Universal Health Day – Recovering lost public health gains in a post-pandemic Americas

Cristina Mitchell

12 Dec 2022

The Public Works Ministry on Monday issued a final warning to vendors on New Market Street opposite Georgetown Public Hospital (GPHC) to remove their stalls or they will be demolished and taken away. “A final notice is hereby given to vendors who are occupying spaces along New Market Street, between Thomas and East Streets, to ...

The federal system meant to stop health care business owners and executives from repeatedly bilking government health programs fails to do so, a KHN investigation has found.

That means people are once again tapping into Medicaid, Medicare, and other taxpayer-funded federal health programs after being legally banned because of fraudulent or illegal behavior.

In large part that’s because the government relies on those who are banned to self-report their infractions or criminal histories on federal and state applications when they move into new jobs or launch companies that access federal health care dollars.

The Office of Inspector General for the U.S. Department of Health and Human Services keeps a public list of those it has barred from receiving any payment from its programs — it reported excluding more than 14,000 individuals and entities since January 2017 — but it does little to track or police the future endeavors of those it has excluded.

The government explains that such bans apply to “the excluded person” or “anyone who employs or contracts with” them. Further, “the exclusion applies regardless of who submits the claims and applies to all administrative and management services furnished by the excluded person,” according to the OIG.

Federal overseers largely count on employers to check their hires and identify those excluded. Big hospital systems and clinics typically employ compliance staff or hire contractors who routinely vet their workers against the federal list to avoid fines.

However, those who own or operate health care businesses are typically not subject to such oversight, KHN found. And people can sidestep detection by leaving their names off key documents or using aliases.

“If you intend to violate your exclusion, the exclusion list is not an effective deterrent,” said David Blank, a partner at Arnall Golden Gregory who previously was senior counsel at the OIG. “There are too many workarounds.”

KHN examined a sample of 300 health care business owners and executives who are among more than 1,600 on OIG’s exclusion list since January 2017. Journalists reviewed court and property records, social media, and other publicly available documents. Those excluded had owned or operated home health care agencies, medical equipment companies, mental health facilities, and more. They’d submitted false claims, received kickbacks for referrals, billed for care that was not provided, and harmed patients who were poor and old, in some cases by stealing their medication or by selling unneeded devices to unsuspecting Medicare enrollees. One owner of an elder care home was excluded after he pleaded guilty to sexual assault.

Among those sampled, KHN found:

• Eight people appeared to be serving or served in roles that could violate their bans;
• Six transferred control of a business to family or household members;
• Nine had previous, unrelated felony or fraud convictions, and went on to defraud the health care system;
• And seven were repeat violators, some of whom raked in tens of millions of federal health care dollars before getting caught by officials after a prior exclusion.

The exclusions list, according to Blank and other experts, is meant to make a person radioactive — easily identified as someone who cannot be trusted to handle public health care dollars.

But for business owners and executives, the system is devoid of oversight and rife with legal gray areas.

One man, Kenneth Greenlinger, pleaded guilty in 2016 to submitting “false and fraudulent” claims for medical equipment his California company, Valley Home Medical Supply, never sent to customers that totaled more than $1.4 million to Medicare and other government health care programs, according to his plea agreement. He was sentenced to eight months in federal prison and ordered to pay restitution of more than $1 million, according to court records. His company paid more than $565,000 to resolve allegations of false claims, according to the Justice Department website.

Greenlinger was handed a 15-year exclusion from Medicare, Medicaid, and any other federal health care program, starting in 2018, according to the OIG.

But this October, Greenlinger announced a health care business with government contracts for sale. Twice on LinkedIn, Greenlinger announced: “I have a DME [durable medical equipment] company in Southern California. We are contracted with most Medicare and Medi-Cal advantage plans as well as Aging in Place payers. I would like to sell,” adding a Gmail address.

Reached by phone, Greenlinger declined to comment on his case. About the LinkedIn post, he said: “I am not affiliated directly with the company. I do consulting for medical equipment companies — that was what that was, written representing my consulting business.”

His wife, Helene, who previously worked for Valley Home Medical Supply, is now its CEO, according to LinkedIn and documentation from the California Secretary of State office. Although Helene has a LinkedIn account, she told KHN in a telephone interview that her husband had posted on her behalf. But Kenneth posted on and commented from his LinkedIn page — not his wife’s.

At Valley Home Medical Supply, a person who answered the phone last month said he’d see whether Kenneth Greenlinger was available. Another company representative got on the line, saying “he’s not usually in the office.”

Helene Greenlinger said her husband may come by “once in a while” but “doesn’t work here.”

She said her husband doesn’t do any medical work: “He’s banned from it. We don’t fool around with the government.”

“I’m running this company now,” she said. “We have a Medicare and Medi-Cal number and knew everything was fine here, so let us continue.”

No Active Enforcement

Federal regulators do not proactively search for repeat violators based on the exclusion list, said Gabriel Imperato, a managing partner with Nelson Mullins in Florida and former deputy general counsel with HHS’ Office of the General Counsel in Dallas.

He said that for decades he has seen a “steady phenomenon” of people violating their exclusions. “They go right back to the well,” Imperato said.

That oversight gap played out during the past two years in two small Missouri towns.

Donald R. Peterson co-founded Noble Health Corp., a private equity-backed company that bought two rural Missouri hospitals, just months after he’d agreed in August 2019 to a five-year exclusion that “precludes him from making any claim to funds allocated by federal health care programs for services — including administrative and management services — ordered, prescribed, or furnished by Mr. Peterson,” said Jeff Morris, an attorney representing Peterson, in a March letter to KHN. The prohibition, Morris said, also “applies to entities or individuals who contract with Mr. Peterson.”

That case involved a company Peterson created called IVXpress, now operating as IVX Health with infusion centers in multiple states. Peterson left the company in 2018, according to his LinkedIn, after the settlement with the government showed a whistleblower accused him of altering claims, submitting false receipts for drugs, and paying a doctor kickbacks. He settled the resulting federal charges without admitting wrongdoing. His settlement agreement provides that if he violates the exclusion, he could face “criminal prosecution” and “civil monetary penalties.”

In January 2020, Peterson was listed in a state registration document as one of two Noble Health directors. He was also listed as the company’s secretary, vice president, and assistant treasurer. Four months later, in April 2020, Peterson’s name appears on a purchasing receipt obtained under the Freedom of Information Act. In addition to Medicare and Medicaid funds, Noble’s hospitals had received nearly $20 million in federal covid relief money.

A social media account with a photo that appears to show Peterson announced the launch of Noble Health in February 2020. Peterson identified himself on Twitter as executive chairman of the company.

It appears federal regulators who oversee exclusions did not review or approve his role, even though information about it was publicly available.

Peterson, whose name does not appear on the hospitals’ Medicare applications, said by email that his involvement in Noble didn’t violate his exclusion in his reading of the law.

He said he owned only 3% of the company, citing OIG guidance — federal regulators may exclude companies if someone who is banned has ownership of 5% or more of them — and he did not have a hand in operations. Peterson said he worked for the corporation, and the hospitals “did not employ me, did not pay me, did not report to me, did not receive instructions or advice from me,” he wrote in a November email.

A 2013 OIG advisory states that “an excluded individual may not serve in an executive or leadership role” and “may not provide other types of administrative and management services … unless wholly unrelated to federal health care programs.”

Peterson said his activities were apart from the business of the hospitals.

“My job was to advise Noble’s management on the acquisition and due diligence matters on hospitals and other entities it might consider acquiring. … That is all,” Peterson wrote. “I have expert legal guidance on my role at Noble and am comfortable that nothing in my settlement agreement has been violated on any level.”

For the two hospitals, Noble’s ownership ended badly: The Department of Labor opened one of two investigations into Noble this March in response to complaints from employees. Both Noble-owned hospitals suspended services. Most employees were furloughed and then lost their jobs.

Peterson said he left the company in August 2021. That’s the same month state regulators cited one hospital for deficiencies that put patients “at risk for their health and safety.”

If federal officials determine Peterson’s involvement with Noble violated his exclusion, they could seek to claw back Medicaid and Medicare payments the company benefited from during his tenure, according to OIG records.

Enforcement in a Gray Zone

Dennis Pangindian, an attorney with the firm Paul Hastings who had prosecuted Peterson while working for the OIG, said the agency has limited resources. “There are so many people on the exclusions list that to proactively monitor them is fairly difficult.”

He said whistleblowers or journalists’ reports often alert regulators to possible violations. KHN found eight people who appeared to be serving or served in roles that could violate their bans.

OIG spokesperson Melissa Rumley explained that “exclusion is not a punitive sanction but rather a remedial action intended to protect the programs and beneficiaries from bad actors.”

But the government relies on people to self-report that they are banned when applying for permission to file claims that access federal health care dollars through the Centers for Medicare & Medicaid Services.

While federal officials are aware of the problems, they so far have not fixed them. Late last year, the Government Accountability Office reported that 27 health care providers working in the federal Veterans Affairs system were on the OIG’s exclusion list.

If someone “intentionally omits” from applications they are an “excluded owner or an owner with a felony conviction,” then “there’s no means of immediately identifying the false reporting,” said Dara Corrigan, director of the center for program integrity at CMS. She also said there is “no centralized data source of accurate and comprehensive ownership” to check for violators.

The OIG exclusion list website, which health care companies are encouraged to check for offenders, notes that the list does not include altered names and encourages those checking it to vet other forms of identification.

Gaps in reporting also mean many who are barred may not know they could be violating their ban because exclusion letters can go out months after convictions or settlements and may never reach a person who is in jail or has moved, experts said. The exclusion applies to federal programs, so a person could work in health care by accepting only patients who pay cash or have private insurance. In its review, KHN found some on the exclusion list who were working in health care businesses that don’t appear to take taxpayer money.

OIG said its exclusions are “based largely on referrals” from the Justice Department, state Medicaid fraud-control units, and state licensing boards. A lack of coordination among state and federal agencies was evident in exclusions KHN reviewed, including cases where years elapsed between the convictions for health care fraud, elder abuse, or other health-related felonies in state courts and the offenders’ names appearing on the federal list.

ProviderTrust, a health care compliance group, found that the lag time between state Medicaid fraud findings and when exclusions appeared on the federal list averaged more than 360 days and that some cases were never sent to federal officials at all.

The NPI, or National Provider Identifier record, is another potential enforcement tool. Doctors, nurses, other practitioners, and health businesses register for NPI numbers to file claims to insurers and others. KHN found that NPI numbers are not revoked after a person or business appears on the list.

The NPI should be “essentially wiped clean” when the person is excluded, precluding them from submitting a bill, said John Kelly, a former assistant chief for health care fraud at the Department of Justice who is now a partner for the law firm Barnes & Thornburg.

Corrigan said the agency didn’t have the authority to deactivate or deny NPIs if someone were excluded.

The Family ‘Fronts’

Repeat violators are all too common, according to state and federal officials. KHN’s review of cases identified seven of them, noted by officials in press releases or in court records. KHN also found six who transferred control of a business to a family or household member.

One common maneuver to avoid detection is to use the names of “family members or close associates as ‘fronts’ to create new sham” businesses, said Lori Swanson, who served as Minnesota attorney general from 2007 to 2019.

Blank said the OIG can exclude business entities, which would prevent transfers to a person’s spouse or family members, but it rarely does so.

Thurlee Belfrey stayed in the home care business in Minnesota after his 2004 exclusion for state Medicaid fraud. His wife, Lanore, a former winner of the Miss Minnesota USA title, created a home care company named Model Health Care and “did not disclose” Thurlee’s involvement, according to his 2017 plea agreement.

“For more than a decade” Belfrey, his wife, and his twin brother, Roylee, made “millions in illicit profits by cheating government health care programs that were funded by honest taxpayers and intended for the needy,” according to the Justice Department. The brothers spent the money on a Caribbean cruise, high-end housing, and attempts to develop a reality TV show based on their lives, the DOJ said.

Federal investigators deemed more than $18 million in claims Model Health Care had received were fraudulent because of Thurlee’s involvement. Meanwhile, Roylee operated several other health care businesses. Between 2007 and 2013, the brothers deducted and collected millions from their employees’ wages that they were supposed to pay in taxes to the IRS, the Justice Department said.

Thurlee, Lanore, and Roylee Belfrey all were convicted and served prison time. When reached for comment, the brothers said the government’s facts were inaccurate and they looked forward to telling their own story in a book. Roylee said he “did not steal people’s tax money to live a lavish lifestyle; it just didn’t happen.” Thurlee said he “never would have done anything deliberately to violate the exclusion and jeopardize my wife.” Lanore Belfrey could not be reached for comment.

Melchor Martinez settled with the government after he was accused by the Department of Justice of violating his exclusion and for a second time committing health care fraud by enlisting his wife, Melissa Chlebowski, in their Pennsylvania and North Carolina community mental health centers.

Previously, Martinez was convicted of Medicaid fraud in 2000 and was excluded from all federally funded health programs, according to DOJ.

Later, Chlebowski failed to disclose on Medicaid and Medicare enrollment applications that her husband was managing the clinics, according to allegations by the Justice Department.

Their Pennsylvania clinics were the largest providers of mental health services to Medicaid patients in their respective regions. They also had generated $75 million in combined Medicaid and Medicare payments from 2009 through 2012, according to the Justice Department. Officials accused the couple of employing people without credentials to be mental health therapists and the clinics of billing for shortened appointments for children, according to the DOJ.

They agreed, without admitting liability, to pay $3 million and to be excluded — a second time, for Martinez — according to court filings in the settlement with the government. They did not respond to KHN’s attempts to obtain comment.

‘Didn’t Check Anything’

In its review of cases, KHN found nine felons or people with fraud convictions who then had access to federal health care money before being excluded for alleged or confirmed wrongdoing.

But because of the way the law is written, Blank said, only certain types of felonies disqualify people from accessing federal health care money — and the system relies on felons to self-report.

According to the DOJ court filing, Frank Bianco concealed his ownership in Anointed Medical Supplies, which submitted about $1.4 million in fraudulent claims between September 2019 and October 2020.

Bianco, who opened the durable medical equipment company in South Florida, said in an interview with KHN that he did not put his name on a Medicare application for claims reimbursement because of his multiple prior felonies related to narcotics.

And as far as he knows, Bianco told KHN, the federal regulators “didn’t check anything.” Bianco’s ownership was discovered because one of his company’s contractors was under federal investigation, he said.

Kenneth Nash had been convicted of fraud before he operated his Michigan home health agency and submitted fraudulent claims for services totaling more than $750,000, according to the Justice Department. He was sentenced to more than five years in prison last year, according to the DOJ.

Attempts to reach Nash were unsuccessful.

“When investigators executed search warrants in June 2018, they shut down the operation and seized two Mercedes, one Land Rover, one Jaguar, one Aston Martin, and a $60,000 motor home — all purchased with fraud proceeds,” according to a court filing in his sentencing.

“What is readily apparent from this evidence is that Nash, a fraudster with ten prior state fraud convictions and one prior federal felony bank fraud conviction, got into health care to cheat the government, steal from the Medicare system, and lavishly spend on himself,” the filing said.

As Kelly, the former assistant chief for health care fraud at the Justice Department, put it: “Someone who’s interested in cheating the system is not going to do the right thing.”

KHN Colorado correspondent Rae Ellen Bichell contributed to this report.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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In this article I will explain what these breakouts mean and why the change of seasons affects our skin, how we can use telemedicine for treatment and change daily practices to combat these unwelcome reactions.

Acne is a skin condition that occurs when your hair follicles become clogged with dead skin cells and oils. Hormone fluctuations may also cause acne breakouts. It may show up as pimples, whiteheads and/or blackheads. Although most common in teenagers, anyone of any age or gender can be affected by acne anywhere on the body.

Eczema, on the other hand, is a chronic, itchy inflammatory condition that affects the skin. It may cause a defective skin barrier which struggles to hold moisture and keep harmful substances out. It may also cause the skin to have an immune response with parts of the skin overreacting to harmless substances. Eczema is commonly characterised by inflammation, lesions, rashes and/or redness of the skin which can range from mild to severe. Like acne, it can affect you on any part of your skin, not just your face.

Christmastime in Jamaica may not see a huge drop in temperature; however, the days do become cooler, often windier and not as hot as summer. This small change in temperature may still affect your skin and cause seasonal breakouts. The following are some things to focus on to protect your skin during this time.

1. Be vigilant with your skincare. The season has changed and therefore your skincare routines need to change too. While moisturising should already be a part of your daily routine, it becomes more crucial during cooler periods. Additionally, although the sun may not be as harsh, do not forget to continue to use sunblock daily, especially if you spend a lot of time outdoors.

2. Stay hydrated. During warmer months you may frequently be sweaty and feel dehydrated. While symptoms of dehydration may not be as obvious in cooler temperatures, it's important that you remain hydrated. The more hydrated you are, the stronger and more resistant your skin's moisture barrier will be.

3. Pay attention to allergies. Christmastime welcomes a series of seasonal allergies whether that be a particular flower that only blooms during this time, or otherwise. Allergic reactions may trigger eczema breakouts including inflammation and rashes. Consult your doctor about any allergic reactions you may be observing on your skin during this season. They may help you to combat side effects and avoid your triggers.

4. Avoid hot baths. A hot shower is particularly comforting on a cool day but it may not be the best thing for your skin. Hot showers or baths are easy ways to suck the moisture out of your skin. Additionally, hot water may cause increased irritation to breakouts already on the skin.

Telemedicine and your skin

Online health-care platforms such as MDLink provide you with telemedicine access anywhere you are in the world. By using this private platform you will be able to consult with top dermatologist regarding any skin breakouts. Your doctor may assess if your breakouts are hormonal, allergic or due to bad skin care habits.

You can easily get a prescription to treat your seasonal or regular breakouts by developing, with your doctor, a personalised treatment plan. This may be prescribed medicine or a hormone treatment, if your doctor thinks necessary. In addition to that, your prescription can be sent directly to your nearest pharmacy for pick-up cutting your overall wait time down by hours.

The nature of eczema and acne breakouts are such that your doctor can assess them through photo or video footage of your skin without having to see them in-person at a health-care facility. This makes telemedicine a quick and convenient way of treating your skin while not interfering with your busy holiday season.

Dr Ché Bowen, a digital health entrepreneur and family physician, is the CEO & founder of MDLink, a digital health company that provides telemedicine options. Check out the company's website at www.theMDLink.com. You can also contact him at drchebowen@themdlink.com.

ARTIFICIAL intelligence (AI) is emerging as a crucial component of health care to help improve performance and efficiency of physicians. Below we will examine how AI can aid in chest X-rays and cardiac ultrasounds.

AI and chest X-rays

Researchers have developed a deep learning model that uses a single chest X-ray to predict the 10-year risk of death from a heart attack or stroke from atherosclerotic heart disease. Results of the study were presented at the yearly meeting of the Radiological Society of North America (RSNA) in Chicago (November 27 to Dec 1, 2022).

Deep learning is an advanced type of AI that can be trained to search X-ray images to find patterns associated with disease. This finding offers huge potential solution for population-based large-scale screening of cardiovascular disease risk using existing chest X-ray images and could be potentially significant in low resource environments since X-rays are widely available and often inexpensive. This type of screening could be used to identify individuals who would benefit from primary and secondary prevention using proven treatment strategies like the "statin" class of cholesterol reducing agents. Current guidelines recommend estimating 10-year risk of major adverse cardiovascular disease events to establish who should get a statin for primary prevention.

This risk is calculated using the atherosclerotic cardiovascular disease (ASCVD) risk score, a statistical model that considers a host of variables, including age, sex, race, systolic blood pressure, hypertension treatment, smoking, type 2 diabetes, and blood tests. Statin medication is recommended for patients with a 10-year risk of 7.5 per cent or higher. The variables necessary to calculate ASCVD risk are often not available, which makes alternative approaches for population-based screening desirable. As chest X-rays are commonly available, an AI deep learning model may help identify individuals at high risk. The investigators showed that based on a single existing chest X-ray image, deep learning model predicted future major adverse cardiovascular events with similar performance and incremental value to the established clinical standard.

AI and cardiac ultrasounds (echocardiography or echo)

Just a few days ago, UltraSight, an Israeli-based digital health pioneer, announced new findings from a landmark pivotal study using AI in cardiac ultrasound. According to the results, UltraSight's AI guidance technology allowed medical professionals, with no prior sonography experience, to accurately perform echocardiographic examinations and acquire high quality diagnostic images of the heart comparable to those performed by professional cardiac sonographers.

This multi-centre study evaluated 2D transthoracic echocardiography images acquired by providers with no prior cardiac ultrasound training or experience, using UltraSight's AI real-time guidance software compared to those performed by a professional sonographer, without using the software.

The quality of the exams conducted by both the novice users and professional cardiac sonographers were remarkably comparable. Health-care professionals without prior sonography were able to capture diagnostic quality ultrasound images of patients' hearts just by following the guidance offered by the software. The study demonstrated that UltraSight's technology allowed health-care professionals, regardless of their sonography experience, to capture diagnostic quality cardiac ultrasound exams. This is a potential game changer that would allow wide scale availability of echocardiography (cardiac ultrasound) examinations, a critically important tool in the clinical evaluation of many cardiac and non-cardiac patients.

AI-based models allow for quantitative measures, which allow clinicians to provide both diagnostic and prognostic information that helps improve the overall care of patients.

Solutions offered by AI not only enable prediction and prevention of problems, but also could eventually help diminish health disparities and the burden on health systems and clinicians, especially in low-resource environments.

Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists for Heart Institute of the Caribbean (HIC) and HIC Heart Hospital. HIC is the regional centre of excellence for cardiovascular care in the English-speaking Caribbean and has pioneered a transformation in the way cardiovascular care is delivered in the region. HIC Heart Hospital is registered by the Ministry of Health and Wellness and is the only heart hospital in Jamaica. Correspondence to
info@caribbeanheart.com or call 876-906-2107

Santo Domingo, DR
Brigades from the Mayor’s Office of the National District (ADN), in collaboration with the Ministry of Public Health and other institutions, carried out a cleaning operation yesterday in which solid waste was fumigated and collected in the La Zurza sector of the capital, where two cases of cholera were recently detected.

“Today we are here with the city council cleaning the entire riverbank, giving attention to the families, bringing them supplies such as masks, gel, so that they can sanitize the whole area since we had two positive cases of cholera, which are already stable,” said Damian Almonte, coordinator of the Program for the Reduction of Traffic Accidents (Premat).

He assured me that the patients affected by cholera had already been treated and discharged. “We are finishing the sanitation of all the parts so that we can have a clear idea of where the cholera cases came from or if they were imported or if they were referrals from this same episode,” added Almonte.

Regarding the drinking water, he assured that it has already been treated by the Santo Domingo Aqueduct and Sewage Corporation (CAASD), and they are waiting for the results to be able to notice any abnormality in the liquid.

She also affirmed that there is no landfill in the community; instead, there is a “transfer” for solid waste, where the neighbors deposit the debris and collect it three times a week. Furthermore, the Vice Minister of Social Assistance, Raiza Bello Arias, declared that support and follow-up had been given to the community since the rains of last November 4, which caused havoc in Greater Santo Domingo, leaving irreparable human and material losses.

He expressed that “when these landslides occur, one is ready for epidemics to come, diseases such as dengue fever, in view of this we have followed up.”

The mother of Edwin Alexander Cedano, a 25-year-old young man who was crushed to death by a wall in this sector on the day of the torrential rains, considers that this action by the authorities is something beneficial for the whole community and explained that after the fateful day of her son’s accident, the authorities have been keeping an eye on the area.

In Part 1 the Caribbean Superheroes series you read about the lived experiences of children and young people with type 1 diabetes.

Jawan, 7 and Tiana, 4, who are aspiring scientists from Trinidad and Tobago shared their dislike for checking their blood sugar levels, taking their insulin, and waiting for their insulin to start working before they can eat. Their mother, Penelope, outlined her daily routine which includes checking in on them during the night and at school.

Kerro, 20, an aspiring graphic artist from Antigua and Barbuda recalled some of her classmates and general public’s curiosity about her condition and the stigma she experienced. Kerro and Xarriah, 22, race car driver fan from Barbados both agreed on the importance of supportive friends on their type 1 diabetes journey.

Given that they have to live with the condition, these superheroes are also experts on how the wider society can better support people living with diabetes. Their recommendations focus on: 1. Diabetes Education, 2. Destigmatization, 3. Prioritizing spaces and environments that support healthy children, 4. Access to Medication and devices.

Aligned with the theme for World Diabetes Day 2022, “access to diabetes education”, all the superheroes agreed that education on one of the most common conditions in the Caribbean is critical. In particular, Xarriah and Kerro think that there should be improved education around all types of diabetes – including type 1. These superheroes have been educators since their diagnosis. However, they need help. Xarriah noted,

As much as we try to educate people, there is still a lot to be learned. And a lot of people still aren’t certain and a lot of people still group together the diabetes, the types, they still group together type 1 and type 2 and I think there needs to be a lot more information about what is type 1 versus what is type 2….not just bulking them all in one place and separating them and giving them their own identities so people understand.

Kerro agreed and she shared that even though diabetes runs in her family, she wasn’t aware of type 1 until she was diagnosed. She said,

Most times I just used to think it was older people. But now I know that people are born with it, you have babies who develop it. So I just think they need to start educating more, because, as I said, a lot of people in my class, at the age of 11 didn’t even know you could get it at such a young age.

Kerro and Xarriah recommend the integration of diabetes education into primary and secondary school subjects including Health and Family Life Education, Physical Education or Science across the Caribbean. Xarriah firmly believes in this approach as she notes that school-based education would have helped her when she got diagnosed as she, like Kerro, wasn’t aware of the realities of living with type 1 diabetes,

And in the event that one person gets type 1 they have an understanding of okay, this is what is happening to my body and this is what I may have to do for the rest of my life. And this is what I might have to endure. Because I feel like I was not very well educated when I was diagnosed. I had a general idea of diabetes because people in my family have type 2 but i didn’t have the knowledge of type 1 until I got diagnosed.

Widespread education on diabetes is critical in addressing the misinformation and resulting stigma that many persons living with diabetes experience.

Kerro recalls numerous cases where she has felt like her condition was misunderstood:

I feel like diabetics are part of that group that people tend to overlook. They just say “If you’re diabetic, it is caused by sugar and if you end up in the hospital it is because you eat too much sugar. “ So essentially you’ve caused it. That is something that I have encountered myself at a hospital.

This is a common misconception with type 1 diabetes. Persons living with type 1 diabetes don’t develop the condition as a result of lifestyle choices. Type 1 diabetes is an autoimmune disease in which your body’s immune system attacks the insulin-producing beta cells in your pancreas which drastically reduces the ability of your body to produce insulin, a hormone that regulates blood sugar.

The lack of understanding of type 1 diabetes has also resulted in people treating those with the condition differently. Kerro, Xarriah and Penelope wished that people would treat children and young people living with diabetes like anyone else.

Kerro shared that, when diagnosed, “It’s not changing personality, it is not changing the person. It is not contagious. It is not going to harm you in any way – you as in the other person.”

For Penelope, she reassures her children that there is “nothing they cannot do” despite the world saying otherwise. She notes that her children are “even more amazing” as they live with diabetes.

In the absence of formal education or mass media awareness campaigns, Kerro encourages people who are curious about the condition to “just ask”.

In addition to improved education across age groups, Penelope, as a parent, highlights the need for schools to better care for children living with diabetes. She said she would value the presence of nurses, even if sporadic, on the school compound and the use of a sanitized private room to assist Jawan and Tiana with administering insulin or anything else they may need.

An effort to better care for children could also be extended to the implementation of healthy school nutrition policies to protect the school food environment. Although Penelope packs lunches for Jawan and Tiana, given their condition, she agreed that a school policy that would restrict the availability of ultra processed foods and improve the availability of fruits would be valuable. Relatedly, Penelope also noted the importance of physical activity at school but also at home. Penelope advises parents to prioritize physical activity and diversify, if possible, the kinds of activities that children do. Jawan, unlike his mom, loves to do burpees (a full body exercise that includes a pushup followed by a leap in the air) and they do them and other physical activities together. Jawan says he can do 20 burpees in 27 seconds and holds his mom accountable.

The final challenge outlined by the superheroes is access to insulin and appropriate glucose monitoring devices. Tiana said insulin gives her “super powers”, like Elsa from the movie Frozen. Children and young people need access to insulin and testing strips daily to be able to carry out their daily superhero duties.

The governments of Antigua and Barbuda, Barbados and Trinidad and Tobago provide a glucose monitoring device (GMD), insulin and testing strips but the quality of the GMD, insulin and the number of test strips provided varies.

Penelope shared her reality with trying to access what Tiana and Jawan need, “We have gotten one device per child and they provide us with the strips for the machines. I have written 2 Letters [to government] to increase the number of containers of strips for both children.” Her request, which had to be written by a doctor, was approved.

The glucose monitoring device that all the superheroes currently have requires them to prick their finger to test the sugar levels in their blood. Their dream is to be able to have access to a GMD that offers continuous glucose monitoring and does not require the user to prick themselves. Kerro painted the reality that unfortunately, “ it isn’t available here and the accessories or counterparts to it are very expensive.” She noted that the Antigua and Barbuda Diabetes Association has been lobbying to make them more widely available locally; currently each sensor costs $200 XCD and lasts 2 weeks (a total of $400 XCD a month).

But for her the Freestyle Libre would be ideal, “It’s much easier to use, and it motivates me to check my blood sugar more. It’s more convenient since I don’t have to continuously prick myself. I just put on the sensor/patch on my arm and put the monitor close to it. It’s almost like using Bluetooth to check my blood sugar”

Penelope shared similar sentiments, “I can’t afford the Libre, it would be so helpful to have access to it. It will definitely benefit my children with their lifestyle and assist me by being able to relax and not have to worry so much.”

In addition to the Freestyle Libre, Penelope said, “ I would love to have access to at least 3 different insulin,  needles (suitable for children) and Glucose Gummies to help raise blood sugar when needed.

In Barbados, Xarriah was quite pleased that the insulin pen had recently been added to the drug registry. The insulin pen is an insulin delivery system that generally looks like a large pen; it uses an insulin cartridge rather than a vial, and uses disposable needles. Xarriah says it is particularly convenient because it does not have to be on ice, unlike insulin vials. With the pens being added to the list, this means that “they are available at pharmacies across the island at a significantly reduced cost. This has been a tremendous help for those who prefer the pens and may not have been able to afford them before. The Diabetes and Hypertension Association of Barbados also provides insulin pens and vials to its members for free once they are available”

The superheroes are managing their reality but their quality of life could be improved with changes from all stakeholders – policymakers and you as a reader. The superheroes are calling for Diabetes Education, Destigmatization, Prioritization of spaces and environments that support healthy children and improved access to medication and devices. So, next time you see a child or young person testing their sugar levels or taking insulin, you can be curious but also be kind. If you hear a mother, like Penelope, asking for changes to the school environment to make it healthier and easier to navigate for her children (and yours) – support her.

Diabetes Month is highlighted every November, but let us not wait until November 2023 to share Tiana, Jawan, Penelope, Kerro and Xarriah’s experiences and solutions for change. Diabetes Day is their reality, let us do what we can to cheer on and support our superheroes on their daily journey.

November is World Diabetes Awareness month and November 14th has been deemed World Diabetes Day. The date was chosen in honour of Canadian Sir Frederick Banting, who, together with Charles Best discovered insulin, 100 years ago.

Danielle Walwyn is the Advocacy Officer at the Healthy Caribbean Coalition (HCC) and helps to coordinate its youth arm, Healthy Caribbean Youth. She is also working alongside Xarriah, superhero and member of the HCC People living with NCDS Advisory Committee, to create a space for young people living with NCDS to connect. Send feedback to danielle.walwyn@healthycaribbean.org

The post Caribbean Superheroes – Children and Youth living with Type 1 Diabetes Part 2 appeared first on Healthy Caribbean Coalition.

Pharmalot (this will be first up). And what about you? There are some holidays just around the bend, so this may be an opportunity to open those catalogs or visit the nearest temple of consumption. You know what they say — act now, before prices rise still further. There is still time, of course, to plan a holiday getaway. Or you could hit the pause button and take stock of life. Well, whatever you do, have a grand time. But be safe. Enjoy, and see you soon. …

Medicare is willing to reevaluate its coverage of Alzheimer’s drugs in light of a new therapy, called lecanemab, that has shown potentially more promising patient data than its controversial predecessor, Aduhelm, STAT tells us. “I can’t speak to any specifics, but just to say that our door is really open,” Chiquita Brooks-LaSure, the Centers for Medicare and Medicaid Services administrator, said at the Milken Institute Future of Health Summit when asked about how the agency will approach the drug. “We will look at it as new data comes.” Last April, Medicare finalized a coverage policy in which it would only pay for Aduhelm if patients were enrolled in a clinical trial.

Continue to STAT+ to read the full story…

DM Pediatric Nephrology or Doctorate of
Medicine in Pediatric Nephrology also known as DM in Pediatric
Nephrology is a super
specialty level course for doctors in India that is done by them after completion
of their postgraduate medical degree course. The duration of this super
specialty course is 3 years, and it focuses on the diagnosis, treatment and management of
diseases affecting the kidney and urinary tract in children.

The course is a
full-time course pursued at various recognized medical colleges across the
country. Some of the top medical colleges offering this course include St. Johns Medical College- Bangalore and, All India Institute of Medical
Sciences- Rishikesh.

Admission to this
course is done through the NEET-SS Entrance exam conducted by the National
Board of Examinations, followed by counselling based on the scores of the exam
that is conducted by DGHS/MCC/State
Authorities.

The fee for
pursuing DM (Pediatric Nephrology) varies from college to college and may range
from Rs.5000 to Rs. 20,00,000 per year.

After completion of their respective course,
doctors can either join the job market or can pursue certificate courses and Fellowship programmes recognised by
NMC and NBE. Candidates can take
reputed jobs at positions as Senior residents, Consultants etc. with an
approximate salary range of Rs. 5,00,000 to Rs. 30,00,000 per year.

What is DM in Pediatric Nephrology?

Doctorate of
Medicine in Pediatric Nephrology, also known as DM (Pediatric Nephrology) or DM
in (Pediatric Nephrology) is a three-year super specialty
programme that candidates can pursue after completing postgraduate degree.

Pediatric Nephrology is the branch of medical science dealing with the diagnosis, treatment and management of diseases
affecting the kidney and urinary tract in children.

National Medical Commission (NMC), the apex
medical regulator, has released guidelines for a Competency-Based
Postgraduate Training Programme for DM
in Pediatric Nephrology.

The Competency-Based Postgraduate
Training Programme governs the education and training of DMs in Pediatric Nephrology.

The postgraduate
students must gain ample of knowledge and experience in the diagnosis,
treatment of patients with acute, serious, and life-threatening medical and
surgical diseases.

The PG education
intends to create specialists who can contribute to high-quality health care
and advances in science through research and training.

The required
training done by a postgraduate specialist in the field of Pediatric Nephrology would help the specialist to recognize the
health needs of the community. The student should be competent to handle
medical problems effectively and should be aware of the recent advances in
their speciality.

The candidate is
also expected to know the principles of research methodology and modes of the
consulting library. The candidate should regularly attend conferences,
workshops and CMEs to upgrade her/ his knowledge.

Course Highlights

Here
are some of the course highlights of DM
in Pediatric Nephrology

Name of Course

DM in Pediatric
Nephrology

Level

Doctorate

Duration of Course

Three years

Course Mode

Full Time

Minimum Academic Requirement

Postgraduate medical degree obtained from any
college/university recognized by the MCI (Now NMC)/NBE

Admission Process / Entrance Process / Entrance
Modalities

Entrance Exam (NEET-SS)

INI CET for various AIIMS, PGIMER Chandigarh, JIPMER Puducherry, NIMHANS Bengaluru

Counselling
by DGHS/MCC/State Authorities

Course Fees

Rs.5000 to Rs. 20,00,000 per year

Average Salary

Rs. 5,00,000 to Rs. 30,00,000 per year

Eligibility Criteria

The eligibility criteria for DM in Pediatric Nephrology are defined as the set of rules or
minimum prerequisites that aspirants must meet in order to be eligible for
admission, which include:

• Candidates must
  be in possession of a postgraduate medical Degree (MD/MS/DNB) from any
  college/university recognized by the MCI (Now NMC)/NBE.
• The candidate must have obtained permanent
  registration of any State Medical Council to be eligible for admission.
• The medical college's recognition cut-off
  dates for the Postgraduate Degree courses shall be as prescribed by the Medical
  Council of India (now NMC).

Admission
Process

• The admission process contains a few steps to be followed in
  order by the candidates for admission to DM
  in Pediatric Nephrology. Candidates can view the complete admission process
  for DM in Pediatric Nephrology
  mentioned below:

• The NEET-SS or National Eligibility Entrance Test for Super
  specialty courses is a national-level master's level examination conducted by
  the NBE for admission to DM/MCh/DrNB Courses.

• Qualifying
  Criteria-Candidates placed at the 50th percentile or above shall be declared as
  qualified in the NEET-SS in their respective specialty.

• The
  following Medical institutions are not covered under centralized admissions for
  DM/MCh courses through NEET-SS:

1. AIIMS, New
   Delhi and other AIIMS
2. 2.PGIMER,
   Chandigarh
3. 3.JIPMER,
   Puducherry
4. 4.NIMHANS, Bengaluru

• Candidates
  from all eligible feeder specialty subjects shall be required to appear in the
  question paper of respective group, if they are willing to opt for a super specialty course in any of the super specialty courses covered in that
  group.

• A
  candidate can opt for appearing in the question papers of as many groups for
  which his/her Postgraduate specialty qualification is an eligible feeder
  qualification.

• By
  appearing in the question paper of a group and on qualifying the examination, a
  candidate shall be eligible to exercise his/her choices in the counseling only
  for those superspecialty subjects covered in said group for which his/ her
  broad specialty is an eligible feeder qualification.

Fees Structure

The fee structure for DM in Pediatric
Nephrology varies from college to college. The fee is generally less for
Government Institutes and more for private institutes. The average
fee structure for DM in Pediatric
Nephrology is around Rs.5000 to Rs. 20,00,000 per year.

Colleges offering DM in Pediatric Nephrology

There are
various medical colleges across India that offer courses for pursuing DM in (Pediatric Nephrology).

As per
National Medical Commission (NMC) website, the following medical colleges are
offering DM in (Pediatric
Nephrology)
courses for the academic year 2022-23.

Sl.No.

Course Name

Name and Address of
Medical College / Medical Institution

Annual Intake (Seats)

1

DM - Paediatric Nephrology

St. Johns Medical College, Bangalore

1

2

DM - Paediatric Nephrology

All India Institute of Medical Sciences, Rishikesh

6

Syllabus

A DM in Pediatric Nephrology is a three years specialization
course that provides training in the stream of Pediatric Nephrology.

The course
content for DM in Pediatric Nephrology
is given in the Competency-Based Postgraduate Training Programme
released by National Medical Commission, which can be assessed through the link
mentioned below:

NMC Guidelines For Competency Based Training Programme For DM Pediatric Nephrology

.1 SUBJECT SPECIFIC THEORETICAL COMPETENCIES

3.1.1 Cognitive domain (Knowledge domain)

3.1.2 Affective domain (Attitudes including Communication and Professionalism)

3.2 SUBJECT SPECIFIC PRACTICE-BASED OR PRACTICAL COMPETENCIES

The curriculum outlines competences that trainees must reach by the end of the programme (combining 3.1 and 3.2)

A. Investigation of the kidney

1. Renal Anatomy and Physiology

Knowledge

• To understand the embryology and development of genito-urinary system
• To understand the development of renal function and physiology for the assessment of:

a. GFR from height and plasma creatinine

1. Calcium, phosphate & bone mineral metabolism

c. Urinary concentrating and diluting ability

d. Tubular handling of fluid and electrolytes

e. Acid-base balance

• To explain the practicalities, limitations and special precautions of measurement of:

a. Creatinine clearance

b. Protein and calcium excretion

c. Tubular handling

d. Tests for urinary acidification

Skills

To appropriately request and interpret the above investigations

Multidisciplinary

aspects

Laboratory Medicine Department

Resources

Clinical Physiology of Acid-Base and Electrolyte Disorders – Burton David Rose

Principles of Renal Physiology – Chris Lote

Pediatric Renal Investigations – Chapman & Taylor

1. Imaging

Knowledge

• To understand the role, limitations and interpretation of commonly used imaging modalities
• To know the practicalities and safety precautions associated with each test

· To understand the role of arteriography and percutaneous

nephrostomy tube placement

Skills

· To appropriately request the different radiological investigations

· To be able to interpret scan images

Multidisciplinary aspects

• Liaison with radiologists in deciding the most appropriate investigations

Resources

• Nephro-urology radiology meetings/Posting in nuclear medicine unit

· Bank of typical case images

2. Renal Biopsy and nephropathology

Knowledge

· To describe the anatomy of both native and transplant kidneys

· To know the indications for renal biopsy

· To describe the procedure of renal biopsy and its complications

• To know the type of solutions used for light (LM), immunofluorescence (IF), and electron microscopy (EM) specimens immediately post-biopsy
• To have a basic knowledge of handling and processing of renal biopsy tissue and utility of various stains (hematoxylin and eosin, periodic acid Schiff, Trichrome (Masson), silver-stains, and Congo

red /immuno-fluroscence used in the diagnosis of renal disease.

Skills

• To counsel families in preparation for renal biopsy, thus allowing informed consent

· To perform a native (and transplant) biopsy safely

• To recognize the histopathologic characteristics of normal kidney on LM, IF, and EM
• To recognize common histological appearances and consequences for diagnosis, prognosis and treatment
• Able to interpret slides, including all the components: LM, IF and EM.

· Obtain adequate clinical background and information from the

appropriate nephrologist submitting the specimen to allow optimal

interpretation of the biopsy.

Multidisciplinary

aspects

Radiologist and pathologist

Resources

Nephropathology meetings Bank of typical case histology

Training day for processing, staining and interpreting of renal biopsy

samples

(B) Urinary Tract Infection (UTI) and Vesicoureteric Reflux

Knowledge

· To know the epidemiology of UTI

· To understand current theories about renal scarring

· To be aware of issues in diagnosis of UTI

• To describe the role of ultrasound scan, MCU, DMSA and other investigations for UTI
• To know the medical and surgical options in the management of UTI
• To describe the mechanisms of action of antimicrobials and their adverse effects

· To understand the secondary progression of renal damage and its

prevention

Skills

• To appropriately manage urinary tract infection in different age groups

· To show ability to counsel parents about relevant investigations of

UTI, and possible management of siblings of children with reflux

Multidisciplinary aspects

· To know the appropriate follow-up into adult life

· To recognize the role of microbiologists, urologists and radiologists

• To be able to contribute to the development of strategies for management of UTI at local and regional level

Resources

· Microbiology department

· Nephro-pediatric surgery-radiology meeting

• Structural Malformations

Knowledge

· To understand renal embryology and developmental anatomy

• To describe the anatomy of the urinary tract and the sites and causes of urinary obstruction
• To know the presentations of developmental variants and abnormalities, including obstruction
• To describe the fluid and electrolyte disturbances occurring following the relief of obstruction
• To be aware of the different reconstructive procedures performed, and their implications for future management
• To be aware of other urological diagnoses, including genital anomalies

· To know the importance of ambiguous genitalia and intersex in

renal disease: structural as well as neoplastic

Skills

· To be able to provide medical support to urological services,

especially following relief of obstruction

Multidisciplinary aspects

• Liaison with radiologists, obstetricians and surgeons in management decisions and antenatal counseling

· To show ability to communicate and work together with other health

professionals

Resources

· Department of Pediatric Surgery

· Radiology meeting

· Department/Division of Neonatology

(D) Disorders of Micturition

Knowledge

• To know the common renal and non-renal diagnoses associated with enuresis

· To know the appropriate use of urodynamic studies

• To explain the rationale for various management strategies in enuresis using behavioral and pharmacological therapies

Skills

• To be able to interpret urodynamic studies, and instigate appropriate management

· To know the practicalities involved in enuretic alarms

Multidisciplinary aspects

· Liaison with urodynamic staff

· Role of the psychologist

Resources

Pediatric urologists/surgeons

Bank of images

(E) Neurogenic bladder

Knowledge

· To know the pathophysiology of neurogenic bladder

· To know the role of basic urodynamic investigations

• To know the appropriate surgical management of different types of bladder dysfunction

· To understand the treatments available to regularize bowel and

bladder habit

Skills

• To be able to appropriately asses the whole child with neurogenic bladder

· To show ability to investigate and manage the upper and lower

urinary tract

Multidisciplinary

aspects

· To know the importance of shared care with surgeons and urologists

Resources

· Pediatric urology services

(F) Hematuria

Knowledge

• To know the pathophysiology of macroscopic and microscopic hematuria
• To describe the methods of investigation in microscopic hematuria, including the role of renal biopsy
• To understand the various findings of phase contrast microscopy and their meaning
• To know the underlying causes of hematuria
• To know the long term outcome of the underlying causes

Skills

• To be able to perform urinalysis
• To demonstrate appropriate investigation and management of the child with hematuria, including role of imaging,

urological assessment, and genetic and molecular studies

Multidisciplinary aspects

• To explain the mode of inheritance of hereditary nephritis, and implications for other family members
• To appreciate the role of the pediatric surgeon
• To understand the need for long-term follow up

Resources

• Nephropathology meeting
• Pathology laboratory (microscopy of urine)

(G) Proteinuria

Knowledge

• To know the pathophysiology of proteinuria
• To know the physiological and pathological causes of asymptomatic proteinuria
• To describe the methods of investigation of asymptomatic proteinuria
• To list the indications for renal biopsy
• To know the long-term prognosis of the various conditions causing proteinuria

Skills

• To be able to differentiate between pathological and physiological proteinuria
• To show ability to manage the child with proteinuria

Multidisciplinary aspects

• To understand the requirement of long-term follow-up

(H) Glomerular disease

Knowledge

• To describe the etiology, pathophysiology and immunological basis of glomerulonephritis
• To know the different forms of presentation
• To understand the clinical course and prognosis of acute and chronic glomerulonephritis
• To know the indications for immunosuppressive agents,

cytotoxic drugs, plasmapharesis and dialysis

Skills

• To appropriately investigate and manage the acute

nephritic syndrome, and new presentation of chronic

glomerulonephritis

• To demonstrate the appropriate use of general and specific measures to treat glomerulonephritis

Resources

• Pathology laboratory

(I) Nephrotic syndrome

Knowledge

• To know the causes of nephrotic syndrome
• To be aware of the pathophysiology of nephrotic syndrome, including latest research
• To understand the investigation of nephrotic syndrome including indications for renal biopsy
• To understand the complications of the nephrotic state
• To know the pharmacology and side-effects of steroids, other immunosuppressive agents and other treatment modalities

Skills

• To appropriately investigate and manage initial episode of nephrotic syndrome and relapses and the complications
• To appropriately investigate and manage steroid resistant nephrotic syndrome and the complications
• To manage adverse effects of immunosuppressive medications
• To demonstrate the appropriate use of general and specific

measures to treat secondary causes of nephrotic syndrome

Multidisciplinary aspects

Liaison with local pediatricians in long-term management

Resources

Pediatrics, Pathology

(J) Systemic lupus erythematosus (SLE)

Knowledge

• To describe the pathogenesis of SLE and underlying immunological mechanisms
• To list the histological classification of lupus nephritis
• To describe the clinical course of lupus nephritis
• To describe the different treatment options

Skills

• To perform a relevant clinical examination to diagnose and assess a patient with SLE
• To plan and interpret investigations, including renal histology and immunology
• To appropriately manage acute renal failure due to SLE, including use of plasmapharesis
• To show ability to undertake long-term management of the

patient with lupus nephritis

Multidisciplinary aspects

• To appreciate the role of other specialists, especially rheumatologists
• To counsel the patient about long-term implications of SLE, including problems with renal transplantation and

impact on reproductive potential

Resources

Adult nephrology, rheumatology services

(K) Other Vasculitis

Knowledge

• To understand the pathophysiology and immunology of vasculitis
• To know the different causes of vasculitis
• To know the presentation of vasculitis, patterns of multisystem involvement and spectrum of disease
• To describe the investigation and monitoring of the patient with vasculitis
• To list the different therapeutic options available, including

adverse effects

Skills

• To perform a relevant multisystem clinical examination
• To be able to appropriately investigate and treat vasculitis, including use of immunosuppression, in the short and long- term

Multidisciplinary aspects

To work with other specialists including rheumatologists

Resources

Pediatric and adult rheumatology clinics

(L) Hemolytic uremic syndrome (HUS)

Knowledge

• To understand the pathophysiology of microangiopathic hemolytic anemia
• To know the epidemiology of VTEC, S. dysenteriae
• To know the presentation and clinical course of diarrhea- positive and atypical HUS
• To be aware of non-renal manifestations of HUS
• To understand the long-term consequences and prognosis of D+ HUS
• To understand principles of treatment, including conservative, and the role of plasma exchange and dialysis
• To understand the investigation of atypical HUS
• To be aware of the long-term management of atypical HUS including implications for transplantation

Skills

• To be able to investigate, diagnose and manage the initial presentation of HUS
• To appropriately initiate dialysis and plasma exchange
• Interstitial nephritis

Knowledge

To list the causes of interstitial nephritis and tubulo-

interstitial disease, and the relationship to systemic conditions

Skills

To appropriately investigate and manage the child with

interstitial nephritis, including use of corticosteroids

(N) Hypertension

Knowledge

• To define and understand how to diagnose hypertension
• To know the common renal and non-renal diagnoses implicated in hypertension in different age groups
• To describe the possible mechanisms causing primary (essential) and secondary hypertension
• To describe the investigation of hypertension including the use of arteriography and renal vein sampling ; nuclear imaging
• To describe the mechanism of action and side-effects of

anti-hypertensive agents

• To understand vascular interventions in renal artery stenosis

Skills

• To show ability to appropriately investigate the child with hypertension
• To be competent in the management of hypertensive emergencies
• To be competent in the management of chronic hypertension, and in using the different classes of drugs
• To be able perform and interpret ABPM read out and

modify prescription

Multidisciplinary aspects

• Liaison with local pediatricians; interventional radiologist

Resources

• Intensive care unit; Radiology services

(O) Nephrolithiasis

Knowledge

• To know the etiology of renal stone formation, including underlying tubular abnormalities
• To know the biochemical and radiological investigation of renal stones
• To understand the acute and chronic medical (including prevention of the development of renal stones) and surgical

management of renal stones (including lithotripsy)

Skills

• To demonstrate ability to appropriately investigate the child with renal stones
• To show ability to manage the child with renal stones

Multidisciplinary aspects

• To involve pediatric urologists where indicated
• To show understanding of the significance of the family history and genetic implications in some cases

Resources

Departments of Laboratory Medicine, Pediatric Surgery,

Urology and Radiology

(P) Tubular disorders

Knowledge

• To understand the different presentations of primary and secondary tubular disorders
• To know the different causes
• To understand the investigation of tubulopathies

Skills

• To be competent in the investigation and management of

tubular disorders

Multidisciplinary aspects

• To understand the role of other specialists (hepatologists, neurologists, biochemists, geneticists) in the diagnosis, management and treatment of these disorders
• To be able to provide dialysis support to other specialists

Resources

Metabolic clinics, Endocrine clinic

Biochemistry department

• Cystic disease

Knowledge

• To list the different causes of renal cystic disease in different age groups
• To describe the mode of inheritance and methods of screening
• To know the clinical course and associated features of autosomal recessive and autosomal dominant polycystic

kidney disease

Skills

• To appropriately examine and investigate the child with renal cysts in different age groups
• To appropriately manage the child with polycystic kidney

disease

Multidisciplinary aspects

• To appreciate the implications of a diagnosis of autosomal dominant polycystic kidney disease on other family members
• To recognize the importance of genetic counseling

Resources

• Radiology services

(R) Genetic disorders (Inherited diseases of the kidneys)

Knowledge

• To know the presentation and management of commonly encountered inherited renal disease including renal involvement in syndromes, familial nephritis and polycystic kidney disease
• To understand basic genetic principles

Skills

• To be able to advise parents of the risks of recurrences and the need for family screening in commonly inherited

diseases

Multidisciplinary aspects

To understand the role of the geneticist in diagnosis

and counseling, including antenatal diagnosis

Resources

Geneticist

(S) Fluid and electrolyte disturbances

Knowledge

• To understand the physiology underlying fluid and electrolyte imbalance in the child without primary renal disease
• To know the principles of treatment of fluid and electrolyte imbalance
• To know the endocrine diseases associated with electrolyte

imbalance and their management

Skills

To be able to manage fluid and electrolyte imbalances in

non-renal disease including overdose

Resources

• Intensive care unit
• Endocrine clinics

(T) Acute Kidney Injury (AKI)

Knowledge

• To know the differential diagnosis of AKI
• To know the investigation including role of renal biopsy
• To describe the methods to correct fluid and biochemical abnormalities and to know the indications for dialysis
• To describe the principles of dialysis and filtration
• To know the treatment of reversible causes of AKI

Skills

• To perform a reliable and accurate clinical assessment of

the patient's fluid status

• To be able to appropriately manage the complications of AKI – conservative and dialysis
• To be able to select and practically manage the different dialysis modalities including peritoneal dialysis, hemodialysis and hemofiltration
• To be able to commence correct treatment of the underlying cause
• To manage the patient with multiorgan failure or systemic

disease requiring acute renal replacement therapy

Multidisciplinary aspects

• To recognize the role of nurses in the management of AKI
• Liaison and share care with the intensive care unit

Resources

Intensive care and neonatal intensive care units

(U) Chronic Kidney Disease (CKD)

Knowledge

• To know the epidemiology of CKD
• To list the causes of CKD
• To know the investigations required in a child with new presentation of CKD, including assessment of the degree of renal failure and reversibility of the condition
• To understand the natural history and prognosis of common diseases causing CKD, and treatment strategies that may ameliorate the condition
• To understand the factors involved in failure to thrive in CKD
• To describe the pathophysiology, investigation and indications for treatment in the management of renal bone disease
• To describe the pathophysiology of renal anemia, and its investigation and management, including use of

erythropoietin and iron therapy

Skills

• To identify and appropriately manage the underlying cause

• To manage the child with CKD including biochemical disturbance, bone disease and anemia
• To appropriately counsel the family to facilitate the selection of dialysis modality and prior to referral for renal transplantation
• To make an accurate clinical assessment of nutritional status and to use appropriate dietary advice with the assistance of dietitians
• To prescribe and monitor treatment for hyperlipidemia
• To show ability to prevent, diagnose and manage renal bone disease
• To diagnose and appropriately treat renal anemia

Multidisciplinary aspects

• To appreciate the role of the multiprofessional team including dietitian, psychologist, social worker
• To understand the role of the dialysis nurses and transplant coordinator
• To audit biochemical and hematological results against national guidelines
• To appreciate the impact of CKD on cardiovascular disease

in adult life

Resources

• Chronic kidney disease clinics
• Multidisciplinary team meeting

(V) Transplantation

Knowledge

Pre-Transplantation

• To understand the ethical issues surrounding organ donation/ transplant
• To know the principles of recipient selection, indications and contraindications
• To describe the theoretical and practical application of

blood grouping, HLA matching and donor-recipient cross

matching

• To know what is involved in a transplant work-up
• To know the advantages and disadvantages of deceased versus live related donor transplantation
• To know the acceptability criteria for deceased organ donation
• To describe the advantages and disadvantages of preemptive transplantation

Transplantation

• To understand the unique needs of children undergoing organ transplantation
• To know the basic surgical procedures involved
• To know the medications used, including side-effects and recent advances and trials
• To know the approach towards handling deceased organ transplantation

Post-Transplantation

• To know the indications for and knowledge of the procedure of renal transplant biopsy
• To understand the immune mechanisms of rejection
• To know the recurrence rate of the original disease, and other complications pertaining to the original diagnosis and their management

Skills

Pre-transplantation

• To assess the suitability of a patient for renal transplant
• To discuss the issues of transplantation

Transplantation

• To be able to manage the peri-operative transplant period
• To assess renal transplant function
• To plan and modify immunosuppressive therapy

Post-transplantation

• To be competent in the diagnosis and management of acute rejection episodes
• To understand the role of fine needle cytology and histopathology for diagnosing rejection
• To be able to manage the stable transplant patient
• To be able to advise the child, family and school
• To be able to diagnose and manage chronic rejection
• To be aware of the diagnosis and management of the short and long-term complications of transplantation
• To counsel patients with a failing graft and discuss future

management on renal replacement therapy

Multidisciplinary aspects

To understand the role of the transplant coordinator

To appreciate the role of the multidisciplinary team

Resources

• Transplant clinics
• Tissue typing laboratory
• Transplant surgeon

(W) DIALYSIS

1. Hemodialysis

Knowledge

• To describe the principles of hemodialysis and compare and contrast with other methods of dialysis
• To describe the anatomy of the neck veins, and their assessment
• To describe the methods of vascular access and arterio venous fistulas, and their complications
• To understand the principles of water treatment and maintaining water quality
• To define the methods to assess adequacy of hemodialysis
• To list the complications occurring during dialysis
• To list the particular infections which may occur in patients on dialysis, and to define strategies to prevent

blood-borne viral infections in patients on hemodialysis

Skills

• To be able to plan the initiation of hemodialysis

• To manage different forms of vascular access, and their difficulties
• To assess the functional status of AV fistula and cannulate
• To operate hemodialysis machine and respond to alarms; disinfection of machines and circuits
• To be able to handle dialyzers and the dialyzer tubings appropriately
• To adjust the prescription of hemodialysis based on adequacy and monitor change
• To manage the complications of hemodialysis
• To diagnose, investigate and treat infection

Multidisciplinary aspects

• To understand the role of the nurses in preparing the patient physically and psychologically for hemodialysis, and in the long term management
• To counsel patients about blood borne infection
• To work closely with the microbiologist in developing protocols and in audit and management of infection

Resources

Hemodialysis technician and nurses

Departments of Nephrology, Microbiology and Surgery

2. Peritoneal Dialysis

Knowledge

• To describe the principles of acute and peritoneal dialysis, and know the advantages and disadvantages compared to hemodialysis
• To describe methods to assess adequacy of peritoneal dialysis and ultrafiltration
• To describe the anatomy and outline the surgical procedure of insertion of peritoneal dialysis catheters
• To know the complications of peritoneal dialysis, both

infective and mechanical

Skills

• To be able to prescribe peritoneal dialysis and monitor change and measure adequacy
• To perform peritoneal equilibration test (PET)

• To operate and troubleshoot PD cyclers
• To manage the complications of peritoneal dialysis

Multidisciplinary aspects

Pediatric surgeon

(X) Pharmacology

Knowledge

• To define the principles of pharmacokinetics and drug handling in renal impairment
• To list ways in which different classes of drugs act on the nephron
• To describe how drugs may affect renal function
• To list the effects of hemodialysis, hemofiltration and peritoneal dialysis on drug prescribing
• To describe the principles of drug interactions especially

immunosuppressive agents

Skills

• To prescribe safely to patients with renal disease

Multidisciplinary aspects

• To educate patients regarding importance of compliance

and reporting of problems with medication

Resources

Pharmacologists

• Psychosocial and Ethical issues

Knowledge

• To understand the impact of chronic illness on the child, adolescent, parents, siblings and extended family
• To understand the ethics of research in children
• To know the process of informed consent in different ages
• To know the procedures for clinical trials

Skills

• To demonstrate competence in communication skills at initial diagnosis and thereafter
• Liaison with pediatricians and other health professionals
• To show interest in ethical discussions within the department
• To show ability to take informed consent

Multidisciplinary aspects

• To understand the role of the psychologist, psychiatrist,

social worker, teacher and religious leaders

• To understand the care of the dying child

Resources

Multidisciplinary team meeting

(Z) Teaching skills

Knowledge

• To understand the principles of adult learning and different teaching techniques
• To understand the role of clinical audit and research

Skills

• To demonstrate formal and informal teaching skills at undergraduate and postgraduate level, and to other professionals within the multidisciplinary team
• To demonstrate continuing self-education and self- reflection
• To show support or active involvement in research
• To show ability to critically evaluate literature reviews, audit and research papers
• To demonstrate ability in oral presentation skills and

manuscript preparation

(A1) Nutrition

Knowledge

• To develop basic knowledge of nutritional requirements of children with acute kidney injury and chronic kidney

disease including those on dialysis and transplantation

Skills

• To be able to counsel and provide nutritional advice for

children with chronic kidney disease

Multidisciplinary aspects

• Nutritionist

Competency in Procedural /Practical Skills:

The post graduate student should be able to perform independently the following procedures

• Renal biopsy

Satisfactory performance of percutaneous biopsy of native and transplant kidneys entail:

• knowledge of indications for the procedure,
• obtaining informed consent,
• performance of the procedure itself including minimizing patient discomfort, and
• interpretation of results of the biopsy.

• Central venous access insertion for hemodialysis

Satisfactory placement of vascular access entails:

• knowledge of informed consent,
• proper Seldinger technique,
• knowledge of vascular anatomy,
• minimizing patient discomfort, as well as
• functional catheter placement and recognize/manage complications

• Acute peritoneal dialysis catheter insertion

Satisfactory placement of peritoneal catheter placement entails:

• knowledge of informed consent,
• proper technique,
• minimizing patient discomfort, as well as
• functional catheter placement.

In addition they should be able to perform independently the following:

To be able to write a prescription, conduct and supervise acute and chronic intermittent hemodialysis

• Entails knowledge of proper indications for hemodialysis,
• knowledge of first dialysis precautions,
• writing of dialysis order which includes choosing dialysis filters,
• estimating dry weight and modification during special circumstances (critically ill child, in-born errors of metabolism),
• choosing dialysate composition,
• understanding and treatment of complications, and
• modifying dialysis prescription for inadequate clearance in chronic hemodialysis patients.

To be able to write a prescription, conduct and supervise acute and chronic peritoneal dialysis:

• Entails knowledge of proper indications of peritoneal dialysis,
• writing orders for peritoneal dialysis which includes dialysis prescription (volume of dialysate, frequency of exchanges, and use of different hypertonic solutions),
• understanding and treatment of complications, and
• modifying dialysis prescription in special situations (lactic acidosis, metabolic disorders) and inadequate clearance in chronic peritoneal dialysis patients

To be able to write a prescription, conduct and supervise continuous renal replacement therapy (CRRT)

• Entails knowledge of proper indications of CRRT,
• writing orders for continuous renal replacement therapy (flow rate of dialysate, choosing ultrafiltration rate,
• choosing dialysate composition including the use of bicarbonate based solutions),
• understanding and treatment of complications, and
• modifying dialysis prescription for inadequate clearance in patients undergoing continuous renal replacement therapy

To be able to write a prescription, conduct and supervise slow low efficiency daily dialysis (SLED)

• Entails knowledge of proper indications of SLED,
• writing orders (flow rate of dialysate,
• choosing ultrafiltration rate,
• choosing dialysate composition,
• understanding and treatment of complications, and
• modifying dialysis prescription for inadequate clearance in patients undergoing SLED

To be able to write a prescription, conduct and supervise plasmapheresis

• Entails knowledge of proper indications of plasmapheresis,
• writing orders (volume of plasma replacement,
• choosing rate of plasmapheresis, monitoring,
• understanding and treatment of complications, and modifying plasmapheresis prescription based on the goal of plasmapheresis.

To be able to perform urine analysis at bedside

• To perform correctly urinalysis and interpret findings and to know the limitations of interpretation as applied to patient care

Procedure

O

A

P

SJ

Renal biopsy

Hemodialysis catheter access

Acute peritoneal catheter insertion

Urine analysis

O- Observed; A- Assisted; P- Performed independently; SJ- Supervised junior colleague

Career Options

After
completing a DM in Pediatric Nephrology,
candidates will get employment opportunities in Government as well as in the
Private sector.

In the Government sector, candidates have various options to
choose from which include Registrar, Senior Resident, Demonstrator, Tutor, etc.

While in the Private sector the
options include Resident Doctor, Consultant, Visiting Consultant (Pediatric Nephrology), Junior Consultant, Senior
Consultant (Pediatric Nephrology), Pediatric Nephrology
Specialist.

Courses After DM
in Pediatric Nephrology Course

DM
in Pediatric Nephrology is a specialisation course which
can be pursued after finishing a Postgraduate medical course. After pursuing
specialisation in DM in Pediatric Nephrology, a candidate could also
pursue certificate courses and Fellowship programmes recognised by NMC and NBE,
where DM in Pediatric Nephrology is a feeder
qualification.

Frequently Asked Question (FAQs) –DM in Pediatric Nephrology Course

Question: What is the
full form of DM?

Answer: The full form of
DM is Doctorate of Medicine.

Question: What is a DM in Pediatric Nephrology?

Answer: DM Pediatric Nephrology or Doctorate of Medicine in Pediatric Nephrology also
known as DM in Pediatric Nephrology is a super specialty level
course for doctors in India that is done by them after completion of their
postgraduate medical degree course.

Question: What is the
duration of a DM in Pediatric
Nephrology?

Answer: DM in Pediatric Nephrology is a super
specialty programme of three years.

Question: What
is the eligibility of a DM in Pediatric
Nephrology?

Answer:
Candidates must be in possession of a postgraduate medical Degree (MD/MS/DNB)
from any college/university recognized by the Medical Council of India (now
NMC)/NBE.

Question: What is the scope of a DM in Pediatric Nephrology?

Answer: DM in Pediatric
Nephrology offers candidates various employment opportunities and career
prospects.

Question: What is the average salary for a DM in Pediatric Nephrology candidate?

Answer: The DM in
Pediatric Nephrology candidate's average salary is between Rs. 5,00,000 to Rs. 30,00,000 per year depending on the experience.

Question: Can you teach after completing
DM Course?

Answer: Yes, candidate can teach in
a medical college/hospital after completing DM course.