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Endocrinology THE AMERICAN BOARD OF PEDIATRICS® CONTENT OUTLINE Pediatric Endocrinology Subspecialty In-Training, Certification, and Maintenance of Certification (MOC) Examinations INTRODUCTION This document was prepared by the American Board of Pediatrics Subboard of Pediatric Endocrinology for the purpose of developing in-training, certification, and maintenance of certification examinations. The outline defines the body of knowledge from which the Subboard samples to prepare its examinations. The content specification statements located under each category of the outline are used by item writers to develop questions for the examinations; they broadly address the specific elements of knowledge within each section of the outline. Pediatric Endocrinology Each Pediatric Endocrinology exam is built to the same specifications, also known as the blueprint. This blueprint is used to ensure that, for the initial certification and in-training exams, each exam measures the same depth and breadth of content knowledge. Similarly, the blueprint ensures that the same is true for each Maintenance of Certification exam form. The table below shows the percentage of questions from each of the content domains that will appear on an exam. Please note that the percentages are approximate; actual content may vary. Initial Maintenance Certificatio of Content Categories n and Certification In-Training (MOC) 1. Carbohydrate Metabolism 16% 16% 2. Bone and Mineral Metabolism 8% 8% Thyroid Hormones (Thyroxine 3. [T4] and Triiodothyronine [T3]) 13% 14% 4. Adrenal Disorders 12% 12% 5. Pituitary/Hypothalamus 10% 10% 6. Growth 12% 14% 7. Reproductive Endocrine System 12% 12% 8. Other Hormones 3% 3% 9. Lipoproteins and Lipids 3% 3% Multiple endocrine neoplasia and 10. polyglandular autoimmune disease 2% 2% 11. Methods and Biological Principles 4% 2% 12. Core Knowledge in Scholarly Activities 5% 4% Endocrinology 1. Carbohydrate Metabolism A. Integrated hormone effects on metabolism 1. Physiology a. Know the sources of glucose from: digestion and absorption of dietary carbohydrates; endogenous release of glucose from the liver b. Know the enzyme systems (glycogenolysis, glycogen synthesis, glycolysis, gluconeogenesis, tricarboxylic acid cycle, and pentose phosphate shunt) involved in the storage, oxidation, and production of glucose c. Understand the processes and regulation of nutrient and substrate metabolism in the fasted and fed states with regard to glycogen, glucose, fatty acids, ketone bodies, amino acid, and protein metabolism d. Know effects of insulin on protein synthesis and proteolysis; lipolysis and ketogenesis; glucose production and utilization e. Understand the mechanisms of action of cortisol, growth hormone (GH), epinephrine, and somatostatin on carbohydrate, fat, and protein metabolism f. Be familiar with the endocrine and metabolic responses to fasting g. Know the effects of lipotoxicity and glucotoxicity on beta cell function and insulin resistance 2. Homeostasis a. Know the criteria for a normal blood glucose concentration in children, and adolescents, and the definitions of biochemical hyperglycemia and hypoglycemia at these ages b. Know the rate of glucose production (expressed as glucose infusion rate) in normal neonates, children, and adolescents, and the factors which regulate it c. Know the duration of time glycogen stores and gluconeogenesis can maintain normal blood glucose concentrations in normal neonates, children and adolescents B. Insulin 1. Physiology a. Ontogeny/embryology 1. Know the genes that are responsible for pancreatic development b. Synthesis/processing/storage 1. Know biochemistry of insulin biosynthesis and post-translational processing 2. Know the structural homology of insulin-like growth factor (and other growth factors) with insulin c. Secretion 1. Understand physiologic regulation of insulin secretion including the effects of blood glucose, amino acids, glucagon, adrenergic mechanisms, gastric inhibitory peptide (GIP), and somatostatin 2. Know the importance of the sulfonylurea receptor, chromium picolinate, the potassium channel, and the role of calcium flux in insulin secretion 3. Understand the role of glucokinase in insulin secretion 4. Know the interactions of medications and other exogenous substances that regulate insulin secretion with beta cell receptors and channels d. Receptor/action 1. Tissue/organ specific a. Know the plasma membrane location, structure, and function of the insulin receptor b. Know the role or lack thereof of insulin on glucose transporters in different tissues c. Know that different glucose transporters are expressed in different tissues d. Know the relationship of the structures of IGF-I and insulin receptors and the related membrane molecules e. Understand insulin receptor signaling mechanisms 2. Pathology a. Insulin deficiency with hyperglycemia 1. Type 1 diabetes a. Pathophysiology (classification/etiology) 1. Know the association of HLA and DR loci in the etiology of type 1 diabetes 2. Recognize histologic appearance of islets early and late in the course of type 1 diabetes with preferential destruction of beta cells and late persistence of alpha and delta cells 3. Know the current concepts of the role of autoimmunity including cell- mediated immunity and cytoplasmic and surface autoantibodies and insulin autoantibodies in the pathogenesis and prediction of type 1 diabetes 4. Know the rationale for the use of immunomodulating agents for the treatment of early type 1 diabetes 5. Know the prevalence of glutamic acid decarboxylase, islet cell, and insulin antibodies in recent-onset type 1 diabetes and in individuals of various ages b. Epidemiology and clinical manifestations 1. Know the different prevalence rates of type 1 diabetes in people of different ethnicities 2. Know the risk of type 1 diabetes development in identical twins, other siblings, offspring, and parents of patients who have type 1 diabetes 3. Understand the clinical differentiation of ketoacidosis from other causes of altered states of consciousness, such as hypoglycemia and nonketotic hyperosmolar coma, in diabetes mellitus 4. Understand the pathogenesis of ketoacidosis and disturbances in body fluid, electrolytes, substrates, and acid-base balance (pH, O2 dissociation), and the significance of relevant laboratory findings in type 1 diabetes 5. Recognize the mechanism, presentation, and natural history of neonatal diabetes c. Diagnosis 1. Recognize the stages of clinical development of type 1 diabetes with progressive carbohydrate intolerance, and the pathophysiology of the polyuria, polydipsia, weight loss, and fatigue d. Treatment of diabetic ketoacidosis 1. Know the methods, rationale, consequences, and principles of administration of insulin (bolus and IV infusion) in the treatment of diabetic ketoacidosis 2. Know the rationale and strategy for monitoring blood glucose, serum electrolytes, acid-base balance and ketone concentrations in the management of patients with diabetic ketoacidosis 3. Know when and how to change to subcutaneous insulin and oral intake in patients recovering from diabetic ketoacidosis 4. Know the complications (cerebral edema, hyperkalemia, hypokalemia, renal failure, hyperchloremia, hypoglycemia, persistent hyperglycemia, thrombosis, and/or ketonemia), pathophysiology, clinical manifestations and management in the treatment of diabetic ketoacidosis 5. Recognize that repeated episodes of ketoacidosis in a child or adolescent are most likely a result of failure to administer insulin regularly rather than dietary indiscretions or infectious illness 6. Know the methods, rationale, consequences, and principles of administration of fluid and electrolytes in the treatment of diabetic ketoacidosis 7. Know the methods, rationale, consequences, and principles of administration of glucose in the treatment of diabetic ketoacidosis 8. Know the risk factors for cerebral edema in diabetic ketoacidosis e. Daily management 1. Know the formulations and action profiles of rapid, short, intermediate, and long-acting insulins 2. Recognize blood glucose values requiring insulin dose adjustments in patients with diabetes using home glucose monitoring 3. Understand the effects of meals, exercise, illness, trauma, and surgery on blood glucose concentration and insulin requirements of patients who have diabetes 4. Know the use and significance of glycosylated hemoglobin and factors other than blood glucose concentration (eg, hemolytic anemia) that affect or alter its value in the management of patients with diabetes 5. Know the carbohydrate content of common foods 6. Know how to calculate an insulin-to-carbohydrate ratio for determination of insulin dosing for patients with diabetes 7. Be able to identify patients with type 1 diabetes who will succeed with insulin infusion pump therapy and know the steps required to prepare a patient for insulin pump therapy 8. Know how to calculate an initial basal and bolus insulin dose for a patient beginning insulin pump therapy 9. Know the pros and cons of intensification of diabetes management with both multiple daily insulin doses and with continuous subcutaneous insulin infusion therapy 10. Know how to make insulin dose adjustments in patients with type 1 diabetes using home glucose monitoring 11. Understand the rationale and appropriate use of continuous glucose monitoring devices in children with type 1 diabetes, including clinical indications and limits 12. Know how to convert insulin dose from intermediate/rapid-acting insulin regimens to basal-bolus regimens using
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