for all inpatient pediatric endocrinology and diabetes admissions, as well as pediatric endocrinology interdepartmental consultations and emergencies. Diabetes education of patients as well as nurses will also be his/her responsibility.

The candidate is expected to attend Pediatric Endocrine clinic at Jehangir Hospital .

Books and study materials: 

Textbooks in Endocrinology (the minimum):

1.    Handbook of Clinical Pediatric Endocrinology – CGD Brook, R. S. Brown, Blackwell Publishing, 2008

2.    Pediatric Endocrine Disorders – Orient Longman, Editors: Meena Desai, Vijayalaxmi Bhatia, PSN Menon 

3.    Handbook of Endocrine investigations in children – IA Hughes, Wright publications.

Journals:.

1.    Journal of Endocrinology and Metabolism Journal of the American Endocrine Society

2.    Journal of Pediatric Endocrinology and Metabolism- Journal of the European Pediatric Endocrine Society

Curriculum: 

1. Principles of hormone measurement

Principles of RIA/IRMA/ELISA. Definition of sensitivity, specificity, inter and intraassay CV.  When to accept or reject an assay -preliminary knowledge.  Practically perform at least 2 immunoassays and observe 2 ELISAs and 2 spectrophotometric assays. 

2.    Principles of hormone action

Categories (and examples) of hormones, type of receptors, second messengers -broad categories with some examples, particularly relevant to disease.

3.    Genetics in pediatric endocrinology

Definition of and familiarity with Southern, Northern and Western blots, RFLP, PCR, FISH, karyotyping.

Awareness of genetics forms of pediatric endocrine diseases, for example,   hypopituitarism /growth hormone deficiency, childhood thyroid disease, genes in sexual differentiation.

4.    Fetal-neonatal

Adult consequences of fetal disease

o    neonatal hypoglycemia and IDM 

o    neonatal hypo and hyper calcemia and magnesemia 

o    neonatal thyrotoxicosis and hypothyroidism

5.    Growth : short and tall stature

Normal growth – patterns, control of (including details of hormonal control of growth), measurement, bone age and growth charts

Short staturecauses, diagnosis and management

Tall staturedifferential diagnosis, treatment, Marfan, SotosDysmorphic syndromes – Details of Turner, Noonan, Prader Willi, Klinefelter.

Others – Briefly (Down, Russell Silver, Laurence Moon Beidel)

6.    Skeletal dysplasias

Achondroplasia, spondyloepiphyseal dysplasia (SED), SEMD, Morquio, hypochondroplasia, metaphysial dysplasia - clinical and radiological features

7.    Disorders of Growth Hormone (GH) production and action and treatment of GH deficiency.

Etiology of GHD including genetic causes, cranial irradiation (GHD) and tumours, clinical features.  (Detailed knowledge of problems in GH testing).  Detailed knowledge of indications for monitoring of GH therapy.  Clinical features and diagnosis of Laron dwarfism and gigantism, of tall stature, differential clinical features and diagnosis of gigantism.

8.    Puberty

Initiation of normal puberty, physical changes in normal puberty

Delayed puberty, definition, CDGP, hypo and hyper hypogonadotropic hypogonadism.  Kallman, Klinefelter and Turner syndromes in detail, diagnosis and management primary and secondary amenorhoea. Precocious puberty -definition, true puberty, peripheral puberty, precocious thelarche and pubarche, diagnosis and management. 

Gynecomastia-causes and treatment.

9.    Periphebertal hyperandrogenism

PCOD – pathogenesis, differential diagnosis and management

10.    Thyroid

Physiology.

Genetic causes of congenital hypothyroidism

Interpretation of thyroid function tests

Congenital hypothyroidism-newborn screening, etiology, treatment, outcome studies.

Goitre in childhood, thyroiditis

Iodine deficiency disorders- daily requirement, typical syndromes of iodine deficiency

Graves disease-etiology, clinical features, treatment including permanent ablation. Neonatal graves – details of clinical features and treatment                     -Thyroid hormone resistance – preliminary knowledge, types and important clinical features

11.    Adrenal

Steroidogenic pathways – names of intermediary, metabolites and enzymes

CAH -21 hydroxylase deficiency – genetics, clinical features, management, long term outcome; prenatal diagnosis and therapy – basic knowledge. 

11 βOH, 3β HSD, 17OH, 17  βHSD – presentation and management

Cushing syndrome-clinical features, peculiarities of different etiologies of Cushings and differences from adults; interpretation of the various screening and definitive tests, imaging, IPSS. Treatment medical, surgical, radiotherapy and outcome.  Non Cushing adenoma, carcinoma, incidentaloma 

Hypertension with hypokalemia, and differential diagnosis.

Addisons disease – etiology, clinical features and treatment, polyglandular autoimmune syndromes.  

Phaeochromocytoma-clinical features, diagnosis (biochemistry, precautions and interpretation), imaging and treatment.

12.    Sexual differentiation, Cryptorclindism, Micropenis, Hypospadias Normal embryology and hormonal influences.

Genes involved – basic knowledge of current status.

Details of clinical features, diagnosis and treatment

13.    Pituitary:

Hypopituitarism

Diabetis insipidus and SIADH, cerebral salt wasting-basic knowledge of osmoregulation., differentiation of central/nephrogenic/primary polydipsia and treatment

Craniopharyngionia-detail knowledge of presentation imaging and management

14.    Diabetes mellitus and lipids

Classification, differences between type 1, type 2 and FCPD.

MODY – basic knowledge of differentiating clinical features and management

Type 1-pathogenesis – (basic knowledge) and pathophysiology

Details of clinical features, management, long term follow-up-detail, including

complication screening, DKA/hypoglycemia.

Lipids –only basic knowledge relevant to clinically management.

15.    Hypoglycemia

Neonatal hypoglycemia and IDM - details of causes, but only superficial

Knowledge for disorders of fuel metabolism.  Persistent hyperinsulinemic hypoglycemia of infancy – details of pathogenesis, clinical features management and outcome.

16.    Obesity

Control of appetite and satiety

Definition – clinically relevant knowledge

Management – strategies and some knowledge of outcome

17.    Metabolic Bone Disease, Calcium, Phosphorus and Magnesium metabolism

Hypocalcemia, especially neonatal hypocalcemia etiology, diagnosis and management.

Hypercalcemia, etiology, diagnosis and management.

Calcium sensing receptor disorders and William syndrome

Rickets – complete details of etiology, clinical features, diagnosis and

management.

Bone turnover studies, bone physiology – clinically relevant areas only

Osteogenesis Imperfecta, glucocorticoid induced osteoporosis

Fibrous dysplasia and metabolic bone disease of prematurity-full details of

pathogenesis and management.

Pediatric DEXA (bone densitometry): interpretation and use.

Suggested names and designation of potential examiners:

1.    Dr. Raghupati, Pediatric Endocrinologist, Sagar Apollo Hospital, Bangalore

2.    Dr. Archana Arya Dayal, Sir Ganga Ram Hospital, New Delhi

3.    Dr. Sudha Rao, BJ Wadia Hospital for Children, Mumbai

4.    Dr. Shaila Bhattacharya, Pediatric Endocrinologist, Manipal Hospital, Bangalore

5.    Dr. Anurag Bajpai, Pediatric Endocrinologist, Consultant Pediatric and adolescent Endocrinologist, Regency Hospital Limited, A2 Sarvodaya Nagar,
Kanpur UP 208 005

6.    Dr. Ahila Ayavoo, G Kuppuswamy Naidu Memorial Hospital No 6327, Nethaji Road, Papanaickenpalayam, Coimbatore - 641037,