Research is expected during this two-year fellowship program. Formal clinical research training is part of the first year curriculum of UCSD’s Clinical Research Enhancement through Supplemental Training (CREST) program. The first year of this two-year CREST program includes weekly classes covering epidemiology, patient-oriented research, health services research, and informatics. Those dedicated to completion of a master’s degree during the two-year program may integrate this training with a more intense curriculum schedule. A research project and mentor is chosen after the first quarter of the first year. Research may be in any area of pediatric hospitalist medicine. Research is presented at either Pediatric Academic Societies, Society of Hospital Medicine, or other similar forum upon completion.
The schedule is flexible, but follows the template. (See Table 1, p. 30: “Pediatric Hospitalist Fellowship Program Schedule.”)
One fellowship position is offered every year, with application submissions accepted through Dec. 1, interviews granted Dec. 15-Feb. 1 and final selection by Feb. 15. You can obtain an application from the CSSD Web site “Fellowships” page (http://childrensspecialists. com/body.cfm?id=580) or by e-mailing Fellowship Coordinator Susan Stafford at [email protected].
PEDIATRIC SPECIAL SECTION:
IN THE LITERATURE
Retrospective Study Attempts Criteria for Diagnosing MAS
Reviews by Julia Simmons, MD
Ravelli A, Magni-Manzoni S, Pistorio A, et al. Preliminary diagnostic guidelines for macrophage activation syndrome complicating systemic juvenile idiopathic arthritis. J Pediatr. 2005;146(5):598-604.
Macrophage activating syndrome (MAS) is a complication of connective tissue disorders, most often associated with active systemic juvenile idiopathic arthritis (S-JIA). It is a rare disorder and the exact incidence is unknown. It is characterized by uncontrolled activation and proliferation of T-lymphocytes and macrophages. If not recognized and treated aggressively, MAS can be life threatening.
In this article, the authors’ purpose was to review the available clinical, laboratory, and histopathologic data in patients with active S-JIA and in those with active S-JIA complicated by MAS. The goal was to develop criteria to diagnose MAS.
The retrospective study was designed using the classification, criteria approach. The index cases included patients with MAS complicating S-JIA. The “confusable” condition was active S-JIA. There were 74 patients in the index cases. Seventeen of the cases were observed at the authors’ institution. These patients were diagnosed with S-JIA using the International League of Association for Rheumatology criteria. They were identified using a database search. Fifty-seven of the cases were obtained from a Medline search. Of these 74 patients, eight were disqualified because they did not meet the definition of S-JIA, and 11 were excluded because of insufficient data. The control group contained 37 patients observed at the authors’ sites. The sensitivity rate, specificity rate, area under receiver operating characteristic curve, and diagnostic odds ratio were applied to the data to differentiate MAS complicating S-JIA from S-JIA.
The study results found hemorrhages and central nervous dysfunction were the strongest clinical discriminating factors. The strongest laboratory discriminators included thrombocytopenia, leukopenia, elevated aspartate aminotransferase, and hypofibrinogenemia. Histopathological criterion included evidence of macrophage hemophagocytosis in the bone marrow aspirate. Other useful discriminators included hypertriglyceridemia, elevated ferritin, hepatomegaly, hand hyponatremia. Final guidelines were developed after analyzing the statistics and determining the clinical importance: “The diagnosis of MAS requires the presence of any two or more laboratory criteria or of any two or three or more clinical and/or laboratory criteria. A bone marrow aspirate for the demonstration of hemophagocytosis may be required only in doubtful cases.”
In summary, MAS complicating S-JIA is a disorder without concrete diagnostic criteria. The authors have performed preliminary studies to diagnose MAS. They appropriately recognized the need for prospective larger clinical studies.