Endocrinology

Overview

Our program is designed to train pediatricians to become skilled clinicians and prepare them for a successful academic career. While the first year of training is primarily devoted to gaining clinical expertise in pediatric endocrinology and diabetes, research mentorship and the design of a research project are also established. The second and third year of training are mainly focused on research activities, with a gradually decreasing involvement in clinical training.

Faculty

There are four full-time and one part-time faculty members in the Section of Endocrinology and Diabetes.

Francesco De Luca, MD, Program Director and Section Chief
Elizabeth Suarez, MD
Rita Ann Kubicy, MD
Kimberly Fuld, DO
Iraj Rezvani, MD

Educational Curriculum

Educational Goals

1. Knowledge
   At the completion of the program the fellow is expected to have an adequate understanding of:
   1. Cardinal elements of endocrine physiology, including mode of synthesis, release, and action of hypothalamic factors, pituitary hormones, thyroid hormones, parathyroid hormone, adrenal hormones, gonadal hormones, and vitamin D system
   2. The normal anatomy of the genitalia and its development, and the etiology of ambiguous genitalia
   3. Mechanisms and events characterizing normal puberty, and variations of normal (premature thelarche and adrenarche, pubertal gynecomastia, constitutional delay of growth and puberty)
   4. Etiology, signs, symptoms, and management of precocious and delayed puberty
   5. Causative mechanisms, signs and symptoms of autoimmune (Hashimoto's) thyroiditis
   6. Clinical manifestations and laboratory features of congenital and acquired hypothyroidism and hyperthyroidism
   7. Pharmacological characteristics of l-thyroxine and anti-thyroid medications
   8. General principles of human growth, with special emphasis on variants of normal growth
   9. Common causes of short stature and diagnostic work-up of endocrine-related forms of growth failure (growth hormone deficiency, Cushing's disease, hypothyroidism)
   10. Causes of pathological tall stature
   11. Mechanisms of hypoparathyroidism (genetic, autoimmune, post-surgical, calcium receptor-related) and its effects on calcium/phosphorus metabolism
   12. Etiology, clinical manifestations, diagnosis and treatment of adrenal failure, congenital adrenal hyperplasia, and Cushing's disease
   13. Features and management of pheochromocytoma
   14. Etiology, clinical manifestations, and management of type 1 and type 2 diabetes, and their acute and long-term complications
   15. Causes, signs, symptoms, and management of the most frequent metabolic disorders, such as hypoglycemia, hypo- and hypercalcemia, hypophosphatemia, and hypomagnesemia
   16. Cardinal features of rickets
   17. Physiology of bone mass accrual during childhood and adolescence, with special emphasis on the mechanisms causing osteoporosis, its prevention and treatment
   18. Features of the metabolic syndrome
   19. Disorders of fluid and electrolyte balance (diabetes insipidus and SIADH)
   20. Fundamentals of medical research including methods of molecular biology, epidemiology, clinical trial design
2. Skills and attributes
   At the completion of this program the fellow is expected to have acquired skills to:
   1. Diagnose endocrine disorders using the patient's history, physical examination, laboratory tests, and radiological studies
   2. Search relevant medical literature to seek guidance for the diagnosis and management of challenging clinical problems
   3. Recognize age-related changes in endocrinological laboratory values
   4. Develop an effective therapeutic plan for endocrine disorders, and monitor response to the treatment and adverse effects
   5. Interact with colleagues as consultant, treating physician or team member
   6. Provide knowledge and referral to pertinent medical literature to endocrinological matters to medical students, other physicians, and non-physician members of the healthcare team
   7. Develop and present educational material for conferences and seminars, for both healthcare professionals and patients' families
   8. Recognize and manage psychosocial difficulties in endocrinological patients and their families

First Year

The goal is to support the fellow in the process of learning the cardinal elements of endocrine physiology and pathology through didactic lectures, exposure to patients in the inpatient and outpatient settings, and by attending clinical conferences. The fellow will give two journal clubs and lectures to the residents and students attending the endocrine elective. He/she will also learn to diagnose and manage children with the most frequent acute and chronic endocrine disorders under the direct supervision of the attending, both in the inpatient and outpatient setting. He/she will also learn research methods and techniques and develop a research hypothesis

Second Year

The fellow will consolidate his/her clinical expertise and progressively gain more knowledge regarding physiology and pathophysiology of all endocrine disorders, including the more unusual ones. In addition, he/she will acquire a more definite supervisory role among the first-year subspecialty residents, residents, and students. The fellow will also gain more responsibility in organizing clinical conferences and leading work rounds. With respect to research, he/she will carry out the research project(s) developed in the first year, and present the research data at the sections' research conferences and scientific meetings.

Third Year

The fellow will continue to gain a more in-depth knowledge of endocrine physiology and pathophysiology through conferences, journal clubs, and reading. Regarding patient care, he/she will be able to diagnose and manage children with all types of endocrine disorders, with a progressively reduced input from the attending. At the end of the year, he/she will be able to be an effective clinician and teacher. The fellow will complete his/her research project(s) and submit his/her findings to peer-reviewed journals.

Clinical Rotation

The fellow will have clinical responsibilities for 1-month rotations, assigned as follows:

1. In the first year, 7 months of clinical rotations (4 months of research rotations and 1 month of vacation)
2. In the second year, 6 months of clinical rotations (5 months of research rotations and 1 month of vacation)
3. In the third year, 4 months of clinical rotations (7 months of research rotations and 1 month of vacation)

The fellow's clinical responsibilities include both inpatient and outpatient care.

In case there is only one fellow on clinical rotation, he/she will be assigned to the outpatient clinic four sessions (half-days) a week (first-year fellow) or two sessions a week (second- and third-year fellows). The rest of the time will be devoted to inpatient care.

If two fellows are on clinical rotation, two of the four weeks will be devoted to outpatient clinical responsibilities (7-8 sessions a week for the first-year fellow, 3-4 sessions for the second- and third-year fellows), and two weeks to inpatient responsibilities. In the two weeks of inpatient responsibilities, the fellow will have outpatient care responsibilities only during his/her continuity-of-care clinics (two sessions a week).

Inpatient Care Responsibilities

The fellow will gain knowledge and experience of the management of acute endocrine disorders, with particular emphasis on the diagnosis and treatment of acute complications of diabetes mellitus (ketoacidosis and hypoglycemia), mineral disorders such as hypocalcemia and hypercalcemia, acute adrenal insufficiency and congenital adrenal hyperplasia, diabetes insipidus and SIADH.

In the morning, the fellow will first review the inpatients' laboratory studies and then will discuss them with the attending on service before morning rounds. During the day, he/she will take calls for in-house or outside (referring pediatricians, other hospitals) consultations and discuss them with the attending. In-house consultations will be carried out by the fellow on service and pediatric residents/medical students on the endocrine elective, and then discussed with the attending before the afternoon inpatient rounds. Endocrine inpatients and in-house consultations evaluated by the fellow on service will be followed by the same fellow in his/her outpatient continuity clinic, if necessary. It is expected that the fellow keeps a logbook with the initials, birth dates, and diagnoses of all the patients seen by him/her during the inpatient rotation.

Outpatient Care Responsibilities

The fellow will gain knowledge and experience of the management of chronic endocrine disorders, with particular emphasis on growth, thyroid and parathyroid disorders, type 1 and type 2 diabetes, the metabolic syndrome, rickets and osteoporosis, adrenal insufficiency and congenital adrenal hyperplasia, hypopituitarism, diabetes insipidus, and SIADH. In the outpatient portion of the clinical rotation, emphasis will be also placed on the interaction between chronic endocrine disorders (especially diabetes, hypopituitarism, obesity and the metabolic syndrome, pubertal disorders and short stature) and psychosocial/behavioral difficulties often associated with such disorders. Such interaction will be addressed through personal reading and input from the attending, psychiatrist, and social work staff.

In the outpatient clinic, the first- and second-year fellows will evaluate a patient and discuss his/her findings and propose a diagnostic and therapeutic plan to the endocrinology attending who will then examine the patient and set a management plan. During the continuity-of-care clinics (two outpatient clinic sessions a week), the first- and second-year fellows will evaluate new patients and established patients previously evaluated by him/her, either on the inpatient ward or in clinic. Patient evaluation will be performed under the direct supervision of the endocrinology attending. The third-year fellow will be the primary caregiver for the patients seen in his/her continuity-of-care clinics, and he/she will discuss any concerns or changes in the management plan with the attending during or after the outpatient clinic session. It is expected that the fellow keeps a logbook with the initials, birth dates, and diagnoses of all the outpatients seen by him/her in clinic.

During the clinical rotation the fellow is instructed in clinical and basic sciences related to Pediatric Endocrinology, with particular emphasis on endocrine embryology, physiology, pathology, and biochemistry. Such instruction is provided during Clinical and Research conferences, Attending Rounds, Data Club, and with the Program Director and the endocrine faculty providing textbook chapters and review articles focused on specific topics.

Fellows are instructed in the proper use of laboratory techniques for measurement of hormones, with emphasis posed on recognizing the limitations and pitfalls of result interpretation. Fellows are also instructed in the interpretation of endocrine dynamic tests (stimulation and suppression) and fasting study. Such instruction is provided during clinical conferences, a 1-day course on Clinical Laboratory Techniques, and during daily inpatient and outpatient clinical activities.

During periodical conferences given by the Department of Radiology faculty (“Imaging Syllabus”) throughout the 3-year training, fellows are also provided with instruction on the use and interpretation of current radiologic procedures applied to endocrinology (Ultrasonography, CT scanning, MRI, Nuclear Medicine). Instruction on Cytogenetics techniques and their application in Endocrinology is provided by the Director of the Cytogenetics Laboratory during an annual half-day course.

Research Rotation

During the first year the fellow is expected to attend a formal course as part of the Core Curriculum lecture series. He/she will gain knowledge in research study design, laboratory and clinical research methodology, epidemiology, biostatistics, data collection and analysis, critical reading of the scientific literature, preparation of abstracts and manuscripts, preparation of protocols for IRB and IAUCUC, and mechanisms of funding and grant submission.

A 1-day course will be focused on gaining knowledge of research laboratory techniques, with special emphasis in molecular and cell biology techniques (immunohistochemistry, in situ hybridization, Western and PCR analyses) as well as cell and tissue culture techniques. Dr. De Luca and his research associate (Dr. Wu) will be responsible for planning and supervising the fellow during this course.

The Program Director and the endocrine faculty will expose the fellow to the research fields familiar to the section and will help him/her to formulate the research hypothesis to be tested. If the fellow chooses a laboratory research study, he/she will be mentored by Dr. De Luca with the additional guidance of their very experienced research associate (Dr. Wu). Should the fellow choose a clinical research project, he/she will be mentored by any of the endocrinology faculty. Based on the research project, the fellow may choose a research mentor outside the institution.

The mentor is responsible for setting goals, evaluating the progress of research, and overseeing completion of work, presentation of findings, and writing the manuscript(s). With the supervision of the mentor, the fellow also learns how to search the pertinent literature in order to formulate a sound research hypothesis. The fellow is expected to have written his/her research project and relative human or animal study protocol toward the end of the first trimester of the first year.

In addition, the fellow is assigned to a Scholarship Oversight Committee, which is responsible to monitor and advise the fellow on his/her research progress. The Committee meets twice a year with the fellow. Research progress is also evaluated by the program director and the mentor periodically (1x/month) during the data club.

During the research rotation, the fellow will attend the outpatient clinic only for his/her continuity-of-care clinics.

Educational Strategies

1. Participation in Pediatric Endocrinology Inpatient Service and Outpatient Service and interaction with the endocrine attendings and nurses
2. Attendance at the weekly Clinical Conferences and Grand Rounds
3. Participation in Pediatric Endocrinology monthly Journal Club
4. Attendance at the Core Curriculum seminars (multiple seminars during the first month of training, and monthly seminars throughout the 3 years of training)
5. Attendance at the Clinical Chemistry Laboratory and Cytogenetics courses, and at the Imaging Syllabus
6. Participation in local, regional and national conferences
7. Participation in monthly data clubs

Research Interests

Faculty members of our section are actively involved in several clinical and laboratory research studies focused on:

• Molecular mechanisms regulating growth plate chondrogenesis and longitudinal bone growth
• Nutrition and statural growth
• The metabolic syndrome in minority groups

Representative Publications 

1. Kubicky RA,Dunne C, Nandi-Munshi D, De Luca F. Long-term effects of a non-intensive weight program on Body Mass Index and metabolic abnormalities of obese children and adolescents. International Journal of Pediatric Endocrinology (in press).
2. Kubicky RA, Weiner E, Carlson B, De Luca F. Effects of prolonged discontinuation of l-thyroxine replacement in a child with congenital hypothyroidism.  Case Reports in Endocrinology, 2012; vol. 2012, Article ID 841947
3. Kubicky RA, Wu S, Kharitonenkov A, De Luca F. Role of Fibroblast Growth Factor 21 (FGF21) in undernutrition-related attenuation of growth in mice. Endocrinology, 2012; 153: 2287-2295.
4. Mu D, Wu S, de Pauls RA, Oostdijk W, Lankester AC, van Duyvenvoorde HA, Ruivenkamp CAL, Losekoot M, van Tol MJD, De Luca F, van de Vosse E, Wit JM. A mosaic de novo duplication of 17q21-25 is associated with growth hormone insensitivity, disturbed in vitro CD28 mediated signaling and decreased STAT5B, PI3K and NF-κB activation. Eur J Endocrinol., 2012; 166: 743-752.
5. Wu, S, Morrison A, SunH,  De Luca F.  NF-kB p65 interacts with Stat5b in growth plate chondrocytes and mediates the effects of Growth Hormone on chondrogenesis and on the expression of Insulin-like Growth Factor-1 and Bone Morphogenetic Protein-2. J Biol Chem. 2011; 286(28):24726-34.
6. Wu S, Aguilar AL, Ostrow V, De Luca F. Insulin resistance secondary to a high-fat diet stimulates longitudinal bone growth and growth plate chondrogenesis in mice. Endocrinology, 2011; 152(2):468-75
7. Ostrow V, Wu S, Aguilar A, Bonner Jr R, Suarez E, De Luca F. Association between oxidative stress and masked hypertension in a multi-ethnic population of obese children and adolescents. J Pediatr. 2010 Nov 13. [Epub ahead of print].
8. Reiter EO, Mauras N, McCormick K, Kulshreshtha B, Amrhein J, De Luca F, O’Brien S, Armstrong J, Melezinkova H. Bicalutamide plus Anastrozole for the Treatment of Gonadotropin-Independent Precocious Puberty in Boys with Testotoxicosis: A Phase II, Open-Label Pilot Study (BATT). J Pediatr Endocrinol Metabol., 2010; 23(10):999-1009.
9. Aguilar A, Ostrow V, De Luca F, Suarez E. Elevated ambulatory blood pressure in a multi-ethnic population of obese children and adolescents. J Pediatr, 2010; 156(6): 930-935.
10. Wu S,  Walenkamp MJ, Lankester A, Bidlingmaier M, Wit JM, De Luca F. Growth hormone (GH) and Insulin-like Growth Factor-1 (IGF-1) insensitivity of fibroblasts isolated from a patient with an IkB α mutation. J Clin Endocrinol Metabol., 2010; 95(3): 1220-1228.
11. Kubicky RA, Faerber E, de Chadarevian J-P, Wu S, Rezvani J, De Luca F. An adolescent with weight loss and a mediastinal mass, diagnosed with Graves' disease and thymic hyperplasia. Pediatrics, 2010;  125(2): e433-43
12. Flint JK, Wu S, Shott S, Suarez E. De Luca F. Relationships between osteoprotegerin (OPG), receptor activator of nuclear factor kappaB ligand (RANKL), and growth hormone (GH) secretory status in short children. J Pediatr Endocrinol Metabol., 2009; 22(12): 1105-1112
13. Ostrow V, De Luca F: Long-Term Follow-up of a child with Ambiguous Genitalia, Mixed Gonadal Dysgenesis, and Unusual Mosaicism. J Pediatr Endocrinol Metabol., 2009; 22(9): 863-866.
14. Aguilar A, Wu S, De Luca F: P450 oxidoreductase (POR) expressed in rat chondrocytes modulates chondrogenesis via cholesterol- and Indian hedgehog (Ihh)-dependent mechanisms. Endocrinology, 2009; 150(6): 2732-2739.

How to Apply

Our fellowship program participates in the Pediatric Specialties Spring Match. We accept applications through the Electronic Residency Application Service (ERAS). Applications can be submitted at www.aamc.org/students/eras, beginning November 15th, 19 months prior to the desired July 1st starting date. Interviews will be scheduled after December 1st.

Prospective fellows must provide evidence of:

1. Successful completion of training in an ACGME accredited residency training program in pediatrics
   
   Or, if the prospective fellow is a graduate of a non-U.S. medical school (a Foreign Medical Graduate, FMG) he/she must have successfully completed training in Pediatrics comparable to that of an ACGME accredited residency training program. This training (medical school and residency training) must be approved by the ACGME.
    
2. U.S. Citizenship/Permanent Residence or a valid U.S. J-1 Visa

Inquiries regarding the pediatric endocrinology fellowship program can be made to:

Christina Suarez
Program Coordinator
(215) 427-3482
Christina.Suarez@tenethealth.com

 or

Francesco De Luca, MD
Program Director
(215) 427-8100
Francesco.deluca@drexelmed.edu

St. Christopher's Hospital for Children
3601 A Street
Philadelphia, Pa. 19134