The use of handheld computers in medicine has grown dramatically. This session is intended for those who have a handheld computer (Palm or Pocket PC), or are considering purchasing one, but who have not yet learned how to use it. The goal of the session is to help the beginner achieve a working familiarity with handheld computing such that they will leave the session ready, able and eager to use their own device in their daily life and clinical practice. Ideally, all participants should bring their own handheld. The session will include an overview of the devices and their desktop software; mastery of the basic (built-in) functions: datebook/calendar, address book, memo pad, to-do lists; and add-on applications: where to find them, how to install them and what applications are available specific to clinical pediatrics. Participants should be familiar with the use of personal computers and the Internet, but no prior knowledge of handheld computing is assumed.

Introductions and Overview of Mini Course

Lecture (with Audience Participation)—PDA Basics, Hardware and Software, the Palm OS and Its Functions

Palm OS Functions, Continued; PPC OS

Medical and Pediatric Applications for the PDA

This 6-hour mini course is intended for faculty who teach and do research on pediatric environmental health problems. We will use an evidence-based approach and focus on research that is needed to clarify unresolved issues. The challenges and controversies in the field of pediatric environmental health will be presented, and there will be time to discuss prevention strategies for the clinic and the community. The participants will develop and share ideas to use in teaching, research and practice. (There is a separate workshop for Chief Residents on May 4, 2003.)

In the current climate of funding opportunities, the ability to successfully obtain extramural support involves applying for grants that are appropriate for an investigator's career stage and drafting a clear and focused application. In this session, we will discuss career-stage-appropriate funding opportunities from the NIH. We will also address how to write a grant application, focusing on strategies with proven success. The working of NIH study sections will be reviewed along with how to best address the concerns of review panels. We will also focus on how to obtain funding for fellowship postdoctoral training and early stages of an academic career.

Background: Observational research studies have become increasingly complex. The results of observational research studies can be driven by properties other than chance or causation. While these factors may drive the p values of the results, they also change the appropriate interpretation.

Workshop Methods: In the first half of this workshop, we will formally define confounding, effect modification, restriction vs. heterogeneity of exposure, intermediate variables, selection bias and differential vs. nondifferential information bias. In the second half, we will use a case-based approach to illustrate examples of studies in which the results are driven by these factors and compare differences in the appropriate interpretation in the presence and absence of these factors. Minimal math skills will be needed, however, familiarity with basic concepts of study design and data analysis (case control vs. cohort study, interpretation of Ors, etc.) is recommended. We will specifically illustrate examples of effect modification vs. confounding, intermediate variables vs. confounding, selection bias, underpowered studies, and the role of measurement error in determining effect estimates.
 

Coffee Break

The primary objective of this mini course is to convey the array of issues intrinsic to caring for older adolescents and young adults with chronic, life threatening disease. For several reasons, cancer provides an ideal paradigm for this adolescent/young adult challenge.

1. The spectrum of disease is broader for cancer at many levels of biological organization than it is for any other disease. Virtually all organ systems and organs may be diseased in patients with cancer, whether due to the disease or its treatment. The affected organs include CNS, hematopoeitic, cardiovascular, hepatic, renal, endocrine, musculoskeletal, immune, pulmonary, gastrointestinal, cutaneous, ocular, otic and oral tissues.
2. The affected levels of biological organization include molecular, cellular, tissue, organ, organ system, connective, and psychological. The latter is particularly challenging among adolescents with cancer.
3. The clinical and translational research programs in oncology are among the most organized medical enterprises at the national and tertiary center level in all of medicine, with the cooperative infrastructure that has supported this success among the most successful in the history of science. The advances among children with cancer have been among the most dramatic in the history of medicine.
4. Despite the organizational achievements, there is emerging evidence that patients with cancer in this age group have been ignored relative to the scientific and clinical focus that has been successfully applied to younger and older patients with malignant disease.

The field of medicine is replete with examples of ways that handheld computers may be used to educate, organize and inform clinicians. There are also examples of how researchers may benefit from this technology. During this more advanced session, we will discuss some of these uses of handheld computers. We will provide examples of software in a variety of domains and discuss their historical, current and future use. We also will demonstrate some future technology and discuss its implications. At the conclusion of this session, participants will have increased familiarity with state-of-the-art applications, techniques to install them and the future of handheld computers and wireless networking.

Introductions and Overview of Mini Course

Lecture with Audience Participation: The Top 10 Novel Uses of PDAs in Health Care

Exercises and Demonstrations
 

This 6-hour mini course is intended for faculty who teach and do research on pediatric environmental health problems. We will use an evidence-based approach and focus on research that is needed to clarify unresolved issues. The challenges and controversies in the field of pediatric environmental health will be presented, and there will be time to discuss prevention strategies for the clinic and the community. The participants will develop and share ideas to use in teaching, research and practice. (There is a separate workshop for Chief Residents on May 4, 2003.)

Content of this session is similar to session 6200 An Introduction to Children's Environmental Health

This interactive session will provide the attendee with basic information on publication of a manuscript, as derived from the perspective of an editor. Issues (with data provided when possible) to be discussed are:

A. View From the Inside

1. Characters involved
2. Manuscript flow
3. Peer review process
4. Working with the author

B. View From the Outside

1. How to choose the right journal for your paper
2. How to prepare the cover letter
3. How to prepare the abstract
4. How to prepare the body of the manuscript
5. How to prepare the references

C. Conflict of Interest and Ethics
 

Exciting new advances in gene expression analysis and animal models of childhood ALL and AML have opened the way for the emerging prospect of new forms of targeted therapy for childhood leukemia.

The 21st century heralds a paradigm shift in medical education with a focus turned to competence and outcomes. The Accreditation Council for Graduate Medical Education (ACGME) is spearheading a competency-based system of graduate medical education coincident with the American Board of Pediatrics’ (ABP) initiative to transition from periodic "recertification" to "maintenance of certification." Our greatest challenge as educators lies in developing tools to evaluate competence during training and to equip all trainees with the skills necessary to achieve quality continuous professional development in order to maintain their certification in pediatrics.

The overarching goal of this workshop is to explore the value of using technology as a tool for promoting self-assessment and lifelong learning in continuous professional development. We will demonstrate how physicians can use an innovative web-centered tool to document competence in practice-based learning and improvement. Participants will discover how to create and manage a personal list of educational needs based on their professional experiences, develop individualized learning plans to address these needs and then document the impact of learning on their practice.

The outcome of implementing this web-based technology will be the ability to demonstrate competence of our trainees in the domain of practice-based learning and improvement to the ACGME and the preparation of tomorrow’s physicians to demonstrate evidence of continuous professional development in maintaining their certification.
 

What should you do when parents want you to continue burdensome treatments, which you think are futile? What should you do when parents want you to stop intensive care treatment, the continuation of which you think is in the best interests of the child? Who ought to make decisions for the not yet competent? Is it the parents, the doctors, the ethics committee, society or some other disinterested third party? The goal of this seminar is to consider the complexity of these difficult decisions, looking at factual and evaluative considerations. Through interactive case discussion we will identify the problems and potential pitfalls in decision-making for the pediatric population.
 

This program will give a "pediatric perspective" to smallpox bioterrorism preparedness planning efforts now under way within federal, state and local public health agencies. It will include a review of smallpox epidemiology, clinical disease, smallpox (vaccinia) vaccine and lessons learned from the WHO Smallpox Eradication Program. The nature of the current threat and responses to that threat will be discussed.

Organ transplantation remains the final therapeutic option for many patients with chronic diseases of many organ systems. Extraordinary advances in molecular and cellular biology have led to new immunological approaches which should make the holy grail of immune tolerance a reality for the 21st century. This symposium will focus on the exciting advances in four areas of pediatric solid organ transplantation: pancreatic organ and islet transplantation as a cure for diabetes, hepatic transplantation for chronic hepatic and metabolic disease, renal transplantation for end stage renal disease and small bowel transplantation for previously untreatable catastrophic bowel injury. This symposium is proudly sponsored by the American Society of Pediatric Nephrology (ASPN), the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN), and the Lawson Wilkins Pediatric , and supported by funding from the American Society of Transplantation and the Juvenile Diabetes Research Foundation International

Receive helpful pointers to make your talks memorable and useful. This session will introduce methods of planning and organizing presentations, preparing and designing visual aids, handouts and clear delivery.
 

The 2001 World Trade Center and anthrax attacks established terrorism as a reality in this country. In addition to anthrax, critical biological agents include smallpox, plague, tularemia, botulinum toxin, and viral hemorrhagic fever. Release of sarin nerve gas in the Tokyo subway system by the Aum Shinrikyo cult in 1995 resulted in some 5,000 casualties, including 12 deaths, and the threat of a radiation incident perpetrated by terrorists is also real. Pediatricians have a key role in the management of illness after a terrorist incident, including biological, chemical or nuclear releases. Effective preparedness requires an increased index of suspicion for unusual diseases or clusters of illness, with prompt reporting to public health authorities to facilitate recognition of an outbreak and subsequent intervention. Psychological effects of a domestic terrorist disaster on children will also need to be managed appropriately. This workshop will address the epidemiologic, clinical, preparedness and response issues relevant to biological, chemical and nuclear threats to children, who are especially vulnerable. Specific and detailed diagnostic and management information will be provided, as well as emergency contact and educational resource information.
 

The objective of this symposium is to better understand the molecular and genetic basis of three prototypes of primary immunodeficiency disorders that are of interest to hematologists and the curious pediatrician. Exploring the function of the genes involved in these rare disorders not only contributes to the understanding of the clinical phenotypes but also may lead to improved treatment and ultimately will make gene therapy a reality.

Dr. Notarangelo will describe the different phenotypes of the known Hyper-IgM Syndromes and correlate the clinical findings with the molecular defects associated with these diseases. He will discuss in detail the consequences of mutations of CD40 ligand and its receptor, CD40, on activation of B and T cells and will dissect the molecular events resulting from mutations of activation induced cytidine deaminase (AID) and NEMO.

The clinical spectrum of symptoms associated with mutations of WASP, the gene responsible for the Wiskott-Aldrich Syndrome (WAS) if mutated, will be presented in the second talk. An attempt will be made to correlate mutations of WASP with clinical phenotypes and ultimate outcome.

In the last talk, Dr. Puck will discuss the consequences of the immune dysregulation caused by defects in the cell death pathway and the genetic basis for Autoimmune Lymphoproliferative Syndrome (ALPS).

In the face of dramatic alterations in health care delivery during the 1990s, the roles of pediatric generalists and subspecialists have changed. This has led to national debate as to how general pediatricians and subspecialists should be trained, how they should interact and what final product or solution is desired. Both the United States and Canada are affected by these changes. In this session three experts will cover important aspects of this emerging problem.

Children return to their referring hematologists/oncologists or pediatricians for follow up post hematopoietic stem cell transplant (HSCT). This session will discuss some of the issues, both immediate and long term, that these children face. Many patients may require special care due to chronic graft vs. host disease, and the current treatment, challenges and particular infectious concerns of these patients will be discussed. Immune reconstitution post HSCT will be described, with presentation of newer therapies to accelerate reconstitution. Finally, survivors of HSCT are at risk for multiple endocrinologic abnormalities, including growth failure, hypogonadism and hypothyroidism. The endocrinologic follow-up of these patients and current intervention will be discussed.

Family presence for procedures is a relatively new concept in pediatric medicine. Studies have shown that many parents prefer to be with their children when they undergo painful or invasive procedures. Some physicians are reluctant to accept this break with tradition and refuse to allow parents in the room. The purpose of this workshop is to develop an approach to successful procedures with parental presence. Workshop leaders (including physicians, social work, housestaff) will address critical issues such as:

• Review of the literature—what do parents/families want?
• What is best for the children?
• What rights do the parents have? How about the physicians?
• Are some situations/procedures (i.e., resuscitations) "off-limits"?
• How can we instill confidence in trainees when the family is watching?
• Can we preserve teaching opportunities?
• Are there safety risks? Legal issues?
• Enlisting the help of others: the role of liaisons, social workers, therapists

Using case scenarios and role-playing, workshop leaders will address the pros and cons of family presence for procedures. Participants will be expected to share their experiences and ideas to move forward with this "unconventional" approach to medical care. It is expected that through discussion and debate we will implement a system for success.

for procedures. Participants will be expected to share their experiences and ideas to move forward with this "unconventional" approach to medical care. It is expected that through discussion and debate we will implement a system for success.
 

The incidence of lawsuits in the United States continues to rise. Within this environment, pediatricians are vulnerable to litigation yet often have limited experience and information about the legal process and relevant principles of law. Legal dilemmas are particularly common in acute care settings and frequently are managed without the immediate advice of counsel. In this workshop, participants will explore basic legal issues that impact on medical practitioners, gain familiarity with the litigation process and examine strategies for testifying in court. A team of specialists in pediatric emergency medicine, malpractice issues, court testimony and forensic medicine will begin the workshop with an interactive presentation of case scenarios that highlight common statutory dilemmas, malpractice issues and the litigation process (civil and criminal). Participants will then view videotapes of court testimony and discuss strategies for testifying as a fact or expert witness. Workshop leaders and participants will conclude the session with small group discussions of individual experiences with civil or criminal proceedings and legal testimony. A complete syllabus will be provided for the workshop that is designed for use as a teaching manual.
 

Al Aynsley-Green, National Clinical Director for Children, Department of Health, Her Majesty's Government, Nuffield Professor of Child Health, The Institute of Child Health, University College London

University of London, Director of Clinical Research & Development, Great Ormond Street Hospital for Children and The Institute of Child Health, London

What happens when there is a public national concern about excessive poor outcomes at a Children's Medical Center? This was the scenario in Bristol, England, where a crisis in the outcome of children after cardiac surgery developed even when well–trained, committed, concerned clinicians and subspecialists were intimately involved. Because of this, Professor Al Aynsley-Green, President of the Academic Paediatricians, was appointed to the new post of National Clinical Director for Children by Parliament and to Chair a Children's Taskforce to answer the question of how can such a negative experience like this be turned into positive outcomes for children? He is charged to secure the health and well-being of all children throughout childhood into adult life by developing a National Service Framework for children's services across health, social care and education.

Lessons he has learned and experiences he has lived will be shared to help pediatricians around the world with our quest to improve the lives and health of children. The goals, activities and experiences of the Children's Taskforce, as well as six external working groups, are exportable, practical and logical. Strategies used for developing opportunities not only to improve child health at a local level but also at a national level will be discussed.

Opportunities for questions and discussion will be provided so attendees can share effective techniques to improve child life and health.

This symposium covers four issues in vaccination. The American Academy of Pediatrics and CDC currently are moving toward a recommendation for universal annual vaccination of infants with killed or live influenza vaccine. Why is this? Now that Rotashield is off the market, a new rotavirus vaccine is needed and may be on the way. Despite good protection of children by vaccination, pertussis infections are rising in adolescents and adults. Can they be controlled? Recent disruptions in vaccine supply have caused pediatricians significant problems. What are the causes and solutions?

Environmental health is an increasingly important field within public health. This course will focus on children's environmental health. Children are different than adults in their exposure and susceptibility to environmental hazards. The workshop will emphasize the special needs of children from epidemiologic, physiologic and public policy perspectives. Participants will be provided with several case studies and access to reference material. They will work through the cases to discover clinical information or public policy approaches to dealing with environmental health problems. Participants will be able to: identify the characteristics of children that make them especially vulnerable to environmental insults; describe the unique exposures that children have to environmental hazards; describe the effects of certain specific pollutants on children, and identify components of federal, state and local governments that have an impact on children's environmental health.

The creation of this workshop is funded by a grant from the Association of Occupational and Environmental Clinics.

Content of this session is similar to session 3151 Pediatric Environmental Health (Part I) and 3650 Pediatric Environmental Health (Part II)
 

Recent financial scandals affecting successful and respected companies have focused public attention on conflicts of interest involving corporate officers, stockholders, and customers. In the medical research world, too, recent events have raised questions about conflicts of interest affecting investigators, research subjects and patients. Examples of the latter include the financial interests of gene-transfer experimenters (the Gelsinger case at the University of Pennsylvania) and study goals versus individual subject/patient interests in the Kennedy Krieger law suit (Hopkins lead abatement study). Despite the potential pitfalls, pediatric researchers receive only perfunctory training in handling them. This workshop will provide investigators with a framework for and experience with considering real and perceived conflicts of interest in their research. We seek to provide guidance and support for investigators who need to recognize and face ethical concerns that may arise from proposed and actual research. During the workshop, we will describe potential conflicts of interest affecting: (1) individual researchers, (2) institutions (hospitals and universities), (3) research subjects/patients and (4) the public at large, including the mass media. Short presentations will set the stage for attendees to participate in role playing with a variety of scenarios and to present and discuss their own cases.
 

This session will address the topic of "perinatal origins of adult disease." The three speakers will address different aspects related to the early origins of adult disease. Dr. Kent Thornburg will address the issues related to the fetal origins of adult-onset cardiovascular disease, Dr. Guiseppe Colasurdo will discuss the impact on adult-onset reactive airway disease due to postnatal exposure to environmental stimulants, and Dr. Pinchas Cohen will cover the influence of postnatal insulin-like growth factor on the development of carcinogenesis. All three speakers will shed light on the mechanisms underlying the phenomenon of "Perinatal Origins of Adult Disease" in three different disease states using various animal models. This session will provide cutting edge information that will help set the stage for future interventions targeted at the mechanisms outlined.

Academic Medical Centers (AMCs) are the result of unique partnerships between medical schools, research institutes, and teaching hospitals and are among the treasures of our society. During the past century, AMCs have evolved in response to need and opportunity as well as to social and economic forces. They have made possible unprecedented advances in human health, in biological sciences, in medical technology, and in the education of a very specialized and knowledgeable cadre of scientists, physicians, and other health care professionals. In the process, AMCs have grown large and ever more complex and require continuous inputs of resources to sustain them. Despite the apparent success of AMCs and their widely appreciated intrinsic value, they are challenged as never before. The diversity and complexity of missions has created stresses upon the social order. Financial pressures resulting from a fragmented, market driven reimbursement system, lack of adequate attention to preventive services and to cost of care issues, questions about true measures of quality, ever more expensive research infrastructure requirements, changing social expectations combined with a relative illiteracy regarding science and health in the general public threaten AMCs existence as we know them. Despite fears that these factors have the potential to create a "perfect storm" that will derail the momentum for progress, a detailed understanding of AMCs history, current circumstances, and future prospects gives cause for optimism. With thoughtful leadership, commitment to values, and a willingness to lead change in many areas, AMCs can continue to thrive and achieve even greater success.

The speakers in this symposium are a practitioner of medicine and historian who has written two very widely read and highly acclaimed books about these issues, Learning to Heal and Time to Heal (Kenneth Ludmerer) and a former medical school clinician, teacher, investigator, and dean who is now one of the nations most ardent and eloquent spokespersons for AMCs in his role as president of the Association of American Medical Colleges (Jordan Cohen).

Discussion

Severe sepsis is an important and relatively neglected public health problem in the United States. National estimates show that more children die with severe sepsis than die with cancer. Despite improving national outcomes (10% mortality in 1995 and 9% mortality in 1999), the burden of severe sepsis continues to increase in the US with an estimated associated annual cost of 4 billion dollars. There is cause for continued optimism in the field. In 1968, 96% of children with severe gram negative sepsis died. Early recognition and aggressive fluid resuscitation has been credited with improved outcomes from septic shock (St. Mary’s Hospital reported a 5% mortality rate in meningococcal septic shock/purpura fulminans, and investigators in Vietnam reported a 0% mortality rate in Dengue shock in 2001). Unlike adults, who die of vascular failure, newborns and children who die of fluid refractory septic shock do so from cardiac failure. The American College of Critical Care Medicine published age-specific evidence-based guidelines for management of newborn and pediatric shock in 2002. Understanding of the pathophysiology and potential treatment of sepsis-induced multiple organ failure is also rapidly advancing. Thrombocytopenia-associated multiple organ failure has been further characterized as a thrombotic microangiopathy. Twenty percent of these patients have disseminated intravascular coagulation pathophysiology (unopposed tissue factor activity and consumptive coagulopathy), but 80% have thrombotic thrombocytopenic purpura pathophysiology (increased ultra large vWF multimers and decreased vWF cleaving protease activity). This has great therapeutic implications because recombinant technology is rapidly producing human coagulation-related proteins (e.g., activated protein C, vWF cleaving protease, tissue plasminogen activator), and prolonged plasma exchange therapy is a proven therapy that reverses TTP pathophysiology. Up to 80% of children who die with sepsis do so with multiple organ failure and uneradicated infection. Primary and acquired immunodeficiency states contribute to most of these poor outcomes. Prolonged neutropenia, lymphopenia and hypogammaglobulinemia are readily measured in the clinical laboratory but research measurements (monocyte HLA-DR expression, and ex vivo whole blood TNF a response to LPS stimulation) are required to diagnose prolonged monocyte deactivation and immunoparalysis. Diagnosis of these immunodeficiency syndromes can have great therapeutic implications as tapering of immunosuppression, and use of recombinant growth factors (e.g., G-CSF, GM-CSF, interferon) and prophylaxis strategies can improve outcome in these children.