AAP NCE October 11th, 2008

The first full day of the NCE began with a "Fun" Run in support of the Friends Of Children fund. This involved waking up at 5:30 AM in order to make coffee and slap contact lenses in my eyes in time to meet the shuttle to Boston Commons downstairs at 06:15. A handfull of us stood outside hopping around in the cold and hoping the shuttle would come to the Westin, being the poor sister to the host hotel. But the shuttle did come eventually, and I rode over with NC Pediatric Society President Marian Earls and her husband, both runners. We chatted about the coming flood of uninsured patients to Guilford Child Health and about GE Centricity EMR before our bus disgorged us onto the Commons.

There we found a hoard of impossibly enthusiastic race volunteers, tables full of Powerade and Power Bars, and possibly the ugliest race tee shirts ever printed. But I was freezing cold in my little shorts and grateful for the insulation, so I donned my shirt and pinned on my race number. We warmed up to the encouragement of a personal trainer hired specially for the event by the AAP. She wore a headset and led about 100 of us through mass exercises and stretches. None of us had the heart to tell her randomized controlled trials have failed to determine whether stretching before running is actually helpful. And then we were off, running three times around the Commons, uphill the entire way. I will say only that I finished and, yet again, I did not suffer a myocardial infarction. But if you ever meet the Kentucky chapter president's wife, do not challenge her to a race. She will whoop up on you (yes, you Sean Lucas).

The heinous but warm official race tee shirt.

By the time I was clean, dressed, and caffeinated the first of the sessions were already underway. I joined my dad in room 301 where we learned about Intercultural Communications To Improve Culturally Effective Pediatric Care from Geri Ann Galanti, PhD and David Katz, MD. Dr. Galanti, a cultural anthropologist, reminded us to ask questions to guage what parents' concerns actually are, and not to treat their beliefs with open scorn. We should ask what the parents think the cause of the disease is and find out what worries them about the course of therapy we prescribe. She also reminded us many pharmacalogically active folk therapies are not viewed by parents as medications per se but are given in the form of teas - if we don't ask the questions broadly enough, we don't get the whole answer. Bottom line: if you don't fully understand parents' belief systems and practices you will fail to collect the right information and compliance will be abysmal.

Dr. Katz served as a civilian advisor to American forces in Afghanistan, and he brought several lessons to us from that conflict. The Medical Civic Action Program (MEDCAP) undertaken by our military forces often undermined the role of Afghani public health services by providing temporary, "bandaid" solutions to problems that were more endemic. Also, if you join one of those missions you are likely to get shot at, and so are the patients who seek your help. He emphasized that whenever we intervene in third world healthcare we focus on building sustainable infrastructure for administering care as opposed to handing out medications that last for a month and then run out. It seems we do much more good strengthening the local care systems than just seeing some kids and leaving on the next plane back to civilization.

From there it was on to the first Plenary sessions. We arrived just in time to hear the children's choir sing the Star Spangled Banner. Once we took our hands off our hearts we found seats at the far left of the ballroom and settled in to hear the opening address from AAP President Renee Jenkins.

But first things first: there's an annual art contest for the NCE, and we got to see the winners in the junior and senior divisions:

Afterward Dr. Jenkins took the stage and spoke about her year as AAP president, framing it in terms of "tiara moments" and "target moments." Tiara moments, for example, included the passage of the Genetic Information Nondisrimination Act. A target moment was when Jenny McCarthy organized protests around the AAP announcement of new vaccine initiatives. The speech was starkly political, noting that the United States currently falls at the bottom of developed countries on measures of child health, doing worse than such superpowers as Hungary, the Czech Republic, Poland, and Greece. She cited the defeat of SCHIP expansion as a major setback to the cause of children's health and reviewed the Telluride Principles of investing in our children as a way of ensuring the secure future of our country. She shared the Vision of Pediatrics 2020 and suggested that this year's election would give us an opportunity to alter the rather dismal trends in children's healthcare over the last eight years.

Following Dr. Jenkins's speech the Education Awards were given to Dr. Kurt Metzel for his pioneering work in pediatric continuing medical education and to Dr. David Bernhardt for his contributions to the field of sports medicine.

Then Timothy Shriver took the stage, looking and sounding every bit the Kennedy he is. He spoke eloquently on the Special Olympics movement and how it has morphed from a simple athletic contest into a force for promoting the competent medical care of intellectually disabled children and adults throughout the world. We learned how 15% of Special Olympics athletes at a screening had to be sent directly to the ED for untreated acute and chronic medical conditions. If any of us is interested, the Special Olympics hosts a variety of training programs to help medical professionals better address the needs of the intellectually disabled. Also, Timothy was not amused by the movie Tropic Thunder.

Timothy Shriver left the stage to Francine Cournos, a psychiatrist and former foster child who spoke movingly of her experience in the foster system and of the pediatrician who inspired her to become a physician herself. She reminded us that children placed in foster care are terrified and grieving the loss of their families, and it should not surprise us they are not eager to bond with new parents or us. She pointed out behavior we might label "oppositional defiant disorder" is simply adaptive in foster children whose sole power over their new existence is the power to say "no". The good news is that by listening to these children and validating their concerns we can be forces of stability in their lives and not merely more sources of trauma.

Finally we heard from Jean Kilbourne, EdD, who spoke on the early sexualization of children in modern society. As father to a nearly 9 year old girl, this one struck home. She displayed such egregious examples as "Lingerie Barbie," the "Child's Pimp and Ho Costumes" for Halloween (sizes 4-6), and Abercrombie and Fitch print ads showing nude teenaged models in a menage a trois. Grand Theft Auto, the most popular video game with American teens, encourages players to have sex with prostitutes then murder them in a variety of violent ways. Jean pointed out that in America we have allowed corporate marketers to suggest throughout the media that sexual roles are appropriate for young girls and that girls and boys should view women as sexual objects, made all the more alluring by the variety of products they can purchase at the local mall. This trend, combined with the ascendance of "abstinence only" sex education, has led the US to lead the developed world in teen pregnancy (most common in areas of the country where abstinence only sex ed is mandated). At this point 1/3 of American girls become pregnant during their teen years. Jean Kilbourne also offered up the coming election season as an opportunity for us to reverse this disturbing trend.

Then it was on to the breakout sessions. But first, a few observations about the convention center. Over every toilet you see the following:

I'm pleased the management cares to protect me, but I'm confused about what I'm being protected from. These dispensers hold sheaves of paper rings, but I can't see what good they would do me faced with, say, a charging rhino or a stray bullet. But you never know; I tucked a few in my bag just in case.

The bathrooms also sport electric hand driers, but these are unlike anything I've ever seen. They're like ram jets mounted to the walls, propelling air with enough force not only to get the water off your hands but to levitate the whole wall:

We need these in Southeastern North Carolina. I'm looking into getting a distributorship.

Unlike 2005, when I was last at the NCE, you no longer sign up for teaching sessions. Instead you just run to the room where your chosen lecture is and hope you get a seat. I was too late for "Neurology In the Office", and by the time they barred that door, all the other good lectures were also closed. So I wandered down to the vast exhibition hall to see how many cheap ballpoint pens I could cram in my bag. The photo below does not begin to show what an overwhelmingly vast maze greets you:

Many of you know I'm a card-carrying member of No Free Lunch, which means I have a moral proscription against accepting free goodies from pharmaceutical and formula companies. This was a major bummer in 2005, when attendees often left the exhibit hall weighted down with two or more giant tote bags full of schwag. This year things have changed. There were still whole villages dedicated to pharmaceutical and nutritional companies, but they were not nearly as dominant. The most elaborate had to be Ross Nutritional's high-tech waterfall:

But there were many, many booths dedicated to various charitable organizations, professional societies, and physician recruitment firms. What did this mean for me? You guessed it: tons and tons of guilt-free pens, flash drives, letter openers, hand sanitizers, and breath mints. Disturbingly for someone deeply invested in an EMR, the electronic health record companies were few and far between, with only two or three exhibitors compared to the dozen or so in 2005.

Having learned my lesson, I arrived early for Dermatologic Therapeutics with Dr. James Gary Dinulos, a man whose skin and hair were flawless. I learned that when thinking about dermatologic therapy I had to consider where it was going: the mucous membranes, eyelids, and scrotum absorb 36 times the topical medication absorbed by the palms, soles, or nails. I also learned a critical difference between ointments and creams: creams have lots of alcohol and preservatives, and when applied to raw, inflammed skin they burn like a mother. Ointments are more soothing, and also more potent in terms of penetration. Ointments are also better in the diaper area, where stool and urine tend to cause excoriation. Oils, including olive oil, can help loosen the scale from seborrheic dermatitis prior to the application of antifungals or steroids to calm the disease. Another tip: use creams in the summer when sweating is an issue, oils in the winter when moisturization is key. I've never prescribed powders, but nystatin powder is perfect for moist intertriginous areas where yeast likes to dwell. Gels and foams are best for hair-bearing surfaces. Medicated tapes like Cordran can help with conditions like lichen simplex and picker's nodules, where manipulation makes things worse.

The pearls from the derm lecture just kept coming: Show parents how to apply creams; some just dab them on, failing to rub them in. People can actually have allergic reactions to topical steroids. Calcineurin inhibitors are safe when used as directed (intermittently). Group A strep loves red, inflammed neck folds in infants. Oral corticosteroids can lead to eczema rebound and ultimately make things worse. Avoid long-term use of mupirocin, to which antibiotic resistance is growing. Think about eczema herpeticum in eczema that just won't go away. Ceramide creams like Ceravae may prove anti-inflammatory by improving the quality of the skin barrier. Don't use any steroid on the face more than two weeks. Every acne regimen should include at least some benzoyl peroxide and at least one retinoid (tea tree oil acts just like benzoyle peroxide). Short-contact therapy can reduce the irritation associated with retinoids while preserving the benefits. I want to take this guy home with me.

I stayed in room 311 for Five Critical Cardiac Problems That Are Important To Diagnose (as opposed to those critical cardiac problems that you can miss without fear of repercussion) with Dr. Stuart Berger. Big pearls: Tachypnea is often the first and sometimes the only sign of significant cardiac disease in newborns. If there's any question of a ductal dependent lesion, start PGE-1 first, get your echo later. Prostaglandin is safe, not giving it is potentially lethal. An active precordium on physical exam should always peak your interest. Not all cyanotic heart disease presents with obvious cyanosis. The absence of a murmur alone does not rule out significant cyanotic heart disease, specifically transposition of the great arteries. Diagnosing dilated cardiomyopathy early is much better than diagnosing it late. Decreased blood pressure is the very last sign of heart failure and should never be used to reassure yourself heart disease is absent. When wheezing fails to respond to bronchodilator therapy think heart disease. Also consider heart disease in any child with unexplained persistent abdominal pain and vomiting. "Drop attacks" could be seizures, but they could also be long QTc syndrome. Always suspect long QTc in deaf children. When a tachycardic heart rate doesn't vary it's likely the problem, not the symptom.

I find once my head is stuffed with clinical pearls it's best to drive the points home by having a drink. So I headed to the Westin bar with my parents and Nancy Chase, a pediatric cardiologist at University of Tennessee. There I had lots of crackers, having last eaten a chicken salad at 10:30 AM.

The Academy hosted a grand shindig at the Boston Public Library across the street, but my folks had already scoped out an Italian joint in the North End, so I can't tell you anything about the library gig. I can tell you I had the best veal maybe ever and if anyone tells my daughter I ate veal I met a guy at the bar who will make sure you never tell her anything else. I leave you tonight with the moon over Boston as seen from my window. Who knows what pearls tomorrow will bring?