14^th International Conference on Clinical Pediatrics June 14-16, 2018 Rome, Italy

Donna Mendez is a Board Certified Pediatrician and Pediatric Emergency Medicine Physician. She completed her Pediatric Residency at University of Texas Health Science Center (UTHSC) in San Antonio, and a Fellowship in Pediatric Emergency Medicine at University of Texas Southwestern in Dallas. She is currently an attending at McGovern Medical School in Houston. She is the Director of the Pediatric Emergency Fellowship established in 2014. She has received her Doctorate in Professional Leadership with an Emphasis in Health Science Education from The University of Houston in 2016. She has published more than 20 papers in journals and online resources.

Background: Simulation Wars, a clinical reasoning simulation, has rarely been incorporated into resident curriculum, but when

included has been shown to improve clinical reasoning skills.

 

Objective: To study the effect of Simulation Wars on in-training examination (ITE) scores and global rating scale (GRS) scores in

emergency medicine (EM) residents.

 

Methods: The quasi-experimental design was used in this retrospective study. The main comparison was with historical controls and the intervention group, who participated in the Simulation Wars.

 

Results: There was a total of 127 residents in this study (70 intervention, 57 control). There was no significant difference found in GRS scores except for communication and professionalism (p<.001). There was a significant (p=.02) improvement in ITE scores in the category of thoracic disorders in first year residents who participated in that category; a significant improvement in the abdominal ITE scores for second year residents who participated in that category (p=.008); and a significant (p=.01) improvement in the ITE scores in trauma for third year residents who participated in that category. Participation in Simulation Wars showed a significant improvement from first to third year and from first year to second year of residency for OBGyn and trauma.

 

Conclusion: Simulation Wars did not improve overall GRS scores nor ITE scores when compared to controls. Simulation wars in such subcategories of abdominal, thoracic, OBGyn and trauma improved ITE scores in those subcategories. Simulation Wars should be considered for EM residents.

Minu Bajpai is a Professor of Pediatric Surgery at All India Institute of Medical Sciences, New Delhi, India. He is a full bright Scholar (Johns Hopkins, Baltimore) and an Executive Editor of Journal of Progress in Paediatric Urology. He is the President of Indian Association of Pediatric Surgeons (IAPS) from 2014-2015. He received ICMR National awards twice: Dr. Kamala Menon award in Pediatrics, 1995 and Kunti Omprakash Gold Medal in Pediatrics, 2009. He Founded the Indian Society for Pediatric Urology & Asian Society for Pediatric Urology in 1998. He has published 201 journals in peer reviewed.

Background: Vesicoureteric reflux (VUR) is a common cause of urinary tract infections (UTI) in children. Continuing VUR can cause renal damage by activating the renin angiotensin system (RAS). Subsequently severe bilateral VUR leads to nephropathy. Therapeutic options are: antibiotic prophylaxis & anti-reflux interventions (endoscopic injection or surgery). The endpoints of these modalities are poorly defined.

 

Aim: To study the incremental changes in renal parameters by anti-reflux intervention in children with VUR who are on antibiotic prophylaxis. Short term and long-term results of anti-reflux procedures: endoscopic injection & surgery, in children with severe grade bilateral VUR. The role of ACE-I therapy in renal recovery is also studied.

 

Methods: A prospective study conducted from July 2009 onwards at our institute and data pertaining to epidemiological, clinical (including blood pressure), biochemical markers: plasma renin activity (PRA), urine microalbuminuria, glomerular filtration rate (GFR), DMSA scan were recorded and compared in patients with severe grade bilateral VUR before & after anti-reflux intervention and after initiation of angiotensin converting enzyme-1 inhibitors (ACE-I) therapy.

 

Results: A total of 76 children with severe VUR who underwent endoscopic injection (n:50) & bilateral Cohen’s reimplantation (n:26) who were on antibiotic prophylaxis for a mean period of 30 months were included. It was seen that 81% patients (61/76) had >20% improvement in their GFR while only 19% (15/76) showed <20% improvement in their GFR after anti-reflux intervention. There was also significant improvement in other markers of renal injury after intervention, such as, PRA, urinary microalbuminuria, GFR, blood pressure & DMSA scan) in both the groups. Further improvement was observed by adding ACE-I therapy.

 

Conclusion: In patients with severe VUR, who are on antibiotic prophylaxis, anti-reflux intervention imparts additional incremental benefit leading to improvement in GFR and other markers of renal injury. In the long term, once the surgical effect plateaus, the use of ACE-I also improves renal recovery.

James E Heubi, MD is an Associate Dean for Clinical and Translational Research; Professor of Pediatrics at the University of Cincinnati College of Medicine. He is the Director of the Center for Clinical and Translational Science and Training which is the vehicle by which the University of Cincinnati, Cincinnati Children’s Hospital and the Veterans Administration Medical Center administer the NIH-funded, Clinical Translational Science Award. He has been an active Clinical Investigator with over 200 peer reviewed publications and was the long term Program Director for the NIH funded General Clinical Research Center. He is the Principal Investigator and Co-Investigator on NIH grants and participates is a local principal or co-investigator on 2 rare disease networks supported by the NIH. His research interests include cholestatic liver disease in childhood and its complications, inborn errors of bile acid metabolism, bone disease in gastrointestinal and hepatobiliary disorders, fat absorption, and cholesterol absorption and metabolism.

To evaluate the safety and efficacy of a novel microbial lipase (NM BL) in a liquid formulation for the treatment of exocrine pancreatic insufficiency in patients with cystic fibrosis, we performed a phase IIa proof-of-concept study. We conducted a doubleblind, randomized, placebo controlled crossover study in patients with cystic fibrosis (CF) and exocrine pancreatic insufficiency  (EPI). Adolescent and adult patients with CF were randomized to receive NM-BL or placebo for 1 week as replacement for their usual pancreatic enzyme formulation. They were subsequently crossed over to the alternate study treatment. The coefficient of fat absorption (CFA) was evaluated as primary end point. Symptoms and adverse events were evaluated as secondary end points. Thirty one patients were randomized in the study and 22 patients completed both treatment periods. During treatment with NMBL, the CFA was significantly higher (72.7%) compared to placebo (53.8%) with a difference between groups of 18.8% (P<0.001). Subjective assessment of stool fat and stool consistency also improved under treatment with NM-BL. Adverse events was mostly gastrointestinal in nature and consistent with the underlying disease. Currently available pancreatic enzyme products are limited because of the lack of liquid formulations and being largely porcine based. The novel microbial lipase NM-BL was safe and effective in this short term trial. The trial provided clinical proof-of-concept for this novel microbial lipase as a treatment for EPI in CF.

Sasigarn A Bowden, MD is a Pediatric Endocrinologist at the Nationwide Children’s Hospital, and an Associate Professor of Pediatrics at The Ohio State University College of Medicine. She is Board Certified by the American Board of Pediatrics (ABP) and Sub-Board of Pediatric Endocrinology. Her clinical and research interests include metabolic bone disorders, pediatric osteoporosis, and diabetes. She is the Associate Program Director for the fellowship program and a Pediatric Bone Expert for the Metabolic Bone Clinic at Nationwide Children’s Hospital. She is the Chief Editor for eMedicine and has published more than 60 articles and abstracts in reputed journals.

Osteoporosis is defined as a systemic skeletal disease characterized by compromised bone strength, and microarchitectural deterioration of bone, leading to fragility fractures. Once thought to be a unique health problem in older adults, osteoporosis has now been recognized as a condition also seen in pediatric patients. Osteoporosis in children has a broad range of etiologies, and is classified into 2 groups: primary osteoporosis or genetic bone disease, and secondary osteoporosis due to underlying chronic diseases. The diagnosis of osteoporosis in children should not be made on the basis of densitometric criteria alone. The presence  of bone fragility with a history of clinically significant fractures and significantly low bone density are required for diagnosis of pediatric osteoporosis. Vertebral fracture in the absence of high energy trauma or local disease is pathognomonic for osteoporosis and can allow the diagnosis without detection of significantly low bone density. Monitoring for bone health should include screening for vertebral fractures that are common and often asymptomatic in children with risk factors for osteoporosis. Other diagnostic studies include biochemical markers of bone turnover, bone mineral density by dual energy x-ray absorptiometry, as well as spinal imaging using densitometric lateral spinal imaging. Optimizing bone health in children with osteoporosis includes treating the underlying condition causing bone fragility, and ensuring adequate weight-bearing exercise, vitamin D and calcium intake. Pharmacologic agents should be offered to patients with fragility fractures. Bisphosphonates have been used successfully in pediatric patients.  This lecture reviews the latest advances in the assessment and treatment of pediatric osteoporosis.