Residency Training Program in General Pediatrics

Adolescence is characterized by unique biological, social, and emotional changes. The adolescent's perception and interpretation of health and illness are closely interwoven with these maturational changes. Adolescents therefore require diagnostic and therapeutic approaches that differ from other age groups. A teenager's ability to cope with illness is complicated by the many as yet uncompleted developmental tasks such as: establishment of independence and identity, development of a moral code, and career decisions.

Comprehensive adolescent health care should be provided with an understanding of the whole individual - biologically, emotionally, and socially. This approach to care should be performed in relation to the patient's particular level of maturation coupled with coordinated and integrated diagnostic and therapeutic services.

With this general approach in mind, some of the goals of care of the adolescent include: (1) the diagnosis and treatment of the presenting problem; (2) the assessment of any unmet medical and psycho-social needs; (3) the provision of preventative health care measures. Indeed, education and prevention of problems related to substance abuse, unwanted pregnancy, and sexually transmitted diseases including AIDS, may well represent areas of greatest need and greatest challenge for health care personnel caring for teenagers.

The Adolescent Medicine Division with its accredited Adolescent Medicine Fellowship Program runs two adolescent clinics in the pediatric outpatient area at Kings County Hospital (one afternoon and one evening) and two morning clinics at University Hospital of Brooklyn in Suite D. In addition, residents attend several sessions of the Health and Education Alternative for Teens (HEAT) Clinic at KCHC which has a particular focus on teens with HIV or at increased risk for HIV. During these experiences, the resident is directly responsible for patient care under the supervision of Dr. Suss (General Adolescent and Adolescent Gyn) or Dr. Birnbaum (HEAT). The division teaches pelvic examinations as well as comprehensive gynecologic care for teens. In 1995, there were 540 adolescent outpatient visits. In addition, nearly 100 consultation requests were answered on such diverse problems as endocrinologic problems, dysfunctional uterine bleeding, pelvic inflammatory disease, contraception, rape, suicide attempts, chronic disease, substance abuse, and ammenorrhea. Research in the division includes risk factors for P.I.D., risk factors for Hepatitis B infection, and epidemiology of suicidal behaviors in urban youth.

The resident experience in Allergy and Immunology consists of contact with patients for evalaution of or with diagnosed autoimmune disorders, vasculitidies, rheumatologic conditions, immunodeficiency disorders (incl. HIV), and allergic diseases. As a conjoint pediatric/adult subspecialty, the division also conducts weekly conferences including clinical rounds, journal club, and interdisciplinary meetings which the resident is expected to attend and participate in. Opportunities are provided for case-based and topic presentations. Interested residents have the opportunity to participate in research activities, and case-based research and case reports have been performed.

The Allergy-Immunology division has an accredited fellowship program as a conjoint program with the Department of Internal Medicine here at S.U.N.Y. H.S.C.B. The division runs two clinics at KCHC and one adult and one pediatric clinic at UHB. In these clinics, residents directly see, evaluate and manage patients under the guidance of supervising faculty. The pediatric immunology clinic also sees a number of patients with AIDS and a fair number of patients with JRA, SLE and other rheumatologic and collagen-vascular diseases. The division also operates the Pediatric Lupus Center at Downstate.

Almost all laboratory services are available on-site, including granulocyte function tests, leukocyte adhesion tests, immunoglobulin levels and subgroups, complement studies, detailed collagen-vascular work-ups, T and B-cell counts and subsets. The mitogen stimulation test is obtained through the laboratories of the Department of Pathology. Research for those interested is available in association with the basic science departments as well as divisional clinical studies.

This experience is available at KCHC  /UHB

At KCHC/UHB, the experience consists of following inpatients admitted by the service, following patients admitted for procedures, attending faculty supervised consultations and daily follow-up on inpatient units, consultations in acute care areas, and ambulatory experiences. The outpatient experiences consist of 2-3 cardiology clinics per week as well as consultation in acute care areas and sessions dedicated to outpatient procedures such as echocardiography, exercise testing and EKG interpretation. Residents attend Cardiac Physiology Catheterization Conferences at New York Hospital. Didactic sessions include evaluation of cyanotic, acyanotic/obstructive congenital heart disease, arrhythmias, EKG interpretation, acquired heart disease, etc.. Residents are expected to attend all departmental conferences as well. A close relationship with the cardiology attending faculty emphasizing bedside teaching and didactics is a highlight of this experience.

Over the course of the four- week elective residents will become familiar with identifying children at risk for abuse, recognize the signs of neglect and maltreatment, and understand the implications of neglect and abuse on the child, family and society as a whole.

Goals:

Increase the knowledge base of child abuse and neglect through observations and didactic sessions.
Identify children at risk for abuse
Understand the pediatrician's role in preventing child abuse and neglect.
Understand the pediatrician's role as a mandated reporter.
Develop skills to help in the evaluation of suspected child abuse and maltreatment through clinical observations.
To understand the role of the child abuse specialist in the evaluation of cases of suspected abuse and neglect.
To understand the interdisciplinary approach to child abuse and maltreatment through the various site visits to agencies involved in child protection.
Site Visits:
It is important that residents become familiar with the multi- disciplinary facets of child abuse prevention by attending various sites. Residents will have the opportunity to attend weekly clinic sessions at the Kings County Child Abuse Clinic where they observe medical evaluations of children who are victims of child physical and sexual abuse. During these sessions patient cases and literature pertaining to the cases will be discussed. Other site visits include, the Jane Barker Child Advocacy Center, The Vincent J Fontana Center for Child Protection, Brooklyn District Attorney' Office- Crimes Against Child Bureau, and the Administration for Children's Services.

The Division of Pediatric Neurology has a professional staff consisting of 4 full-time and 2 part-time pediatric neurologists, 6 Fellows, a neuropsychologist, a clinic coordinator and a social worker. A division of the Department of Neurology, the Child Neurology service has access to a large and active neurology faculty and a full range of neurodiagnostic services such as EEG, EMG, evoked potential laboratories, sleep laboratory and a neuromuscular disease clinic as well as a new Epilepsy Monitoring Unit at UHB.

Pediatric neurology in-patient activity occurs at both Kings County Hospital and University Hospital. There are 2 in-patient teams, one for consultations and one for neurology admissions, each consisting of an Attending, a Fellow and 'rotators' from general pediatrics and adult neurology. Both teams meet at a daily morning report where all consultations and admissions are presented and discussed. The most frequent admissions are children with difficult to control seizures, hydrocephalus, complications of V-P shunts, CNS tumors, and some interesting neurometabolic diseases. The consult service is often involved with severe head trauma, CNS infections and neurologic complications of systemic disorders such as renal diseases, sickle cell disease or metabolic seizures. There are frequent consultations by neonatology and sometimes from child psychiatry.

Weekly out-patient clinics held include one at KCHC and three at University Hospital: (1) Screening Clinic for new patients; (2) General Follow-Up Clinic; (3) Seizure Disorders; (4) one of the following special continuity clinics: Neurosurgical follow-up, Learning Disability, Spina Bifida/Neuroanatomic Disorders Clinic - a multidisciplinary clinic which is the only one of its kind outside the Rusk Institute in Manhattan. The spectrum of patients being seen in the clinics ranges from headaches, seizure disorders, developmental disabilities, motor or cognitive sequelae of head trauma, CNS infections, cerebro-vascular disorders and cerebral infarction. The division works closely with Pediatric Neurosurgery, and 2 out-patient clinics are operated jointly. Patient management conferences and brain tumor board conferences are held as needed.

The teaching program includes daily morning report and bedside rounds, weekly Grand Rounds, a weekly pediatric neurology topic conference and bi-weekly conferences in neuropathology, neuro-ophthalmology and mucle diseases. There is a monthly Journal Club conducted by a bio-statistician and a didactic course in neuroscience and in pediatric neuropsychology. All of the above are open to all neurology residents, fellows, and rotating residents.

Several faculty members are engaged in NIH funded research: studying the mechanisms of epilepsy using hippocampal neurocortical brain slices in vitro; studying long-term memory and long-term potentiation using hippocampal slices; investigating molecular biology of congenital myopathies; studying brain functions using magnetic coil stimulation; studying calcium mediated glutamate excitotoxicity; clinical studies of the role of ionized magnesium in the pathogenesis of migraine. Residents are encouraged to participate in research projects.

All residents have a 2 to 4 week experience in Child Psychiatry. This is a unique opportunity available in very few pediatric programs. The rotation enables pediatric residents to develop competency in the diagnosis and treatment of children and adolescents with emotional, physical, and developmental problems. Residents participate in the assessment of children presenting to the Child Psychiatry walk-in center as well as follow-up of patients receiving outpatient care by the Child Psychiatry service. In addition, resident will also have the opportunity to participate in the evaluation and follow-up of children and adolescents with serious mental illness admitted to the Child and Adolescent Psychiatry inpatient units in the Behavioral Health Facility at Kings County Hospital Center. In addition to being exposed to the broad range of mental health concerns encountered in children and adolescents, residents will become familiar with the management of these patients using group therapy, psychotherapy, behavior modification, other non-pharmacologic methods as well as pharmacologic interventions and their complications.

The required rotation in behavioral and developmental pediatrics is an extensive outpatient experience given in a one month block to all residents. Although occasional consultations are made on the inpatient and critical care units at KCHC and UHB, 95% of the experience is had in a variety of outpatient settings. The rotation begins with an introduction to normal development and behavior and instruction in proper technique for performing the Denver Developmental Assessment II and behavioral screening devices. Throughout the month long rotation at KCHC/UHB, residents can attend:

• Neurodevelopment and High Risk Follow-up Clinics
• Development Evaluation Center (developmental disabilities, autism, pervasive developmental disorders, Aspergers Disorder, communication disorders, mental retardation, learning disabilities, ADHD)
• The early intervention program of the Infant Child Learning Center (premature children, low birth weight, HIV positive, CP, microcephaly, hypotonia, neonatal seizure, hydrocephalus, etc. evaluate psychosocial systems and issues and psychometric testing)
• Walk-in Child Psychiatry Clinic (ADHD, oppositional defiant disorder, conduct disorder, adjustment disorder, school failure, depression, dysthymia, bipolar disorder, psychotic disorders, anxiety disorders, obsessive-compulsive disorders, school refusal)
• Audiology/ENT to learn hearing and language evaluation
• Neuropsychology/Psychology Clinic (IFSP, Bayley, Stanford Binet, therapy/counseling)
• Neurobehavioral Clinic
• Occupational/Speech/Language/Physical Therapy
• Psychopharmacology Clinic
• Orthopedics/Rehab Clinic
• Pediatric Ophthalmology Clinic
• Spina Bifida and Neuroanatomical Disorders Clinic
• Neurobehavior Clinic
• Genetics Clinic

In addition to this wealth of experiences, residents are required to make off-site visits to:

• The United Cerebral Palsy School
• The St. Francis School for the Deaf
• League Treatment Center for autistic/emotionally disturbed/neurodevelopmentally disabled children
• Institute for Basic Research in Developmental Disabilities

Residents maintain a log of all patient encounters, which is reviewed and discussed weekly with the rotation director.

The clinical experiential components of the rotation are enhanced by a comprehensive didactic series.

Longitudinally, the experience and skills acquired during the block rotation is augmented and reinforced in all patient care settings. Developmental and behavioral assessment is an integral component of the evaluation and management of all patient encounters in the inpatient and ambulatory care settings under supervision of pediatric faculty serving as ward and clinic attending. Developmental and behavioral assessment is an important component of the continuity practice. The Division of Developmental Pediatrics and Child Behavioral Services are readily available for education and consultation at all times. Interdisciplinary Psychosocial Rounds are held on an ad hoc basis on inpatient units and critical care units to address the emotional and developmental impact of chronic and life-threatening illness and the antecedents and consequences of traumatic life events.

The experience in pediatric critical care consists of a one month block rotation in the PL2 year in the PICU at KCHC. A second block rotation occurs in either the PL2 or PL3 year in the PICU at UHB or as a PL3 supervising senior in the PICU at KCHC. The Pediatric ICUs at KCHC and UHB are modern units capable of providing state-of-the-art sophisticated intensive care to a full and diverse spectrum of patients.

The residents are directly responsible for the evaluation, management, reassessment and care coordination for a diverse group of patients presenting with acute, severe medical illness, severe exacerbations or complications of chronic disease, post-surgical management (including neurosurgery, thoracic surgery and transplant surgery) and trauma. Residents are involved in every aspect of the critically ill patient's care. Resident participation begins on initial presentation in the emergency room through the daily care, hourly monitoring, all procedures and interventions in the ICU, all communications with patients' families, primary care providers and other members of the care team and preparation and planning for transfer, discharge and home care needs. Residents write all of the orders, admission notes, document daily progress, prepare discharge/transfer notes and consultation requests. Invasive procedures (e.g. intubation, central venous line placement, arterial line placement) are performed by residents under the direction of supervising attending faculty.

Through extensive patient contact, patient care experiences and formal didactic sessions given throughout the month, residents develop an understanding and appreciation for the multiorgan system and multidisciplinary aspects of pediatric critical care. Using faculty trained in critical care and subspecialty consultants residents develop an understanding and competency in the management of complex, life threatening conditions in children across a spectrum of ages. Particular emphasis is placed on nutrition (including TPN), fluid and electrolytes, cardiac management (including pressor support), respiratory management (including intubation and mechanical ventilation), CNS management (including ICP management, cerebral edema and shunts/drains), infection control ( including management of contagious disease and isolation precautions), sedation and pain management, invasive and non-invasive monitoring and support, laboratory data ,and psychosocial implications in critical illness. Basic and advanced life support protocols and techniques are reviewed and practiced. Residents have the opportunity to participate in transport of patients within the hospital and between hospitals or other care facilities. Pediatric residents also participate in the care and pre/post operative management of surgical patients and patients with multiple trauma. Patients with surgical subspecialty problems are cared for by the pediatric medical service in the PICU.

In addition to pediatric critical care specific knowledge and patient care skills, residents are expected to demonstrate practice based learning, appropriate communication skills, appreciation for and adherence to the highest ethical principles (often challenged in the ICU setting) and involvement in system based practice including appropriate risk management, performance improvement and quality assurance activities.

KCHC is a large, busy municipal facility serving an underprivileged inner-city population with a large immigrant community. KCHC has an extremely active emergency department and is a level I trauma center. The PICU at KCHC consists of a brand new 7 patient individual room unit including 2 negative pressure laminar flow isolation rooms in a technologically sophisticated new inpatient care tower. Each bed has capacity for monitoring a full range of invasive and non-invasive parameters along with central station monitoring. There is also a medical information computer workstation at each bedside. In addition, 4 close watch beds on the inpatient unit are co-monitored by the PICU. The unit has a consultation room, a bereavement room, a conference room, and a large visitor's lounge. All approved and standard of care treatment modalities are available including new microprocessor controlled multimodal ventilators, high frequency ventilation, heliox therapy, transcranial doppler and intracranial blood flow monitoring, external pacemaker support, hemo and charcoal perfusion and nitric oxide administration. A robotic pharmacy provides unit dosing and a digital imaging radiography system (PACS) is on-line. Computer stations throughout the unit provide access to medical record information as well as medical references and internet access to the College of Medicine and its online resources. The clinical pathology labs provide comprehensive services and microtechnique for pediatric samples.

UHB is a state operated tertiary care referral facility that also serves the primary care and acute care needs of nearby communities. UHB provides organ transplantation services, stem cell transplantation and hypertransfusion, oncologic services, neurophysiological monitioring, cardiac and cardiothoracic services, hemodialysis and peritoneal dialysis, an asthma and respiratory disease center and a variety of surgical subspecialty services including airway reconstruction, neurosurgical repair, genitourinary reconstruction, etc. Many of the patients receiving these sevices require PICU care. In addition, UHB receives acute admissions through a walk-in urgent care center and an ambulance receiving emergency room. The PICU at UHB consists of a 5-bed open floor plan ICU with one additional double door isolation room. There is a 4-bed step down unit available on the adjacent inpatient unit. This unit can provide plasmapharesis, hemodialysis, 24 hour digital EEG in addition to comprehensive standard monitoring, and all modalities of support and intervention identified for the KCHC PICU. The unit has access to a digitized imaging retrieval system, robotic unit dosing pharmacy and all internet resources. Point of care I-Stat testing is available and the clinical pathology laboratory provides microtechnique for pediatric samples.

Experience in this subspecialty is gained from two major clinics, namely, the Pediatric Dermatology Clinic (PDC) and the Pediatric Eczema Clinic. They both meet one morning a week.

The PDC is a referral center not only for other KCHC-UHB clinics, but also for satellite clinics and other Brooklyn hospitals. It is one of the busiest pediatric subspecialty clinics with approximately 2000 patient visits per year. A wide variety of skin disorders in children (except atopic dermatitis) are seen and treated. Some of the diagnostic procedures available are: skin biopsies, Tzanck test, KOH prep, DTM fungal culture, Wood's lamp examination, and light microscopy. Minor surgical procedures performed in the PDC include excisions, cautery, electrodessication, cryotherapy, and chemical dessication. Ultraviolet A and B phototherapy, and laser surgery are available for selected cases. Before the PDC starts, the staff meet for a journal club.

The Pediatric Eczema Clinic is solely devoted to children with atopic dermatitis. It has an average of 800 patient visits per year. Before the clinic starts, the residents meet with a parents support group. During this meeting, care of the dry skin and other treatment instructions are reinforced.

Participation in these clinics is available as part of the general ambulatory care rotation. In addition, residents can choose Pediatric Dermatology as a specialty elective. The four week elective follows a structured program integrating the following: the major pediatric clinics plus an adult dermatology clinic session each week, consultation on the pediatric wards, nurseries and emergency room, grand rounds and clinical conferences in both the Departments of Pediatrics and Dermatology. Residents serve as supervised consultants with first contact for patients on inpatient units and in outpatient and acute care areas. Consultations are then seen and discussed with the pediatric dermatology attending. Residents attend 4 pediatric dermatology clinics per week. Residents are taught indications and technique for skin punch biopsy and are exposed to treatment modalities including lasers, steroid injection, UV therapy, and dermatologic plastic surgery. Didactic component includes a weekly pediatric dermatology conference, a weekly dermatology grand rounds, weekly biopsy conference and topic discussion sessions. Residents are expected to attend all pediatric department conferences.

Pediatric Emergency Care is a required pediatric specialty experience. Our residency program provides exceptional experiences in pediatric acute care. All residents will have at least four months of rotations in pediatric emergency care during their three years of training. These rotations will be in the EMS receiving facilities of Kings County Hospital, University Hospital of Brooklyn and/or Long Island College Hospital. During this rotation, residents will gain experience in a variety of procedures including suturing lacerations, splinting and casting, extracting simple foreign bodies, resuscitations, and lumbar punctures to name a few. Additional descriptive information about these rotations can be found under the Pediatric Acute Care tab.

The Pediatric Endocrinology Division is staffed by 4 Pediatric Endocrinology faculty, a nurse specialist and 5 subspecialty fellows in a fully accredited fellowship program in a service which is integrated with Maimonides Medical Center. The division conducts very active endocrine clinics throughout the week, at KCHC and at UHB. 15 to 20 patients are evaluated at each clinic by residents and fellows. Each patient is discussed and the treatment plan reviewed with a supervising pediatric endocrine attending. Teaching responsibilities for rotating medical students and residents present in the clinics are shared by the endocrine fellows.

A diagnostic endocrine service at UHB is held weekly where specialized endocrine testing is performed.

The division has a growing Insulin Pump Program and is also an integral part of the Pediatric Obesity/Metabolic Syndrome center at UHB in conjunction with the divisions of general pediatrics, pulmonology, cardiology and gastroenterology.

Consultations in endocrinology include patients admitted to both KCHC and UHB. Residents follow a number of endocrinology patients admitted to the inpatient service. Residents are the first to respond to consultations on inpatient units and in acute care areas. Consultations are then seen with the fellows and then seen by and discussed with supervising teaching faculty. There is a weekly 3 hour pediatric endocrine conference held with the fellows, rotating residents and attendings to discuss in detail inpatients, consultations, clinics and research. Several times each year, the division hosts invited speakers who are nationally and internationally recognized authorities in the field.

The division is very active in research with multiple presentations at international meetings annually and publications in specialty journals. There are several areas of ongoing research including diabetes, growth hormone, and metabolic diseases. The wealth of distinctive pathology seen in Brooklyn also provides ample opportunity for publishing case reports and case series. Participation in any of the division's clinical or basic science research projects is available.

Pediatric Gastroenterology and Nutrition sees much of the spectrum of digestive diseases in children. In addition, nutritional problems are seen as are a variety of liver diseases including evaluation for and post-operative care of liver transplantation patients. The division with its fully accredited subspecialty fellowship program consists of 3 full time and 2 part time attending faculty, 3 fellows, 1 clinical assistant and several collaborating basic scientists. Clinics at both Kings County Hospital and University Hospital are busy and provide the fellows, residents, and students with opportunities to diagnose virtually all presentations of common problems, such as gastroesophageal reflux, abdominal pain, rectal bleeding, malnutrition, diarrrhea, jaundice, and learn to prescribe appropriate management strategies including nutritional support employing enteral and parenteral means.

The experience in Gastroenterology consists of following a variety of patients admitted by the service to UHB as well as participating in responding to a large volume of consultations for gastrointestinal disease and nutrition problems on inpatient units and in acute care areas at KCHC and UHB. Residents have initial contact with patients consulted on. They then see and discuss the patients with the supervising teaching attending and the subspecialty fellow. Residents attend 3-5 outpatient clinics per week and provide direct patient care under attending faculty supervision. Formal didactics include weekly GI Clinical Conference, Journal Club/Research Meeting, Biopsy Conference and regional pediatric GI Conference. In addition, there are weekly topic discussions and residents are expected to attend all departmental conferences.

The division has a very active procedure service. The housestaff and especially those rotating with the division will see invasive procedures such as upper endoscopy, injection of esophageal varices, small bowel biopsies, percutaneous gastrostomy tube placement, colonoscopy, polypectomy and liver biopsies. In addition, pH probe studies and breath hydrogen studies are performed.

The division is involved in research in immunology and inflammation, lipid disorders and other areas. Opportunities for participation in divisional research activities are available. In addition, there are opportunities for medical students and housestaff to write-up interesting cases of hepatic and digestive disease in children for publication.

The genetics program provides quality diagnostic and counseling services to all patients, to increase knowledge of genetic disorders and their treatment among consumers, and to coordinate professional education of students, residents, other physicians and paraprofessionals.

Two main categories of referrals to the program are (1) children and adults with genetic diseases, congenital malformations, and mental retardation, and (2) pregnant women at high risk for bearing children with genetic diseases (chromosomal abnormalities, neural tube defects, sickle cell disease, etc) or malformation syndromes (teratogenic or genetic). As a Regional Perinatal Center and High Risk Obstetrics Facility, University Hospital of Brooklyn is a referral center for newborn prenatally diagnosed or at high risk for having significant congenital anomalies.

The main activities of the program are focused in the departments of pediatrics and obstetrics and gynecology, and referrals are received from other clinical disciplines as well as other hospitals and community health, social agencies and practicing physicians. Consultations are provided to inpatients on the wards and nurseries.

Patients (200-300 annually) are also seen in weekly clinics for birth defects. In addition, hundreds of pregnant women are provided genetic counseling and or prenatal diagnostic examinations. Patients with suspected or proven inborn errors of metabolism are referred for consultation and counseling. Genetic services are provided by an attending geneticist, a genetic counselors, and cytogenetic technologists. Laboratory, an integral part of this specialty, provides karyotypes on blood, bone marrow, skin and amniotic fluid, sex chromatin studies and dermatoglyphic evaluation. Patients with birth defects are also provided long-term follow-up at regular intervals. This allows an opportunity to gather additional data on these patients, and to detect subtle complications and changes in the phenotype. During follow-up, patients and families are given updated information about managing medical problems and obstetric options.

An affiliation with the New York State Institute for Biomedical Research (IBR) on Staten Island gives residents the opportunity to participate in the diagnosis, care and management and counseling of children with inborn errors of metabolism, mitochondrial defects, several chromosomal anomalies including Fragile X Syndrome and neuroanatomical conditions. The primary intention of the training is to give a broad based experience in clinical and laboratory evaluation of genetic diseases, in providing counseling, in cytogenetic techniques, and in research methodology. The clinical program emphasizes dysmorphology, teratology, and genetic counseling.

The Pediatric Hematology and Oncology service provides clinical care for a large group of children and adolescents with hematologic and oncologic problems. Residents and subspecialty residents have first hand experience in managing our patients. Since the early 1960s, our division has been and continues to be very active in diagnosis, management and research of sickle cell disease and its complications. Landmark clinical research relating to pneumococcal infection in patients with sickle cell disease was first reported from this division. We are also a comprehensive sickle cell center established in 1972 under a NHLBI grant. Consequently, our division has a large population of patients with sickle cell disease who are on chronic transfusion regimens. Other areas of research interest include studies of radionucleide and magnetic resonance imaging in the evaluation of patients with sickle cell disease and bone pain, and in parvovirus B19 infections in these patients. The division is an affiliate member of the Children's Cancer Group since 1978, the largest cooperative treatment group for children with cancer. We have access to the most current research protocols and therapeutics for the treatment of childhood cancer.

Of course, we also have a very active teaching program with didactics occurring in clinics, on daily rounds with attending staff, during weekly literature review/seminar, and weekly hematology-oncology rounds. During an experience on this service, residents serve as consultants on inpatients and outpatients. They have first contact for consultations and then see and discuss the consultation with the supervising attending. Rotating residents follow patients admitted to the division's service at UHB and those known to the division admitted to KCHC. Residents participate in the care and management of patients presenting for routine ambulatory treatments of chronic transfusion and chemotherapy administration. In addition, residents attend active outpatient clinics 4 times per week where they provide direct patient care under subspecialty attending supervision. Residents are expected to review slides of peripheral blood and bone marrow and follow-up histopathologic studies. Several didactic sessions held include weekly pediatric tumor board, hematology conference, journal club and research conference. There are also topic based discussion sessions, and residents are expected to attend all pediatrics department conferences.

The division is staffed by four full-time attending physicians, a pediatric nurse practioner, a nurse with special competence in the subspecialty, a clinical research associate and a social worker. Additional support services are provided by all pediatric subspecialists.

An active hematology/oncology service supervised by 2 full time subspecialty attendings also exists at Long Island College Hospital. LICH has a Thalassemia Center and operates a busy transfusion/infusion center at the hospital.

Memorial Sloan-Kettering Cancer Center (MSKCC)
During the PL-2 year, 2 Downstate residents per month rotate as part of a team on the Bone Marrow Transplant Service at MSKCC. Our residents serve as the primary caretakers for these complex patients receiving quaternary care for a range of serious conditions amenable to this intervention, such as malignancies, hemoglobinopathies, inborn metabolic errors, immunodeficiencies. Residents work under the direction and supervision of MSKCCs Pediatric Hematology/Oncology fellows and subspecialty faculty.

During the PL-3 year, 2 Downstate residents per month are assigned to MSKCC as senior supervising residents on the Pediatric Oncology Service. These PL3s will supervise junior residents and guide the assessment and management of pediatric problems associated with and complicating oncologic disorders. The senior residents work alongside the Pediatric Hematology/Oncology fellows and are supervised by MSKCCs esteemed subspecialists.

The elective in Pediatric Infectious Diseases offers the pediatric resident the opportunity to expand their clinical skills in this area. While on the elective, the resident participates in Pediatric Infectious Disease consultations working closely with the Pediatric ID fellow. The resident can also attend a weekly Infectious Diseases Clinic and has the option of attending additional HIV Clinics. The resident will gain experience in the evaluation of children with infectious diseases ranging from the routine to the complex including infections in immunocompromised hosts including HIV, nosocomial infections, and tropical infections. Accompanying the fellow, the resident will liaison with the Microbiology, Mycology, Mycobacteriology and Virology Labs at Kings County and University Hospitals. The resident will gain expertise in the appropriate use of antibiotics and use and interpretation of diagnostic tests, including culture and molecular methods.

There are daily rounds with the attending and weekly didactic and research conferences, and Brooklyn Infectious Disease Rounds, held in conjunction with the adult infectious disease service. There is also a monthly Infectious Disease Journal Club. The elective can also provide opportunities for clinical research.

Rotations in the NICU consist of one-month block experiences. Residents identify patients requiring admission to the NICU. The spectrum of patients seen fills the gamut of neonatal disease including extreme prematurity, congenital malformations, congenital heart disease, RDS, sepsis, anemia, hyperbilirubinemia, birth trauma, fluid and electrolyte disorders, inborn metabolic errors, congenital infections, asphyxia, etc. Residents in the NICU admit, evaluate and frequently re-assess patients, devise a management plan, document progress, obtain and evaluate lab tests, perform invasive procedures (intubation, umbilical line placement, arterial line placement, thoracostomy and chest tube placement), manage ventilators, assess invasive monitoring results (ICP, CVP,IBP), order therapy and make therapeutic changes, communicate with parents and with the team of care providers. Supervision is provided by board certified neonatologists who are present in-house 24 hours per day, 7 days per week.

At the beginning of residency, all residents are trained in and expected to be certified in Neonatal Advanced Life Support. Each month at the start of each rotation, resuscitation protocols and techniques are reviewed using a video presentation, mock codes, discussion and skill demonstration. Resuscitation mannequins are available for practice. Senior residents lead PL1 junior residents and physician extenders in resuscitations in the NICU, delivery room and operating room. Residents respond to calls from the delivery room for all high risk or complicated deliveries. Instruction is provided during the course of the rotation and again as needed in neonatal transport both between institutions and within the institution. Residents are included in the transport team. Staff neonatologists also supervise neonatal transports.

The NICU at KCHC is a new modern 30 bed tertiary care unit. The unit has an open floor plan and each bed is monitored at a central station. This NICU provides high frequency ventilation, microprocessor controlled conventional ventilation, nitric oxide administration, hypothermia therapy along with 24/7 availability of anesthesia and radiology services including CT and MRI. There is a portable C-arm kept on the unit. In addition, there is a treatment/procedure room, several single patient isolation rooms, consultation room, conference rooms and a family bereavement room. All pediatric subspecialties and pediatric surgical specialty services are readily available.

The NICU at UHB is a brand new, state-of-the-art 29 bed high level tertiary care unit capable of advanced and sophisticated neonatal care. Respiratory services are provided by NICU dedicated pediatric respiratory therapists and include inhaled nitric oxide and high frequency ventilation. There is also 24/7 availability of radiology services and various subspecialties. Micromethod laboratory processing, NICU I-Stat labs and blood gases are available. The nurses have extended roles. Physician extenders including nurse clinicians and physician assistants are integral members of the patient care team. There are dedicated social work support and nutrition services. This unit supports a fully staffed and fully equipped transport team. This NICU is designated by the NYS Department of Health as a Regional Perinatal Center.

Current areas of research within the Division include studies on regional blood flow, treatment with hypothermia, indirect calorimetry and energy expenditure, antioxidants and nutrition, and multiple clinical trials and studies of neonatal pharmacokinetics. A newly established borough-wide neonatology consortium has been developed. Building on this and an active academic program, under the new leadership of Dr. Jacob Aranda, plans for resuming a neonatology fellowship program are underway.

The Renal Service is a very active and productive division. The division has a large outpatient and inpatient program. Both glomerular and tubular disorders as well as de novo glomerulopathies in the context of renal transplant are well represented. The division serves a large nephrotic syndrome population. Renal disorders, both idiopathic and secondary to systemic diseases, such as SLE, are routinely seen. Our inpatient service occupies a substantial number of beds at UHB NS42 throughout the year. Patients on the inpatient service have complex fluid and electrolyte problems, acute rejections of their kidney allografts, and frequently are in acute renal failure. In addition, the Renal Service operates one of the country's largest pediatric maintenance hemodialysis units providing renal replacement therapy throughout the week. This complex operation is constantly monitored by Nephrology fellows and supervised by 3 Pediatric Nephrology attendings. We also have an active transplant program; we have established an excellent track record in long-term survival of both living related and cadaveric donor transplants. The division has an accredited pediatric nephrology fellowship training program with 3 fellows.

Residents rotating on this service participate in the care and daily follow-up of patients, primarily end-stage renal disease and renal transplants recipients, admitted under the Renal Service at UHB. In addition, residents serve as supervised consultants for inpatients and outpatients at both UHB and KCHC for problems including renal dysfunction, fluid and electrolyte disorders, hypertension, poisonings, and infection. The residents follow progress of patients presenting for routine chronic dialysis. Residents attend and provide supervised direct patient care in 3 clinics per week. Didactics include weekly divisional clinical rounds, weekly biopsy conference, weekly journal club and research conference, and daily rounds, and residents are expected to attend all departmental conferences. Several sessions are held for topic discussions including electrolyte disorders, hypertension, glomerulonephritis, nephrosis, hematuria, UTI.

Research efforts of our division are very successful. Our fellows present at national and international meetings. There is an extensive bibliography generated by this service on various aspects of renal transplantation, such as vascular thrombosis, chronic rejection, graft survival and growth post-transplantation. In addition, numerous peer-reviewed articles on nephrotic syndrome and other glomerular disorders have been produced.

During this elective rotation, residents will work closely with the team of physicians and allied health professionals involved in the care of children and families infected with HIV, with AIDS or at high risk for contracting HIV. Residents will rotate through a variety of clinics dedicated to the care of this population of patients with highly complicated medical and familial / biopsychosocial issues. Residents will learn the team approach to caring for and advocating for these patients. They will participate in direct patient care as well as multidisciplinary meetings and interventions. Residents will learn about the many medications used for prophylaxis and treatment of AIDS and its myriad complications. Residents will learn how HIV infection is monitored and how to use viral load in assessing treatment response in addition to the many other laboratory studies used in monitoring these patients. Residents will also learn the natural course of the disease as well as the management of associated medical and psychological conditions. In addition to outpatient care and follow-up, residents will consult on and follow patients who have been admitted as well as participate in consulting on patients with suspected HIV infection or significant risk factors for infection. Finally, residents will also learn about preventative care and guidance to assist and educating patients to prevent infection and disease.

The Pediatric Pulmonology Division is one of only 42 accredited Pediatric Pulmonary training programs in the U.S.A.. There are 3 full time and 2 part time Pediatric Pulmonologists, a pediatric pulmonary function technician, a pulmonary physiologist, 2 physician assistants, a nurse educator along with 2 Pediatric Pulmonology subspecialty fellows in a fully accredited fellowship program. The division has a well equipped pediatric pulmonary function laboratory, which includes comprehensive lung function assessment, an infant lung function laboratory, an exercise physiology laboratory and a sleep study laboratory. The clinical responsibilities of the Pediatric Pulmonary Division encompass all children with tuberculosis, chronic asthma, sleep apnea, respiratory insufficiency and complicated pulmonary and respiratory control diseases seen at the Children's Hospital of Downstate and Kings County Hospital. The division is recognized as a center of excellence for the treatment of children with tuberculosis, by the New York City Bureau of Tuberculosis. A Pediatric Asthma Center of Excellence and a Mobile Asthma Center bus are under the direction of the division and have thousands of patient visits annually.

The Pediatric Pulmonology Division has an active endoscopic program and performs a number of bronchoscopies, laryngoscopies and diagnostic and therapeutic bronchoalveolar lavages each year. The division maintains a state of the art digital videobronchoscope cart and several fiberoptic and videobronchoscopes. Procedures are performed on patients ranging from preterm neonates to intubated or tracheostomized children to adolescents with acute and chronic lung or airway diseases.

The Pediatric Pulmonary Division conducts several weekly clinics: the KCH Pediatric Chest Clinic/Sleep Apnea Clinic, where children with all types of pulmonary disease as well as children with sleep apnea.are seen, KCH Pediatric Asthma Clinic where difficult asthmatic children are managed, and three sessions of Pediatric Lung and Asthma Center of Excellence at UHB for asthmatics and a wide variety of other respiratory conditions.

During rotations in this division, residents serve as consultants with first contact for inpatient and acute care services and are supervised by teaching faculty along with subspecialty fellows. Residents see and follow all patients known to the service who are hospitalized at UHB or KCHC. Residents attend 3-4 chest/asthma/OSA clinics per week were they provide direct patient care under attending supervision. Residents also observe, assist and learn interpretation of studies performed by the pulmonary physiology laboratory including exercise challenge, body plethysmography, spirometry, impulse oscillometry, metabolic assessments and sleep studies as well as invasive procedures such as bronchoscopy, bronchoscopic lavage and blood gas determination. Didactics consist of weekly Chest Rounds, core conferences, PFT tutorial, pulmonary physiology conference, and monthly journal club and research conference. Residents are expected to attend all pediatric department conferences. Residents have the opportunity to participate in a variety of clinical research opportunities if they so choose.

Research interest by the members of the division include, tuberculosis, asthma, sleep apnea, pulmonary complications of obesity, pulmonary function testing (e.g. impulse oscillometry), pulmonary manifestations of sickle cell disease, cytokines and mucosal inflammation, and pulmonary inflammation and nitric oxide.

While rotating in Pediatric Radiology, the resident will spend a substantial amount of time alongside the attending pediatric radiologist along with a resident in Radiology reviewing and learning to interpret radiographs, CTs, MRIs, ultrasound exams, and nuclear medicine studies performed on pediatric patients. The resident will learn the approach to reading these studies, clinical correlations and differential diagnoses. In addition, the resident will attend radiologic procedures and assist in performing them. The clinical experience is rounded out by several computer based tutorials and case studies. Web-based teaching and interactive lectures is used to further teach the approach to interpreting imaging studies, for example the approach to chest X-rays, abdominal films, bone surveys, etc. In addition, the resident will join the radiologists for interdisciplinary conferences such as rounds with Pediatric Pulmonology, Pediatric Surgery, Tumor Board, and Mortality Conference. Overall, the resident receives and extensive, immersive, interactive and highly practical experience in Pediatric Radiology.

Anesthesiology **, Ped Surgery, Orthopedics, ENT **, Ophthalmology **

During this experience, the resident attends a variety of pediatric surgical and subspecialty ambulatory clinics in order to appreciate the role of the pediatrician and the surgeon in the outpatient management of surgical problems. The experience includes opportunities to attend 2 clinics in pediatric surgery, 2 clinics in pediatric ENT, 1-2 clinics in pediatric ophthalmology, 2 clinics in pediatric orthopedics, 2 clinics in pediatric GU each week. In these clinics, resident participate directly in the care of patients and in any office-based procedures being performed. In addition, residents have the opportunity to see, consult on and follow patients on inpatient units who are being cared for by these services. Residents can attend weekly clinical conferences for each of the surgical services and are expected to attend all pediatric department conferences. This resident also serves as the pediatric medical consult for patients on the surgical service. In that capacity, the resident is supervised by an inpatient pediatric attending.