August 2003 Volume XXVI Number 3 The Florida Pediatrician The Newsletter of the Florida Pediatric Society/ Florida Chapter American Academy of Pediatrics In this issue............ WHO’S WHO Page 2 THE PRESIDENT’S PAGE Page 3 THE EDITORIAL PAGE Page 5 THE GRASS ROOTS Page 6 FROM THE DEPARTMENT CHAIRMEN Page 7 THE SCIENTIFIC PAGE Page 8 COMMITTEE REPORT SCHOOL HEALTH Page 13 FROM THE RESIDENTS’ SECTION Page 14 THE CATCH CORNER Page 14 MANAGED CARE Page 15 IN MEMORIAM ROBERT A. GOOD Page 16 RISK MANAGEMENT Page 17 FROM THE AAP Page 18 MORE FROM THE AAP Page 19 FROM THE FCAAP Page 20 THE HISTORY CORNER Page 23 LEGISLATIVE REPORT Page 25 Add-a-‘Pearl’ Page 28 UPCOMING CME MEETINGS Page 32 Steve Edwards, President of AAP, addre sses annual meeting
Transcript
August 2003
Volume XXVI Number 3
The FloridaPediatrician
The Newsletter of the Florida Pediatric Society/ Florida Chapter American Academy of Pediatrics
In this issue............
WHO’S WHO
Page 2
THE PRESIDENT’S PAGE
Page 3
THE EDITORIAL PAGE
Page 5
THE GRASS ROOTS
Page 6
FROM THE DEPARTMENT CHAIRMEN
Page 7
THE SCIENTIFIC PAGE
Page 8
COMMITTEE REPORT
SCHOOL HEALTHPage 13
FROM THE RESIDENTS’ SECTION
Page 14
THE CATCH CORNER
Page 14
MANAGED CARE
Page 15
IN MEMORIAM ROBERT A. GOOD
Page 16
RISK MANAGEMENT
Page 17
FROM THE AAP
Page 18
MORE FROM THE AAP
Page 19
FROM THE FCAAP
Page 20
THE HISTORYCORNER
Page 23
LEGISLATIVE REPORT
Page 25
Add-a-‘Pearl’
Page 28
UPCOMING CMEMEETINGS
Page 32
Steve Edwards, President of AAP,addresses annual meeting
WHO’S WHO in the Florida Pediatric Society/Florida Chapter American Academy of Pediatrics
I am truly honored to have been given the opportunity to serve you and thiswonderful organization as your President. Before I begin to outline my agenda, I would liketo give special recognition to Dr. Richard Bucciarelli and commend him for his excellentleadership and guidance of our chapter during the last two years. During his tenure, he keptthe FCAAP at the forefront of children’s issues and advanced our collective agenda in boththe state and the nation. Thank you, Dr. Bucciarelli for a job well done.
Like all of us, I am a product of valuable lessons learned from parents, familymembers, professors, mentors, colleagues, and, most importantly, those children and families that I have had thehonor to serve. My teachers have been many and the knowledge gained from them invaluable. As I write this, twoextraordinary and inspirational individuals immediately come to mind.
* * * * *
“...Thank you, Dr. Bucciarelli, for a job welldone...”
* * * * *
Dr. Herbert Pomerance has been, and continues to be, an indefatigable and enthusiastic advocate for children.In his long and distinguished career, he has been a true innovator and originator of numerous improvements forpediatric healthcare. From his outstanding continuing contributions as a member of the Senior Section, to theadvancement of medical knowledge and enhanced pediatric communication as editor of "The Florida Pediatrician",he has been a true inspiration to all of us and a perfect example of the vision and mission of the FCAAP. Dr. Charles“Chuck” Weiss is another selfless and dedicated champion of children’s issues. Throughout his career, he has shownhis commitment to advancing pediatric healthcare in our state through multi-year contributions to "The FloridaPediatrician" and the Executive Committee of the Florida Chapter on topics related to environmental health andtoxicology. The wonderful friends are each recipients of this year’s District X Special Achievement Awards.
Both of these celebrated and distinguished pediatricians are superb examples of why our organization is agreat one – just as Dr. Pomerance and Dr. Weiss have continued to learn and grow and serve those in need of theirhelp, we as a Chapter continue to learn, grow, and collaborate – and never rest on our laurels. From our humblebeginnings in 1920, when for every 1000 births, ten mothers died, 65 babies were stillborn, and over 100 infantsdied before their first birthday to now, when infant mortality has dropped to a record low and life expectancy hashit a record high – and deaths among children and young adults from unintentional injuries, cancer, and heart diseaseare down significantly, the Florida Pediatric Society/Florida Chapter of the American Academy of Pediatrics hasgrown and matured with each passing year. As always, as the economic, social, and scientific environments change,it is our duty to develop our skills and expertise, improve our knowledge, and collectively make sure children’sissues are given the attention and focus they so very much deserve.
(See President, page 29 <)Page 3
Advertising page
“...a newpresident...”
“solution to themalpractice crisis...”
EDITORIAL OFFICE
Herbert H. Pomerance, M.D., Editor
Carol Lilly, M.D., Associate Editor
Department of Pediatrics
University of South Florida College of Medicine MDC
Yes, we are entering an interesting time. And as usual, when things are interesting, there is usuallygood news and bad news!
Good news first: As you know, and as you will read further in this issue of The Florida Pediatrician, wehave a new president, who took office at the Annual Meeting of the society, in June. DebbieMulligan-Smith is an active communicator among us, and has already given lots of her time onbehalf of the society, during her ‘crawl’ up the ladder of society power. She has lots of ideas forthe society during her tenure as president, and we will see these become obvious very soon.
There is another facet worth noting. Deb is the first woman to hold the presidency of thissociety, and does so coinciding with the election of Carol Berkowitz as President-Elect of the American Academyof Pediatrics. Being one of the early believers that, in a profession like ours, we need to be ‘sex-blind’, I applaudthese events, knowing that both elections occurred because of the excellence of the candidates.
And now the bad news: I am writing in July, and at this time there is still no legislativeaction in an attempt to create a solution to the malpractice crisis. Our practicing physicians,pediatric or other, are still feeling the blade of the guillotine which threatens to behead theirattempts to practice. And everyone has someone on whom to level the blame for lack of change.
Some blame us, the physicians. We should practice better medicine! Statistics suggestthat a very small percentage of physicians are a part of most of the malpractice suits. Someblame the insurance companies, claiming their profit margins are high despite the insurancesettlements. Yet, most of the companies have discontinued Florida business; would they ifbusiness were so good?
And of course, the rest blame the attorneys. They point our that, the bigger the settlement, the bigger thefee collected by the attorney, and that therefore the attorneys do not want to curtail the size of the settlements. I wastold long ago, in a different context, that he who protests most loudly has the most to gain or lose. I do not knowif this is true or not. I do know that relatively few attorneys practice malpractice law.
I do not know whose arguments are best or most true, and I do not believe that, at this point, it really makesmuch difference! We need some kind of plan to provide relief, and I understand that the Governor will push until
he gets a reasonable relief.
Meanwhile, we are the ones who provide help to thechildren of our state, and we shall continue to do so, to thebest of our ability.
The EditorG
Page 5
The Grass RootsTHE REGIONAL REPRESENTATIVES REPORT
(Each month, we provide reports from two of our eight regions)
Region IV reports:
The recent quarter has been productive for the AAPand its mission through the efforts of our District members.Member activities have been recognized on a national,regional and local level.
Dr. Lloyd Werk M.D., FAAP, has been appointedrepresentative to the national Membership Committee forthe AAP and is among 8 FCAAP members serving on anational AAP committee. Joan Younger Meek, M.D.,FAAP, editor of the AAP book New Mother's Guide toBreastfeeding, has been recently quoted by the WashingtonPost, New York Times, Newsweek and Parenting magazineon a variety of issues relating to breastfeeding. TheDepartment of Health and Human Services, section ofMaternal and Child Health will distribute a slidepresentation to promote breastfeeding again edited by Dr.Meek.
Dr. Jan Howell has authored and published aninteractive CD-ROM on the care of children with asthma.The work and has been distributed to all ABFP members.At the state level Ian Nathanson, MD, FAAP, president ofthe Orange County Medical Society, has led efforts from ourarea to impart to our political representatives the need forrelief from malpractice increases, and no less important,assuring methods of access for all children. Our Districtmembership stands at 289 with all but 16 members currentwith their membership dues.
Our region is very active at the level of youngphysicians and in the recruitment of pediatric residents. Ourarea has recently extended the highly successful After HoursPediatrics concept with the operation modeled after theprogram from the Tampa Bay region. The Orlando effort isled by member Robert Cooper, MD, FAAP. The CentralFlorida Pediatric Society, presently presided over byMatthew Seibel MD, FAAP, holds quarterly dinnermeetings which feature a speaker, CME , and anopportunity for central Florida's Pediatricians to network.On June 13, 2003, Daniel J. Friedland, MD discussedEvidence-based Medicine: A Framework for ClinicalPractice.
The AAP super CME 2004 will be held in OrlandoApril 28-May 1, 2004.
David Milov, M.D.Orlando, FL
Regional RepreseentativeG
Page 6
Region VIII reports:
District 8 currently has 368 members of the FloridaPediatric Society, 27 (7%) of whom are Emeritus. Fifty two(14%) new members were recruited in 2002-2003. TheGreater Miami Pediatric Society (GMPS), under theleadership of Francisco A. Medina, the 2002-03 President, isthe primary local organization for community and academiccommunication, holding quarterly meetings with guestlectureships and social activities.
The University of Miami School of Medicine is in thefinal stages of recruiting a new Chairman for the Departmentof Pediatrics. Negotiations are currently underway with theanticipation that an announcement is imminent.
The American Academy of Pediatrics-Section onNeonatal Perinatal Medicine has announced the selection ofEduardo Bancalari, M.D. as the recipient of the 2003 VirginiaApgar Award. Dr. Bancalari is Professor and Director of theDivision of Neonatology at the University of Miami-JacksonMemorial Medical Center. This is the highest honor in thefield of Neonatology and Dr. Bancalari joins other outstandingneonatologists such as Mary Ellen Avery, William Oh,Mildred Stahlman, William Silverman, Avroy Fanaroff andothers. The award will be presented on November 2nd duringthe annual AAP meeting in New Orleans.
The Department of Pediatrics has recently beenawarded an Anne E. Dyson- 5 year Community PediatricsTraining Initiative. Currently ten (10) programs are fundedthroughout the United States with a goal toward thedevelopment of innovative residency training programs thatemphasize a long-term commitment to community concerns.As part of this initiative, the Department of Pediatrics hasdeveloped a youth violence prevention project in Miami’sinner city. The program is directed by Arturo Brito, M.D., andLee M. Sanders, M.D., MPH, with the active involvement andcollaboration of 14 pediatricians, including KimberlySchwartz, the new District 8 representative.
The two Early Intervention Programs in Region 8,located at Miami Children’s Hospital and the Mailman Centerfor Child Development continue to provide services for anincreasing number of children referred for assessment ofpotential developmental delays. This program serves thelargest number of children in the state, with over 3500 clinicvisits this past year, representing an 18% growth rate. Thereare currently 15 Early Intervention Programs in the Stateorganized and administrated by the Department of Healthunder the auspices of Children Medical Services.
Dr. Lee Sanders, an Assistant Professor in theUniversity of Miami’s Department of Pediatrics has recentlylaunched a Florida Campaign called the “Reach Out and ReadCoalition”, which seeks to address the major detriment topersonal and professional success- illiteracy. It involves
(See Region 8, page 30 <)
From the Department ChairmenThe Department of Pediatrics at the Nova Southeastern University
College of Osteopathic MedicineEdward E. Packer, D.O., FAAP, FACOP
Chairman, Department of PediatricsNova Southeastern University
Ft. Lauderdale, FL
Graduation is always an exciting and gratifyingtime for me as a teacher. As I stand up on the podium,I watch with great pride and satisfaction as anotherclass completes their studies and goes off for theirpostgraduate training. As one class graduates, I amwell aware that it will not be long until our newstudents will be starting their education.
Medical education is evolving in both its scopeand goals. As educators, it is becoming vital to trainour students in modern molecular biology and to makethem aware of the effects of the Human GenomeProject on modern health care. Currently, I chair acommittee that is developing methods of incorporatingmodern medical genetic issues into each of the clinicalsubjects presented to our students.
Various evaluations on the effectiveness ofmedical education have demonstrated that studentseducated using the traditional methods of lectures andtextbooks often have difficulty applying theirknowledge in real clinical settings. Our program isutilizing more Problem Based Learning forums topresent new material. In these Problem Based Learningsessions, the students are presented with a writtenpediatric case that they attempt to diagnose and treat.The students work in small groups with a physicianserving as a guide to focus the group and give specificlearning objectives. The Problem Based Group leavesthe session with specific items to research and thenpresents their findings to the group in the followingsession. Students working in the Problem BasedLearning forum learn to research medical material, andlearn medical techniques of problem solving.
One of the goals of modern medical educationis to produce physicians that can perform a properhistory and physical on a patient and reach anappropriate differential diagnosis. The ObjectiveStructured Clinical Examination (“OSCE”) has recentlybeen incorporated as part of the final examination inmany of our courses. Nova Southeastern University hasa specialized suite of examining rooms that are
equipped with video cameras, and a team of “actor”patients that have scripted cases for student evaluations.The “OSCE” experience has proven to be a powerfultool for determining both the skills that our studentshave acquired, and how well we are teaching them tocare for children.
Care of pediatric patients is often an importantcomponent of most primary care practices. For ourstudents to succeed in primary care medicine, they mustlearn to properly care for children and integrate theminto the routine of their office practice. I have workedto incorporate pediatric subjects into any of the coursesour students take that could relate to child healthsubjects. In the past year, pediatrics has been added tothe Preventative Medicine Course with subjects likeinfant nutrition. The Physical Diagnosis Course hasadded presentations on child abuse. The MedicalProcedures Course has added presentations on care ofthe well and sick newborn. I will continue to find othercourses where pediatric subjects can be added over thenext academic year.
An ongoing challenge is to maintain didacticeducation for our students in the clinical years.Hospital rotations offer excellent opportunities for ourstudents to experience patient care and to hear lecturesfrom seasoned clinicians, but continuing the educationin basic pediatric principles requires a different kind ofpresentation. Nova Southeastern University has anextensive network of two-way compressed videoconferencing at all of our major hospital locations.With these video conferencing systems, we have beenable to broadcast discussions on basic pediatricprinciples such as writing and calculating intravenousfluid orders for children.
The pediatrics department is currentlydeveloping a computer web-based site for all of ourstudents to continue their education in basic pediatric
(See Chairman, page 30 <)Page 7
The Scientific PagePEDIATRIC CATARACTS: DIAGNOSIS AND MANAGEMENT
Magda Barsoum-Homsy, MD, FRCSCClinical Professor of Ophthalmology, USF
SUMM ARYCataracts in infants and children are due to d ifferent
causes. Early diagnosis and treatment are key to the prevention ofsevere visual loss. The pediatrician plays a crucial role in the initialscreening and diagnosis of newborn infants as well as children ofall age groups affected with this condition. New surgicaltechniques including intraocular lens (IOL) implants as well ascontact lens correction of aphakia have greatly improved the visualoutcome in these patients, provided early diagnosis and treatment,including amblyopia treatment are administered before irreversiblevisual damage occurs.WHAT IS A CATARACT?
Any opacity in the lens is called a cataract. It may be asmall white dot opacity appearing in the center of the pupil, suchas an anterior polar cataract. This type of cataract rarely causes avisual deficit and often remains stable (Figure 1). Or the opacitymay be large and present in the visual axis leading to legalblindness. The prevalence of cataract is 1.2 to 6 cases per 10,000in infants. There are around 200,000 children worldwide that areblind from cataract. 1
HOW AND W HEN DO WE DIAGNOSE A CATARACT?All newborn babies should be screened for cataracts as
part of their first neonatal physical examination given by thepediatrician in the nursery. They are further screened on their firstoffice visit at 2 weeks of age and on each subsequent visit duringthe first 2 years of life. From then on this is followed by a yearlyexam. The screening test used is the Bruckner Test or Red Eye test.The direct ophthalmoscope is set on the +10 green number; thepediatrician looks through the ophthalmoscope into the pupils ofthe newborn or infant at a distance of approximately 5 to 10 inches.Any opacity or dark spot obstructing the red reflex shining throughthe pupil may be a cataract (Figure 2). Direct examination of theinfant’s eye with a penlight may reveal the opacity to be anterior,such as in the cornea, or further posterior, such as in the lens. Notall cataracts are visible to the naked eye, particularly if the opacityinvolves the posterior layers of the lens, e.g. posterior lenticonus,or persistent hyperplastic primary vitreous. Leukocoria or whitepupillary reflex may be caused by different pathologies (Table 1).
WHATCAUSES CATARACT IN CHILDREN?
Cataracts in children can be divided into 7 major groups.Page 8
I. CO NGENITAL HEREDITARY CATARACT These are frequently autosomal dominant with a positive
family history where one parent is affected. They may beautosomal recessive. In such a case there is often a history ofconsanguinity. Rarely, hereditary cataracts may be recessive, X-linked.II. CONGENITAL OR INFANTILE CATARACTSASO CIATED WITH SYSTEM IC SYNDROM ES
Most cataracts associated with systemic syndromes aretransmitted as autosomal recessive traits with the exception ofLowe’s syndrome, which is X linked recessive and Alport’ssyndrome, which is autosomal dominant.
1. Congenital cataracts with Renal Disease.-Lowe’s occulocerebrorenal syndrome-Alport’s syndrome: hemorrhagic nephritis, deafness andpoor equilibrium.-Ze l lwe ger ’s c e r e b r o he p a to r e na l s yn d r om e :hepatomegaly, polycystic kidneys, aminoaciduria andmental retardation
2. Congenital cataracts with Mental Retardation.-Morinesco-Sjorgen’s syndrome: spinocerebellar ataxia,mental retardation, and nystagmus-Cockayne’s syndrome: deafness, skeletal malformation,pigmentary retinopathy, progressive mental retardationand premature aging.-Flynn-Aird syndrome: deafness, kyphoscoliosis, mentalretardation, epilepsy, subluxated cataracts and highmyopia-Norrie’s syndrome: mental retardation, CNSdegenerative disease, and corneal opacities.
3. Cataracts with Musculoskeletal Anomalies-Conradi’s syndrome or stippled epiphysis syndrome-Myotonic dystrophy
4. Syndromes affecting the Facial and Cranial bones- Hallerman-Streiff syndrome- Albert’s syndrome- Crouzon’s syndrome- Oxycephaly- Smith-Lemli-Opitz syndrome
III. CATARACTS ASSOCIATED WITH PRENATAL ANDPERINATAL FACTORS
Maternally transmitted intrauterine infections(TORCHS) may cause cataracts in the newborn. Rubella infectionduring the first trimester of pregnancy will result in congenitalcataracts, microcephaly, hepatosplenomegaly, deafness and cardiacmalformation. Vaccination against rubella has greatly diminishedthe incidence of congenital rubella syndrome, however it remainsa major problem in developing countries.2 Other congenitalinfections include toxoplasmosis, cytomegalovirus, herpes simplex,and syphilis.
Drug ingestion, such as corticosteroids, by the pregnantmother may cause cataracts. Exposure of the fetus to irradiation,maternal malnutrition and intrauterine anoxia, are other factors thatcan cause cataracts. Maternal metabolic or endocrine disorderse.g. diabetes, hypo or hyperparathyroidism are also associated withinfantile cataracts. Therefore a careful and detailed history of themother’s physical condition during her pregnancy is important.Also a detailed history and physical examination of the newbornshould be obtained. This includes APGAR, birth weight, as well asconvulsions.IV. CATARACTS ASSOCIATED WITH M ETABOLICDISEASES
1- Deficiency of one of the 3 enzymes involved ingalactose metabolism will cause cataracts. It isinherited as an autosomal recessive trait.
a. G a l a c t o s e 1 - p h o s p h a t euridyletransferase deficiency will causegalactosemia manifested by a sick babywith neonatal sepsis, vomiting, diarrhea,hepatomegaly, and jaundice. Cataracts firstappear as an increased density in the lensgiving the appearance of an oil droplet,which progressively opacifies. If thecondition is diagnosed and treated at the oildroplet stage the cataract will regress.
b. Galactokinase deficiency has littlesystemic manifestation. Cataracts appearlater in adolescence or early adulthood.
c. Epimerase deficiency is not typicallyassociated with cataracts and has little ifany systemic manifestations.
2- Diabetes mellitus may cause cataracts and thesehave been reported as early as 11months of age.3
3- Hypoglycemia occurs mainly in boys, small fordates and usually following a complicatedpregnancy. The cataracts are lamellar in appearance.
4- Homocystinuria : autosomal recessive, associatedwith subluxed lens, high myopia, tendency to bloodclotting and mental retardation.
5- H y p o p a r a t h y r o i d i s m a n dpsuedohypoparathyroidism.
6- W ilson’s disease : autosomal recessive,hepatolenticular degeneration, is due to defectivecopper metabolism leading to copper deposits indifferent organs including the cornea giving thetypical bluish and golden Kayser-Fleischer ring.
7- Fabry’s disease: X-linked recessive caused bydeficiency of alph a-galac tosidase enzyme.Symptoms appear around 10 years of age. Typical
eye findings include cataract in the form ofbranching spoke opacities, whorl-like cornealopacities, tortuous conjunctival and retinal vessels,and edema of the optic disc and lids.
V. C A T A R A C T S A S S O C I A T E D W I T HCORTICOSTEROIDS:
Children receiving topical4 as well as systemiccorticosteroids5 over a long period of time will develop posteriorcapsular opacification of the lens. However long term use ofinhaled steroids does not seem to be associated with developmentof cataracts.6 VI. CHRONIC INTRAOCULAR INFLAMATION:
Uveitis can cause cataracts. It can be associated withsystemic disease such as rheumatoid arthritis, or can be restrictedto the eye such as pars planitis. VII. OCULAR TR AU M A: This can be either a blunt or a
perforating injury. A history of physical abuse should beconsidered.
MANAGEM ENT OF CATARACTS IN CHILDRENOnce the diagnosis of b ilateral cataracts is established, a
thorough medical work-up should be conducted so as to determinethe etiologic cause and to institute appropriate medical as well assurgical treatment. In spite of a complete medical workup 20% ofinfantile cataracts remain of undetermined etiology.7,8 Unilateralcongenital or infantile cataracts are most often an isolated ocularmalformation and do not need an extensive workup.
Not all cataracts require surgical intervention. If thecataract is small and is visually insignificant then carefulobservation as well as part-time occlusion of the good eye may benecessary to prevent and/or treat amblyopia. Only those opacitiesobscuring the visual axis and interfering with visual development(Figure 3), whether unilateral or bilateral, should be surgicallyremoved as soon as possible, provided the general physicalcondition of the baby permits it.
The reason for early surgical intervention is based onsolid physiologic and scientific evidence. It has been demonstratedby Weisel and Hubel9 in kittens, as well as by Von Noorden10 inprimates, that unilateral lid occlusion during the critical period ofvisual development will lead to atrophy of the corresponding cellsin the lateral geniculate body and occip ital cortex, leading toirreversible organic amblyopia. In bilateral c ataracts wherethere is lack of visual stimulation, the macula as well as thecorresponding visual cell in the brain will not develop. A pendularnystagmus will appear at about 6 weeks to 3 months of age. Visionwill be permanently compromised once nystagmus is established.The child will be legally blind even after successful cataractsurgery. However if early surgery is instituted within the first fewweeks of life and before the onset of nystagmus, only then is therean excellent chance of developing normal vision.11
Correction of aphakia is necessary following cataractsurgery. In neonates contact lenses are the preferred method ofoptical correction, provided family conditions allow it. Contactlenses are well tolerated by the infant. The parents are taught howto insert and remove the contacts, as well as how to care for anddisinfect them. However if family conditions are not adequate thenoptical correction can be provided with spectacles (Figure
(Continued on next page <)Page 9
Scientific(= continued from previous page)
4). They are not ideal as they are thick and difficult to fit on ababy. They will serve as temporary correction until they can bereplaced by either contact lenses or a secondary intra-ocular lens(IOL) implant.
With newer and improved microsurgical techniques IOL(Figure 5) implants are now the preferred method of surgicaltreatment of cataracts in children 1 year of age and older. 12-14IOL may be implanted as a primary correction during the initialsurgery or as a secondary procedure following intolerance tocontact lenses or spectacles. There still remains controversy as tothe youngest age for IOL implants. This is due to the fact that thereis very rapid growth of the axial length of the eye between birthand the first year of life. This growth is accompanied by a rapidchange in optical power of the eye. Also an infant’s eye has anintense inflammatory reaction to surgical trauma, thus increasingthe complication rate with IOL implants.
Complications following cataract surgery are infrequent.These include hyphema, vitreous attachment to the incision, retinalhemorrhage and detachment. Intraocular infection orendophthalmitis is rare occurring in 7 out of 10,000 cases..15 Likeretinal detachment, aphakic glaucoma can occur in the immediatepostoperative period up to several years following cataract surgery.The incidence of aphakic glaucoma varies between 5-15%. It canappear immediately following surgery, or several years latter.Parents should be informed that amblyopia remains a major threatto the development of good vision, be it in unilateral or bilateralaphakia. They must be committed to the treatment of amblyopiawith part-time occlusion of the better eye, as this is the key to agood visual outcome (Figure 6). It is therefore mandatory that allchildren operated for pediatric cataracts be followed by anophthalmologist for the rest of their life.CONCLUSION:
The ped iatrician p lays a crucial role in the early diagnosisof cataracts in children. An excellent visual outcome is possibleprovided the patient has early surgery and adequate opticalcorrection of aphakia using either contact lenses or intraocular lensimplants. Amblyopia treatment with part time occlusion of theunaffected eye in unilateral cases, or the better eye in bilateralcases, is crucial to the development of good vision.
References:1. Foster A, Gilbert C, Rahi J. Epidemiology of cataract in childhood: a global
perspective. Journal of Cataract and Refractive Surgery. 23 Suppl 1:601-4,1997.
2. Cutts FE, Robertson SE, Diaz-Ortega JL, Samuel R. Control of RubellaSyndrome (CRS) in developing countries. Part 1, Burden of disease fromCRS (Review) Bull. WHO 1997; 75(1): 55-68.
3. Ehrlich RM, Kirsh S, Deneman D. Cataracts in children with diabetesmellitus. Diabetes Care 1987; 10: 798-799.
5. Gasset AR, Bellows RT. Posterior subcapsular cataracts after topicalcorticosteroid therapy. Ann Ophthalmol 1974; 6(12): 1263-1265.
6. Jick SS, Vasilakis-Scaramosa C, Maier WC. The risk of cataract among usersof inhaled steroids. Epidemiology 2002; 12(2): 229-234.
7. Milot J, Massicotte P, Barsoum-Homsy M, Chevrette L. Les cataractescongenitalle et infantiles. I - Leur étiologie et leur modes d’investigation.L’Union Medicale du Canada 1982; 111(8): 1-5.
8. Barsoum-Homsy M, Chevrette L, Jeliu G et al. Les cataractes congenitalle etinfantiles. II – Classification etiologique d’un relevé de 115 cas. L’UnionMedical du Canada 1982; 111(8): 6-11
9. Wiesel TN, Hubel DH. Single cell responses in striate cortex of kittensdeprived of vision in one eye. J Neurophysiol 1963; 26:1003-1017.
10. von Noorden GK, Crawford MLJ. The effects of total unilateral occlusion vs.lid suture on the visual system of infant monkeys. Investig Ophthalmol VisSci 1981; 21:42.
11. Parks MM. Visual results in aphakic children. J Ophthalmol 1982; 94:441
12. Awner S, Buckley EG, DeVaro IM et al. Unilateral psuedophakia in childrenunder 4 years. J Pediatr Ophthalmol Strabismus 1996; 33(4): 230-236
13. Gimbel HV, et al. Implantation in children. J Pediatr Ophthalmol Strabismus1993; 30:69-79.
14. Young TL, Bloom JN, Ruttum M, et al. The IOLAB, Inc. Pediatric intraocularlens study. J AAPOS 1999; 3(5): 295-302.
15. Wheeler DT, Stager DR, Weakley DR Jr. Endophthalmitis following pediatricintraocular surgery for congenital cataract and congenital glaucoma. PediatrOphthalmol Strabismus 1992; 29(3): 139-141.G
Fig. 1: Congenital annterior polar cataract,compatible with good vision
Fig. 2: Central posterior lens opacity partiallyobscuring red pupillary reflex
Fig. 3: Congenital posterior lenticonus, a bulgein the posterior lens capsule associated withprogressive opacification of the lens
Fig. 4: Spectacles for correction of aphakia
Fig. 5: Posterior chamber IOL implant wellcentered in capsular bag
Fig.6: Amblyopia treatment inn a child with
IOL implant following a traumatic cataract.
Page 10
Advertising page
Advertising page
Committee ReportsCommittee on School Health and Sports Medicine
Rani Gereige, M.D.Chairman
Childhood epidemics that emerged at the dawn ofthe millennium, e.g. Obesity, Type II Diabetes mellitus,high-risk behavior, violence/ safety, all made the priority listof the Healthy People 2010 initiative. As we know, thesehealth issues are multifactorial and can only be addressed byusing a team approach targeting the various factors. Thepediatrician, however, is not just a team member but one ofthe key elements in that team. The partnership between themedical and educational systems is one of the first steps onthe road to addressing these priorities. Because these issuesare of public health magnitude, the best way to address themis through the public health model, which includes the triadof: Individual, Environment, and Agent. Schools are a keycomponent of this triad and pediatricians are at a centralposition to interact and influence all three components ofthis triad.
Individual
The Public Health ModelEarlier this year, at the beginning of my term as the
Chair of this committee, I surveyed the FCAAP members ontheir interest to serve on or share their expertise with thecommittee. I would like to thank all of you who returned thesurvey. The response from interested members wasoverwhelming. I was very pleased to see the amount ofinterest in school health among Florida’s pediatricians. Alarge number expressed interest in serving on the committeeor sharing expertise with the committee. Because of thelimited number of members needed for the committee’sworking group, I am pleased to present to you the followingmembers of the FCAAP Committee on School Health andSports Medicine:1) Rani Gereige, M.D., MPH; Chairman , Clearwater, FL
– [email protected]) Karen Toker, M.D. (Ponte Verda Beach)3) Christina Canody, M.D. (Tampa)4) Maureen Novak, M.D. (Gainesville)5) Sharon Leonard, M.D. (Pensacola)6) Pedro Reimon, M.D. (Miami)7) Lisa Cosgrove, M.D. (Cocoa Beach)8) Kelly Crownin Komatz, M.D. (Jacksonville)9) Antoinette Spoto-Cannons, M.D. (St. Petersburg)
I would like to extend an invitation to the ResidentSection to nominate a member of the section who isinterested in serving on our committee. Please e-mail me at:[email protected] with a name of interested resident.
For those of you who expressed interest and
returned the survey, I have kept your name and contactinformation and created a list for the committee to tap intoyour expertise as the need arises depending on the issuesaddressed. The committee will begin meeting periodicallyin few months via conference calls. Please feel free tocontact me for any issues you would like the committee toaddress. I will periodically update the members on the workof the committee in the Florida Pediatrician. In addition,please e-mail me information on any school health projectsyou are conducting to feature in the Florida Pediatrician. Itis through comprehensive school health approach, advocacy,and partnership that we can achieve healthier communitiesand healthier nation, physically and mentally.G
MEMBERSHIP ALERT! Do you know any pediatricians, Fellows of theAcademy or not, who appear to have been overlookedby the Society, and are therefore not members? Contactthe Executive Vice President or Membership Director.There are several kinds of membership in the Society:
Fellow: A Fellow in good standing in theAmerican Academy of Pediatrics - automaticmembership on request.Member: A resident of Florida who restrictshis/her practice to pediatrics.Associate Member: A physician with specialinterest in the care of children.Military Associate Member: An active dutymember of the Armed Forces stationed inFlorida and limiting practice to pediatrics.Inactive Fellow or Member: Absenting selffrom Florida for one year or longer.Emeritus Fellow or Member: Having reachedage 70 and having applied for such status.Affiliate Member: A physician limitingpractice to pediatrics and in the CaribbeanBasin.Allied Member: A non-physician professionalinvolved with child health care may apply forallied membership.Honorary Member: A physician of eminencein pediatrics, or any person who has mededistinguished contributions or rendereddistinguished service to medicine.Resident Member: A resident in an approvedprogram of residency.Medical Student: A student with an interest inchild health advocacy.G
Page 13
Pediatrician
AgentEnvironment
From the Resident SectionCristina M . Estrada, M D
Resident Chairperson for FLUF/Jax Program Representative
[In each issue, we will focus on one of the State’s Residency Programsand/or problems affecting all the programs]
[With this issue, we introduce a new Resident Chairperson forFlorida, Cristina Estrada of Jacksonville, who represents theJacksonville program and also the programs of Florida. Shesucceeds Laura Stadler, who served well, and we thank her!]
Spotlight on Jacksonville
Committed to providing residents with uniqueeducational opportunities, the Pediatric training program atthe Urban Campus of the University of Florida has manythings to offer. The program is the product of thecollaborative efforts of the University of Florida HealthScience Center/Jacksonville, Wolfson Children’s Hospital,Nemours Children’s Clinic, and the Duval CountyDepartment of Health. The cooperation allows our fullyaccredited training program to provide strong pediatricfundamental experiences and a wide range of opportunitiesto explore specific interests. Our residents are thus able toprovide complete primary, secondary, and tertiary care forthe pediatric population of the northeast Florida andsoutheast Georgia region.
The Department of Pediatrics in Jacksonville isexcited to be one of the recipients of an Anne E. DysonCommunity Pediatrics Training Initiative grant. Theprogram has partnered with the Duval County HealthDepartment to provide residents with a better view of thecomplex issues impacting children and the interdisciplinaryknowledge, skills and cultural competence required tounderstand and improve the health of children and families.This pediatric initiative is truly ground breaking in itsintegration of an academic medical center and a departmentof public health to form an academic public health pediatricsprogram.
The city of Jacksonville also provides our residentswith several other community based experiences. Duringthe first and second year, there are rotations specificallydesigned to expose the residents to the multiple resourcesavailable throughout the community for children andfamilies. Senior residents also have enjoyed the MedicalEconomics elective, which provides significant exposure tothe intricacies of healthcare finance as well as first handexperience at our state capital in its political processes.International medical interests have also been pursued tointroduce residents to complementary and alternativemedicine. In addition, several residents have worked withlocal Non-Governmental Organizations providing care toCaribbean islands and have participated in observerships toChina and Southeast Asia.G
Page 14
C.A.T.C.H.
The CATCH CornerDeise Granado-Villar, MD
CATCH Co-Facilitator Regions V-VIII
As the grant application cycle for CATCH 2003closes, we would like to wish all Florida "Catchers", thebest of luck for successful funding.. Five applicationswere submitted for planning funds from our State. Proposals presented highly emphasize the CATCHmission to improve access to care, and to strengthen themedical home. Notifications will be sent prior toDecember 31, 2003. The number of CATCHapplications received this year from Pediatricians andResidents continues to increase nationally. The firstfunding cycle for CATCH took place in 1993 when 20out of the 23 applications submitted were approved forfunding. Since, thanks to the tireless efforts of theAcademy, our District and State Facilitators, and allwho are firm believers in the value of community-basedinitiatives, in 2002 the CATCH program received 179applications of which 59 were awarded. Kudos, to allof us for a job well done!
Residents will have an additional opportunitythis winter to apply for CATCH funding. Check theC AT C H w e b s i t e p e r i o d i c a l l y a twww.aap.org/catch/faqs.htm for more information.
The District X CATCH meeting will be heldjointly with the Southeast Conference on Disabilities,November 13, 2003 in Atlanta, Georgia. This eventwill focus on Working Model of the Medical Home. The agenda includes presentations on medical homemodels from Florida to be addressed by Peter Gorski,David Wood and Karen Toker. If you are interested inattending this most informative meeting please contactMs. Jina Lee, Program Manager Community Access toChild Health 800/433-9016 ext 4903 e-mail:[email protected]
The “Ticked Off” Column.
If you are really “ticked off” about something in yourpractice or about medical economics in general, write about it andsend it in. Any reasonable complaint will find its way into print!G
Note:
The Florida Pediatrician has had and continues to
have a policy to print an article on Managed Care in each
issue. This policy will be adhered to so long as suitab le
articles are submitted. Both sides of the issue will be
represented.
Publication of an article does not indicate any
endorsement of the opinion by The Florida Pediatrician or
by the FCAAP/FPS.G
Managed CareAthletic Screening of High School Students
Louis B. St. Petery, Jr., M.D.Executive Vice President
Tallahassee, FL
As those of you who attended theFPS/FCAAP Annual Meeting last month in Orlando know,there are serious liability issues with the current lawregarding pre-participation sports physicals for high schoolstudents. My purpose in writing is to summarize theproblem, to suggest a short-term "solution", and to let youknow what the Chapter is doing to achieve long-termresolution.The Problem
The current statute (1006.20) requires the FloridaHigh School Athletic Association (FHSAA) to publish apre-participation physical evaluation form.
“...The preparticipation physical evaluation formshall advise students to complete a cardiovascularassessment and shall include informationconcerning alternative cardiovascular evaluationand diagnostic tests. Practitioners administeringmedical evaluations pursuant to this subsectionmust, at a minimum, solicit all information requiredby, and perform a physical assessment accordingto, the uniform preparticipation form referred to inthis paragraph and must certify, based on theinformation provided and the physical assessment,that the student is physically capable ofparticipating in interscholastic athletic competition.If the practitioner determines that there are anyabnormal findings in the cardiovascular system, thestudent may not participate until a furthercardiovascular assessment, which may include anEKG, is performed which indicates that the studentis physically capable of participating ininterscholastic athletic competition...."The entire section is problematic, but the most
problematic is the requirement that physicians"...certify...that the student is physically capable ofparticipating..."Short-term Solution
Several attorneys and a risk manager have beenconsulted regarding this problem. Their suggestion is the
use of a disclaimer. Below are two versions, one forprimary care physicians, and one for cardiologists.Although it is unlikely that the use of a disclaimer willprotect you from a suit, it does help to educate the child'sparents about the limitations of our ability to detect certainconditions. These documents can be printed from theChapter web site, www.fcaap.org.Long-term Solution
The Chapter has discussed this issue withrepresentatives of the Governor, the legislature, and theFHSAA. All have agreed that the current law needs to bechanged. As a result, the malpractice bills currently beingdiscussed in the special session include an amendment tothis statute. I have attached a copy of the amendment,which indicates our proposed additions and deletions. Asyou can see, all but the first sentence above is deleted. (TheFHSAA insisted that the first sentence remain.) If and whena malpractice bill passes, and assuming that this languageremains intact, the use of a disclaimer should no longer beneeded.
Alternatively, if no agreement is reached on amalpractice bill, we will pursue this issue in any furtherspecial sessions this year, or in the 2004 regular session,next spring.
Please contact me if you have any questions about thisissue. Copies of the forms are attached.
(See Managed, page 31 <)
Note:If you are a Fellow of the American Academy of Pediatrics, youare automatically a member of the Florida PediatricSociety/Florida Chapter of the American Academy of Pediatrics,and you automatically receive The Florida Pediatrician. If youhave not already done so, please pay your annual Florida dues,billed through the Academy Office. G
FYIThe AAP will no longer print the tax deductibility disclosure
statement on the membership dues invoice. Since we are incorporatedas a 501 (c) (6) organization, we are required by the IRS to notify ourmembers of the amount of dues that can be deducted as a businessexpense:
Dues remitted to the Florida Chapter are not deductible as acharitable contribution but may be deducted as an ordinary necessarybusiness expense.
However, 30% of the dues are not deductible as a businessexpense for 2002 because of the chapter’s lobbying activity.
Please consult your tax advisor for specific information.GPage 15
In MemoriamRobert A. Good, M.D.
[adapted from “Focus on Health Sciences News, June 26, 2003, University of South Florida]
Dr. Robert A. Good, the father of modernimmunology who translated his tremendous knowledgeof cellular immunity into the first successful bonemarrow transplantation, died June 13.
He was a consummate scientist, a caringpediatrician and an inspired teacher.
Many of more than 300 physicians and scientistshe trained or mentored over the last 50 years holdleadership positions at such esteemedinstitutions as Harvard MedicalSchool, the National Institutes ofHealth, Albert Einstein College ofMedicine and others. D r .Good discovered the role of thethymus in the development of humancellular immunity and laid out theconnection between immune diseasesand the two basic arms of the immunesystem known as T-cells and B-cells.The research resulted in the world’sfirst successful bone marrowtransplant, which Dr. Good performedin 1968. His work was sogroundbreaking that he appeared onthe cover of the March 19, 1973 edition of Timemagazine.
He joined All Children’s Hospital as Physician-in-Chief in 1985, and directed the hospital’s Division ofAllergy and Clinical Immunology. He also developedthe hospital’s first Bone Marrow Transplantation Unit.At the USF College of Medicine, Dr. Good was namedprofessor of pediatrics, professor of microbiology andimmunology, director of the training program inPediatric Allergy and Clinical Immunology, andDistinguished University Professor. He also served aspresident of the St. Petersburg-based Children’sResearch Institute.
At USF and All Children’s, where an endowedchair in pediatric immunology was created in his honor,Dr. Good’s research included the influence of nutritionon longevity, immunity, health span and diseases ofaging, fundamental and practical aspects of bone marrowand stem cell transplantation, and other forms of cellular
engineering. Page 16
He showed that bone marrow transplants inexperimental animals can prevent and cure a widevariety of autoimmune diseases, immunological-basedkidney diseases, and cardiovascular diseasese, amongothers. He helped define the nature and isolation ofstem cells, and contributed greatly to identifying anddefining numerous primary and secondaryimmunological deficience diseases and disorders.
Dr. Good received 13 honorarydegrees from academic institutions across theworld. He garnered more than 100international and national awards throughouthis scientific career.
Known for building the field ofimmunology in Japan, he was personallyrecognized by the Emperor of Japan for hisresearch and educational achievements. Hewas elected to the National Academy ofSciences in 1970 - the only USF facultymember to have achieved that honor.
Dr. Good was the author or co-authorof more than 2,200 scientific papers and wrote or edited50 books.G
“Robert Good was a friend and inspiration to meand to literally thousands of physicians and scientistswho are trying to save children from complex diseases.He taught us to look further than we could see at thetime, to reach for new horizons of ideas we hadn’t yetimagined.”
John Curran, MDVice Dean, USF College of MedicineG
Risk Management[The Florida Physicians Insurance Company (FPIC) is endorsed and sponsored by the Florida Chapter of the American Academy of Pediatrics as its exclusivecarrier of malpractice insurance for its members. In each issue, FPIC will present an article for our readers on matters pertaining to risk management]
What is Informed Consent?Cliff Rapp, LHRM
Vice President of Risk Management, FPIC
Alleging a lack of informed consent is one of theeasiest ways to reach the threshold in tort necessary to bringlegal action against a physician. The mere execution of aconsent form – which may be referred to as formal consent –does not necessarily constitute informed consent. Informedconsent is a process of educating the patient about a proposedprocedure’s risks, benefits, and alternatives. The physician isultimately responsible for educating the patient about theproposed treatment or procedure and discussing the risks,benefits, and alternatives such that the patient’s decision, oncemade, constitutes an informed decision. The patient isresponsible for weighing the information and making aninformed decision. Ideally, the physician, and not a staffmember, should obtain the patient’s signature on the consentform.
Informed consent is a process that encompasses thefollowing four elements: discussion, consent form,documentation, and educational materials.
DiscussionThe discussion is the most important element since
informed consent is an extension of good communicationtechniques and helps establish doctor/patient rapport. Patientshave a right to information and to participate in decisionsaffecting their health.
The discussion should cover the following topics
· Explain the patient’s medical condition and thetreatment or procedure in lay language appropriate forthe patient’s level of education or understanding.
· Disclose the risks.o Include severe risks, e.g., death, paralysis,
loss of function.o Include frequent risks, e.g., infection,
bleeding, possibility of additional procedures.o Include the incidence of risk (e.g., 1 in 10,000
experience this complication) to help thepatient put risk in perspective.
· Provide information about common side effects, e.g.,infection, bleeding, etc.
· Explain the benefits of the procedure.
· Don’t make any guarantees of 100 percent success.
· Provide information about potential outcomes iftreatment is refused.
· Encourage the patient to ask questions.
· Acknowledge that the patient can withdraw consent.
· Make an offer for a second opinion.
Consent FormThe consent form, or formal consent, provides written
information to help the patient remember the risks, benefits,and alternatives you have discussed. It is a good preventivemeasure to give the patient a copy of the consent and retain onecopy in the chart. The consent form should include the sameelements as the consent discussion and should be written ineasily comprehendible lay language. Obtaining the patient’ssignature should not be delegated to your assistant. A witnessis not necessary.
DocumentationWe recommend you write a brief note in the patient’s
chart to document that a consent discussion occurred and thepatient agreed to proceed with the treatment. If you gave thepatient any handouts or instructions, document this action.Place the signed informed consent form in the patient’s chart.Example: Advised patient of need for and benefits ofarthroscopic surgery; discussed risks, benefits, andalternatives. Explained the risks and complications offoregoing surgery. Gave patient handout describing theprocedure. Patient stated he understood and acknowledges heis at increased risk for infection due to his diabetes, signedconsent, and agreed to proceed.
Educational MaterialsStudies show that patients remember approximately 30
percent of verbal information. Educational pamphlets, writtenhandouts, and pre-and post-instructions help the patient makean informed decision and later recall what was consented to ifcomplications occur. Catalog and retain educational materialfor at least ten years – an outdated informational pamphletmight very well be the evidence needed to defeat a claim or suitbrought years after the care or treatment.
Patients are not required to submit to treatment.Several states have case law which mandates that doctors havethe responsibility to disclose the possible outcome if treatmentis refused. This is the Doctrine of Informed Refusal and it holdsthat the physician has the responsibility to inform the patientsof potentially detrimental outcomes.
Although Florida statutes do not contain a Doctrine ofInformed Refusal, it is wise from a claims preventionstandpoint to incorporate this element into your informedconsent discussion. If the patient refuses your recommendation,explain the possible adverse outcome. This conversationshould be documented in the chart and, if possible, the patientshould sign an informed refusal statement.
There are four general categories of circumstances inwhich consent of the patient is not required for treatment. With
(See Risk, page 30 <)Page 17
From the AAPDr. BERKOW ITZ ELECTED
The Academy haselected Carol D. Berkowitz,M.D., FAAP, of Torrance,California, as its new vicepresident. Dr. Berkowitz willtake office as president-elect atthe November 2003 AAPNational Conference andExhibition in New Orleans andwill serve as the 2004-05 AAP president. She will be theAcademy’s th i rd femalepresident.
Dr. Berkowitz currently serves on the AAPCommittee on Pediatric Workforce, and itssubcommittee, Women in Pediatrics. She spent six yearson the Board of Directors of the American Board ofPediatrics.
A native of New York, Dr. Berkowitz attendedBarnard College, Columbia University College ofPhysicians and Surgeons, and completed her pediatrictraining at Roosevelt Hospital. She is now professor andexecutive vice chair in the Department of Pediatrics atHarbor-UCLA Medical Center in Torrance.
She plans to focus on health care access andreimbursement issues. G
Our Congratulations to Dr. Berkowitz
Kudos......to Audrey Schiebler, who has been appointed an HonoraryFellow of the American Academy of Pediatrics, announcedat annual meeting.G
Page 18
Congratulations...
...to Herbert H. Pomerance on receipt oft h e A A P D i s t ri c t X S p ec ia lAchievement Award, for “outstandingcontinuing contributions, as a memberof the Senior Sec tion, to theadvancement of medical knowledge andenhanced pediatric communication aseditor of “The Florida Pediatrician”, thebulletin of the FCAAP”.G
Congratulations......to Charles F. Weiss, on receipt of the District X SpecialAchievement Award, “for both career and outstanding multi-yearcont r ibu t ions to ‘Th e Flo r id aPediatrician’ and the ExecutiveCommittee of the Florida Chapter ontopics related to environmental healthand toxicology”.G
Note:A summary of The Florida Pediatrician is on thewebsite for the AAP. The URL is:
http://www.aap.org/profed/florida.htm G
Audrey Schiebler, with Steve Edwards, President of
AA P and Cha rlie Linder, C hair District X
More from the AAP
Study Fails to Show a Connection Between Thimerosal andAutism
The American Academy of Pediatrics provides the followinginformation for clinicians who may be aware of recent press surroundingan article that claims to show a correlation between thimerosal and autism.1
This paper uses data from the Vaccine Adverse Event Reporting System(VAERS) inappropriately and contains numerous conceptual and scientificflaws, omissions of fact, inaccuracies, and misstatements.
The most important weakness of the article is the reliance onVAERS data to draw conclusions about adverse event associations orcausality. VAERS is a passive surveillance system for reporting possiblevaccine adverse events that depends on health care professionals, patients,and others to file reports. Health effects reported to VAERS as beingassociated with vaccines may represent true adverse events, coincidentaloccurrences, or mistakes in filing. Inherent limits of VAERS includeincomplete reporting, lack of verification of diagnoses, and lack of data onpeople who were immunized and did not report problems. Data fromVAERS are useful for hypothesis generation (raising questions) but shouldnot be used for research aimed at determining whether vaccines causecertain health problems (hypothesis proving), as was done in the article byGeier and Geier. For example, VAERS worked well to quickly alertinvestigators to the possibility of intussusception after rotavirusimmunization but could not prove the association. Proof required numerouscontrolled studies to document the nature and frequency of this association.
The original concern regarding thimerosal in vaccines wassparked not by any trends identified in the VAERS system after 70 yearsof experience with thimerosal use as a vaccine preservative but by theoreticconcerns about total exposures infants might receive from all mercurysources in the environment, including vaccines. Research to date involvingrefined, controlled studies in large populations of patients has failed todemonstrate any association between vaccines that may have usedthimerosal as a preservative and neurodevelopmental disorders includingautism. The authors failed to acknowledge the inherent limitations of theVAERS database when drawing conclusions of adverse event associationscontained in this report and their other publications. They are equallyunclear as to how their data were generated, thus preventing accuratereview of their methods and replication of their outcomes.
Other flaws in the article include the following:
! The law relating to VAERS reporting is misstated. MostVAERS-reported conditions fall into a category in whichvoluntary and passive, not mandatory or required, events afterimmunization are recorded. Only a specific set of more severeadverse events are specified as mandatory under the VaccineInjury Table, and even then, reporting is inconsistent.
! Conclusions of the 2001 Institute of Medicine ImmunizationSafety Review Committee report2 as to what constitutes maximalpermissible dose exposures to mercury are misinterpreted, andmisleading statements are made concerning federal safetyguidelines for mercury exposure levels that might be expected tocause harm.
! The authors fail to depict accurately the differences betweenpharmacokinetics of and exposure to methylmercury (found incontaminated food) and ethylmercury (found in thimerosal) andmake unsubstantiated assumptions about the risks of the route ofexposure (ingested versus injected).
! Adult heart disease is included as a possible thimerosal-relatedcondition, although heart arrest reports in very young childrenare used in the analysis. Heart arrest in very young children (acommon term used on pediatric death certificates and oftenunrelated to the actual cause of death) has nothing to do withadult coronary heart disease. The authors’ implication thatthimerosal in vaccines is a cause of acute cardiotoxic events isunfounded in any scientific or clinical reports and represents amisuse of the terminology found in VAERS reports.
! The authors fail to reveal how thimerosal exposure wascalculated—a critical omission, because much of the datarequired to estimate mercury exposure are not available in
VAERS reports. The authors’ stated estimates of exposureattributable to diphtheria, tetanus, and pertussis combinationvaccines (DTaP or DTwP) do not add up. Some DTaP vaccinesnever contained thimerosal as a preservative, and any child mayhave received 1 or more DTaP doses, which would haveresulted in no ethylmercury exposure.
! The authors claim to have analyzed data from biologicsurveillance summaries by manufacturers, although dataregarding specific manufacturers (some of which incorporatedthimerosal as a preservative and some of which did not) and ageand year of birth of vaccine recipients are not available in thepublication cited. Data as to the number of patients receivingvaccines with thimerosal plus the number of doses of vaccine actually received by patients versus totaldoses of vaccine manufactured cannot be derived from biologicsurveillance summaries, making the authors’ claims forbaselines of actual vaccine use untenable.
! Calculations for incidence rates and relative risk, which requireinformation (age or year of birth) that is not available frombiologic surveillance data, are not shown.
! An appropriate comparison is not made between thimerosalexposure and no thimerosal exposure, which is not possibleusing VAERS data, because one cannot be sure whether a childreceived a thimerosal-containing vaccine at any point before theevent for which the VAERS report was created. Depending onthe manufacturer, many of the children listed in VAERS reportscould have received all vaccines that were free of thimerosal.
! Statistical methodology for calculating the relative risk andcorrelation coefficients is not stated.
! The authors claim to have performed their own analysis of aVaccine Safety Datalink (VSD) thimerosal screening study(reference 17 in Geier and Geier), although the raw data neededto perform an independent analysis are not available in thedocument cited. (Note: neither the original preliminary VSDstudy of thimerosal and neurodevelopmental disorders nor anyof the follow-up expanded studies identified a “signal”indicating any association between thimerosal and autism.)
! The authors claim that data for thimerosal exposure and autismrisk follow an exponential distribution, although none of thethimerosal exposure categories had a significantly increasedrisk of autism. The figures used are confusing and notsupported by an adequate explanation as to how they wereconstructed. Comparing the occurrence of late onset, chronicconditions like autism by using acute vaccine reactions likefever, pain, and vomiting (presumably attributable to othervaccine components) as controls makes no sense as a measureof relative adverse event rates.
! When comparing early (1984-1985) to late (1990-1994) birthcohorts, the authors make arbitrary and unlikely assumptions ofpossible thimerosal exposure for both groups that are contraryto when thimerosal vaccines were introduced and what theirexpected pattern of use in the private and public sector was. Theaverage level of thimerosal exposure claimed by the authors isnot realistic.
! The authors claim high correlation coefficients for thimerosalwith certain neurologic disabilities without describing thestatistical methods used, which makes the results highlyunreliable.
! The authors fail to note that a recently published review byNelson and Bauman3 casts doubt on the biologic plausibility ofsymptom similarities between mercury poisoning and
(See AAP,, page 31 <)Page 19
From the FCAAP
At the June meeting of theFPS/FCAAP, the biennial“changing of the guard”occurred. The presidency of thesociety was taken over byDeborah Mulligan-Smith, whowill serve for the next twoyears. Leadership passed fromRichard Bucciarelli, who servedus well!G
Kudos......to Edward Saltzman, awardeeof the 2003 John WhitcombAward, for his contributions tothe state and its children. Theaward was made at the annualmeeting of the FPS/FCAAP inOrlando.G
Congratulations...
...to Jorge DelToro-Silvestry, M.D., elected by themembership as 2nd Vice President, in the recentelection.G
Kudos... ...to our outgoing Regional Representatives, who have served wellthe past two years:
Region II Donald E. George, M.D., Jacksonville
Region III: T homas Benton, M.D., Gainesville
Region IV: David Milov, M.D., Orlando
Region VI: Bruce Berget, M.D., Ft. Myers
Region VIII: Charles Bauer, M.D., Miami G
Page 20
Congratulations...to the new Regional
Representatives, progressing from Alternate:
Region II James Waler (Jacksonville)
Reagion III Jyoti Budania (Gainesville)
Region IV Lloyd Werk (Orlando)
Region VI John Donaldson (Ft Myers)
Region VIII Kimberly Schwartz (Aventura)G
Congratulations...to our newly elected Alternate Regional Representatives
Region II: Gary Josephson, M.D., Jacksonville
Region III: Mary Grooms, M.D., Gainesville
Region IV: Lisa Cosgrove, M.D., Merritt Island
Region VI: Benjamin Helgemo, M.D., Port Charlotte
Region VIII: Thresia B. Gambon, M.D., Miami Beach,FLG
Kudos...
...to Jaime L. Frías, professor of Pediatrics and director of the USFBirth Defects Center, on his appointment to the newly establishedPediatrics Subcommittee of the National Institute of Child Healthand Human Development at the National Institutes of Health.
for all you want to know about our society, includinga summary of The Florida Pediatrician.G
Our Thanks to Our Supporting Vendors
The Florida Chapter AAP /Florida Pediatric Societywishes to acknowledge the following organizations for their sponsorship of the
Annual Meeting
Alcon Laboratories
Aventis Pasteur
AstraZeneca
Dairy Council of Florida
FPIC
Fujisawa Healthcare
GlaxoSmithKline
Grayson Stadler
McNeil Pharmaceuticals
Mead Johnson Nutritionals
Medimmune, Inc.
Nestle
Ross Laboratories
Wyeth Consumer Healthcare
Page 21
Advertising page
The History CornerPEDIATRICS IN FLORIDA
A TRADITION OF COMPASSIONATE CARINGDeborah Mulligan-Smith, M.D.
[A continuation of the history of FPS/FCAAP, from the previous issue) President
The past causes the present, and so the future.
Major Legislative Achievements of the FPS/FloridaChapter AAP
< Establishment of the Children's Medical Service(CMS) - A state agency that provides care forchildren with chronic or disabling conditionswhose parents cannot afford treatment. CMSreplaced the Florida Crippled Children'sCommission which treated only orthopedicconditions.
< Disease specific programs established underCMS; e.g. Hematology/Oncology clinics,diabetes, kidney screening and treatment,rheumatic fever and rheumatic heart disease,cystic fibrosis, regional genetics program, cardiacdisease program, pulmonary center program,cleft lip/palate, learning disabilities program andothers.
< Regionalization of high risk newborn andobstetrical centers and transportation system.(Perinatal Intensive Care Program) Stategovernment funding for high risk newborn care.Step down care.
< Implementation of Title XIX.< Mandatory use of seat belts in cars for children
under five years. Later increased agerequirements.
< Mandated insurance for newborns under familypolicies.
< Regulation of temperature settings for hot waterheaters.
< Statewide program for the prevention of childabuse and neglect.
< School immunization law. Mandatoryimmunizations for all children before enteringkindergarten.
< Metabolic screening program for newborns.Screening for maple sugar urine disease,galactosemia, hypothyroidism, and PKU
< Scoliosis screening program added by legislationto the infant screening law.
< Medicaid newborn funding for babies ofMedicaid mothers for the first 60 days of life notwithstanding the completion of an application.
< Robert Wood Johnson grant. Rural efforts toassist medically dependent children at home, inconjunction with medical staff from Universityof Florida Department of Pediatrics.
< 1986 was a banner year for the FPS/Chapter.After several years of legislative efforts, theFlorida Child Health Assurance Act was passed.Nationally, the initiative was known by theacronym, CHIRP, Child Health InsuranceReform Program. This legislative victory isremembered as the Chapter at its best! We werethe second Chapter (State) to enact thislegislation which mandated that all family healthinsurance must cover children from birth.
< In 1986, under the watch of Drs.Bud Tanis andMarcus Moore another first was achieved. TheFlorida legislature and Board of Regentsestablished the Institute for Child Health Policy,whose mission was to assist public and privateagencies at the state, regional and national levelsin the development of health policies andprograms appropriate to needs of children andtheir families. Steve Freedman, PhD, was thefirst Director. The Institute is headquartered atthe University of Florida in Gainesville, FL, withan office in St. Petersburg, FL and and office atNova Southeastern University. Dr Freedmancontinues his role as Executive Director.
< Children (< 5yo) and Pick Up Trucks. < Authorization of three poison control centers in
the state, Tampa, Jacksonville, and Miami. By1995 all centers were operating and meeting thestandards of the American Association of PoisonControl Centers.
< Personal Flotation Devices. Children < 6 yearsin a boat < 26 ft when underway and all ages onPWC.
< 1989, Firearm Safe Storage< 1990, Healthy Kids Corporation< 1993, Child Death Investigations; Possible SIDS
< 1yo - autopsy< 1992, State EMS Plan must include Pediatric
Trauma referral centers.< 1996, Bike Helmet Law
(Continued next page <)Page 23
History( = continued from previous page)
< 1997, Create State Emergency Medical Services forChildren (EMSC) committee of child healthproviders to advise on pediatric emergency roomcare, rehabilitation needs, etc“Back in 1990, Senator "Doc" Myers and
Representative Fred Lippman (1996 Receipient of theOutstanding Legislator and Advocate for Children from theFlorida Pediatric Society) joined a strong, bi-partisan effortto establish the Healthy Kids program. Governor Martinezand Treasurer Tom Gallagher were good stewards of thisprogram.
Healthy Kids is one of the most successful preventionprograms we have. It provides access to health care foruninsured children who would otherwise wind up in theemergency room”. Governor Lawton Chiles< 1998, Florida Kid Care includes Healthy Kids and
Medi-Kids< 2000, Graduated License< 2000, Residential Swimming Pool, Spa and Hot tub
Barriers. Associated public education campaign.< 2000, Universal Hearing Screening for Newborns.< 2001, Graduated License and OUI
PAST FLORIDA PEDIATRIC SOCIETY PRESIDENTS1936-37 Luther W. Holloway, MD1937-38 William W. McKibben, MD1938-39 Douglas O. Martin, MD1939-42 Warren W. Quillian, MD1942-46 Ludo Von Meysenbug, MD1946-47 Councill C. Rudolph, MD1947-48 James R. Boulware, MD1948-49 Edgar W. Stephens, MD1949-50 Hugh A. Carithers, MD1950-51 Edgar Hitchcock, MD1951-52 E. V. Anderson, MD1952-53 Charlotte Maguire, MD1953-54 C. Jennings Derrick, MD1954-55 Lewis T. Corum, MD1955-56 Wesley S. Nock, MD1956-57 Joel V. McCall, MD1957-58 Henry G. Morton, MD1958-59 Burns A. Dobbins, MD1959-60 Harry M. Edwards, MD1960-61 Joseph K. David, MD1961-62 Fred I. Dorman, MD1962-63 John H. Cordes, MD1963-64 George W. Griffin, MD1964-65 Robert J. Grayson, MD1965-66 Oliver F. Deen, MD1966-67 James M. Weaver, MD1967-68 Richard Skinner, MD1968-69 Ray O. Edwards, MD1969-70 Thomas M. Brill, MD
Page 24
1970-71 John C. Moore, MD
1971-72 James M. Stem, MD1972-73 Bernard F. O’Hara, MD1973-74 David R. Gair, MD1974-75 James M. San, MD1975-76 W. Reed Bell, MD1976-77 Andrews W. Townes, MD1977-78 Michael Steiner, MD1978-79 Thomas Greiwe, MD1979-80 Myrna B. Ginter, MD1980-82 George A. Richard, MD1982-84 Donald I. Macdonald, MD1984-87 Marcus M. Moore, MD1987-89 Gary M. Bong, MD1989-91 George A. Dell, MD1991-93 Robert F. Colyer, MD1993-95 Kenneth H. Morse, MD
PAST STATE CHAPTER PRESIDENTS
1935-40 Warren Quillian, MD1941-42 Gilbert Osincup, MD1942-48 George Cook, MD1949-51 James Boulware, MD1952-57 Hugh Carithers, MD1958-63 Wesley Nock, MDPage 24
1964-69 Henry Morton, MD1970-75 Robert Grayson, MD1976-78 F. Edwards Rushton, MD1979-81 W. Reed Bell, MD1982-84 Robert Threlkel, MD1985-88 Arnold Tanis, MD1989-92 John Whitcomb, MD1992-95 David Cimino, MD
1995-97 John Curran, MD1997-99 Edward Williams, MD1999-01 Edward Zissman, MD2001-03 Richard Bucciarelli, MD*In 1995, the Florida Pediatric Society and Florida State Chaptermerged into one organization.
Where do we go from here?
“Challenges and New Directions in Delivering Care toChildren”
My thanks to AAP staff, FPS/FCAAP Presidents, ExecutiveCommittee members, Executive Secretary of our Society, Dr.Louis St. Petery, Administrative Assistant, Ms. Edie Lovingood,The Florida Pediatrician Newsletter Editor, Dr. Pomerance andNSU Executive Vice-Chancellor and Provost Frederick Lippmanfor without their reports and contributions this document couldnot have been prepared. G
Legislative ReportSubmitted by
Nancy Moreau, Legislative Liaison
The 2003 Regular Legislative Session concluded withmajor issues unresolved, which has led to a succession of “specialsessions” to address the State budget, medical malpractice reformand a number of other issues. At this writing the State budget hasbeen passed, but a stalemate is ongoing on medical malpracticereform. It appears that we are in for a long contentious summer asthe House, Senate and Governor dig in on malpractice reforms.The Governor and House leadership insist upon a “rigid” cap onnon-economic damages, while the Senate has embraced a“floating” cap to address the severity of injuries in malpracticeincidents. Neither house is close to compromise and the Governorbelieves that keeping the legislature in Tallahassee in a series of“special” sessions will bring about movement. Unfortunately heunderestimates the resolve of each house and the resentment theSenate has over the bullying tactics he has used. Sadly, it appearsthat the focus on patient access to health care and the physician’sability to sustain a viable practice has taken a back seat to a “Battleof the Giants”, trial attorneys and insurance companies, overmoney.
At the beginning of the 2003 Regular Legislative Sessionhope of greater cooperation between the Senate and House ofRepresentatives was quickly dashed as the philosophies of the twohouses took divergent paths. The passage of Constitutionalamendments to lower class size, provide universal pre-kindergartenand ban smoking in all work places provided a challenge that wasapproached in uniquely different ways leading to gridlock duringthe Regular Legislative Session.
Supporters of the education initiatives wanted everyavailab le dollar dedicated to these initiatives while those in thesocial service and health areas knew that revenue shortfalls woulddevastate existing programs leaving many to literally fight for theirlives. As has been widely reported, the Speaker of the House,Johnnie Byrd, dug in and refused to raise new revenue with amantra to members to “live within our means.” Thus once again,Peter was robbed to pay Paul as trust funds were raided andrecurring programs were funded with non-recurring dollars settingin motion an even b leaker situation for 2004.
Following is a listing of bills which may be of interest tothe membership.
CS/SB 2084 — Prescriptions / Format (CH. 2003-41)Written prescriptions for medicinal drugs issued by a
health care practitioner are required by this legislation to be legiblyprinted or typed. Further, it is required that the prescriptioncontain the name of the prescribing practitioner, the name andstrength of the drug prescribed, the quantity in both textual andnumerical formats and directions for use. Additionally, theprescription must be dated with the month written out in textualletters and signed by the practitioner on the day when issued.
Effective Date: July 1, 2003
CS/SB 2156 — M iddle and High School AthleticPreparticipation Medical Examinations (CH. 2003-129)
This legislation amends the requirements forpreparticipation physical assessments of the capabilities of astudent to participate in interscholastic athletic competition.Practitioners who administer such assessments/examinations are
required to follow a form approved by the Florida High SchoolAthletic Association and certify when a student is deemed capableof participating in athletic competition. Additional cardiovascularassessments are required if abnormal cardiac findings are presentin the initial examination. Students will not be eligible toparticipate in any competition, practice, tryout, workout, or otherphysical activity associated with the athletic team until the medicalevaluation clears the student for participation. (An amendment isbeing offered by the FPS in the proposed Medical Malpracticelegislation to negate some of these provisions.)
Effective Date: June 10, 2003
HB 953 — Weight-Loss Pills / Minors (CH. 2003-24)As of July 1, 2004 it will be unlawful to sell, deliver,
barter, furnish, or give directly or indirectly, a weight-loss pill toa person under 18 years of age. Weight-loss pill is defined as a pillthat is available without a prescription, which is marketed,advertised or packaged to indicate that its primary purpose is forfacilitating or causing weight loss. This prohibition includes, butis not limited to, pills containing ephedra species, ephedra alkaloidcontaining dietary supplements or Sida cordifelia. Penalties forviolations are provided.
Effective Date: July 1, 2004
CS/SB 1442 — Child Protective Investigations (CH. 2003-127)The child protective investigation process is modified by
this legislation. Of particular interest to physicians is the repeal ofthe requirement that complaints to the hotline by physicians,judges, etc. must be investigated. The process for acceptingreports for investigation is to be determined by the Department ofChildren and Family Services. Other changes include:authorization for the central abuse hotline to determine theresponse time for institutional child abuse rather than the presentrequirement that the response be immediate; removal of therequirement that Temporary Assistance to Needy Families non-compliance cases be referred for protective intervention;clarification of the directive to proceed with an assessment forchild-on-child sexual abuse reports; and, a prohibition fromamending the DCF operating budget to shift funds or positionsfrom protective investigations to other functions.
A study by the Office of Program Policy Analysis andGovernment Accountability is authorized to look at the impact thatavailab ility of services to families has on the turnover of protectiveinvestigators and on the families’ re-entry into the child protectivesystem. A Protective Investigative Retention Workgroup isestablished to address issues pertaining to the retention ofprotective investigators with a report to the Legislature.
Effective Date: June 10, 2003
(Continued next page <)Page 25
Legislative(= continued from previous page)
CS/CS/SB 1318 — Rilya Wilson Act (CH. 2003- )This legislation creates the Rilya Wilson Act which
requires children, ages 3 years to school entry, who have beenabused, neglected, or abandoned and who are enrolled in earlyeducation or child care programs as a result of being in the care ofthe State pursuant to court proceedings, to participate in suchprogram 5 days a week. The eligibility for school readinessprograms is modified to provide priority for these children.Reporting requirements are set forth to facilitate the quickidentification of children who are missing. A study is required toexamine the role of participation in licensed early education or childcare programs on ensuring safety for these children.
Effective Date:
CS/SB 2404 — Substance Abuse and M ental Health Services(CH. 2003- )
This legislation creates the not-for-profit Florida SubstanceAbuse and Mental Health Corporation, Inc., to provide oversightand policy recommendations for the substance abuse and mentalhealth systems. The corporation will have 12 members to beappointed by the Governor, the President of the Senate and theSpeaker of the House of Representatives. The corporation is to workwith agencies of state government to fully develop and integratemental health and substance abuse systems. A memorandum ofunderstanding is to be developed between the corporation and DCFrequiring the department to consider and respond to therecommendations of the corporation.
The organizational structure for the Department ofChildren and Family Services’ substance abuse and mental programoffices is modified to give these programs direct control of budgetsand contracts including line authority over district program staff.Additional modifications include authorization for the departmentto adopt by rule new payment methodologies that include fee-for-service, prepaid case rate and prepaid capitation contract paymentmechanisms for purchasing mental health and substance abuseservices. The rule is prohibited from increasing local matchrequirements.
S. 409.912, F.S., is amended to require the Agency forHealth Care Administration (AHCA) to seek federal approval tocontract with a single entity to provide comprehensive behavioralhealth care services to all Medicaid recipients in an AHCA area.Each entity must offer a sufficient choice of providers and mustinclude all public health hospitals. AHCA is further required tosubmit a plan for fully implementing capitated prepaid behavioralhealth care services throughout the state. Additionally, a plan mustalso be developed to implement new Medicaid procedure codes foremergency and crisis care, residential services and other services.
This legislation permits non-licensed direct care staff inday programs and intermediate care facilities for thedevelopmentally disabled to administer prescription medications.Training of designated staff by either a registered nurse or physicianis required, as are policies and procedures to ensure the safehandling, storage and administration of the medication.
The health care proxy statute is revised to provide for theappointment of a clinical social worker as a proxy in cases wherethe Page 26
incapacitated person has not appointed a surrogate, does not havea guardian or a living will, and has no person as provided in statuteto be a decision maker for him or her. The appointment of such aproxy must be made through the facility’s bioethics committee orin the absence of such committee, by the bioethics committee ofanother facility.
Effective Date: May 30, 2003
HB 195 — Emergency Medical Dispatch Act (CH. 2003-180) The Emergency Medical Dispatch Act is created by this
legislation which provides a statutory presumption of non-negligence for emergency medical dispatchers and agencies whenthe emergency medical dispatcher has been provided certaintraining and has followed protocols that are substantially similar tostandards developed by the American Society for Testing andMaterials or the National Highway Traffic Safety Administration.Participation in the Emergency Medical Services Grant Program isallowed for such dispatch services.
This legislation requires physicians, nurses, midwives,birth centers, hospitals, ambulatory surgical centers , or mobilesurgical facilities having custody of fetal remains following aspontaneous miscarriage after a gestation period of less than 20weeks to notify the mother of her option to arrange for the burial orcremation of the fetal remains as well as the procedures provided bygeneral law. The Department of Health must adopt rules for thedevelopment of forms to be used by the health care practitioner andthe Agency for Health Care Administration must adopt rules for theuse of facilities for the notifications and elections. Such forms mustbe provided to the mother by the entity having custody of theremains.
Effective Date: May 27, 2003
HB 457 — Indigent Care and Trauma Center Tax (CH. 2003-77)
Authorization for qualifying counties to impose and collectan indigent care and trauma center surtax is continued by repealingthe scheduled termination of this subsection of law. The clerk ofthe circuit court must prepare on a biennial basis an audit of theindigent care trust fund. Beginning February 1, 2004, the auditmust be delivered to the governing body and to the chair of thelegislative delegation of each participating county.
The definition of “rural hospital” is changed to providethat a hospital that received funding under the Medicaiddisproportionate share/financial assistance program for ruralhospitals prior to July 1, 2002, will continue to be a rural hospitalthrough June 30, 2012, as long as the hospital continues to meetcertain criteria. An acute care hospital that has not previously beendesignated as a rural hospital and that meets the criteria may applyto the Agency for Health Care Administrationfor that designation.
The legislation exempts, provided certain conditions aremet, rural hospitals from certificate of need requirements for newor replacement facilities.
The exemption from payment of an initial assessment forcertain infants delivered in a hospital will continue to excludeinfants born in a teaching hospital that have been deemed by theFlorida Birth-Related Neurological Injury CompensationAssociation since fiscal year 1997 to fiscal year 2001.
Effective Date: July 1, 2003G
(To be continued in next issue)
Advertising page
Add-a-Pearl...from Chuck Weiss
FROM WAR FRONT TO HOME FRONT - BetterBand-Aids
Despite the advances of superior detection ion devices,precision bomb guidance systems and other hi-tech gear for thefield of battle. Some of the biggest of advances may come in thefield of medicine.
Half of all combat fatalities stem from bleeding to deathon the battle field. However, new clotting products, bandages andwound dressings are being tested in hopes of reducing the numberof deaths from that cause.
Past military medical breakthroughs include vaccines formalaria and anthrax and early testing or the penicillin and otherantibiotics. This time the more important may be the innovationsin bleeding control. Some of the items and spin-offs of the devicesbeing used in Iraq may appear on your pharmacy/drugstoreshelves.
QUICK CLOT(A granulated powder of mineral zeolite)
HOW IT W ORKS: Like a sponge and absorbs water andplasma, leaving behind the materials that can clot blood quickly.This salt-like substance was developed for military use inconjunction with the U.S. Navy's Office of Naval Research, theU.S. Marine Corps Systems Command. Quick Clot was approvedby the U.S. Food and Drug Administration last year for severebleeding injuries. It was first used during the war in Afghanistan,and is now in Marine first-aid kits in Iraq.
CONSUMER versions of QuickClot should be ondrugstore shelves by August 1 and be in 20,000 stores by the endof the year. . . . A small packet, which will contain more than onedose for minor injuries scrapes and cuts will cost about $10.00. Italready has been distributed to emergency personnel.
HemCon BandageHOW IT WORKS: a four-inch square bandage is coated
with a protein from shrimp shells that causes blood cells to clumpand form clots. The bandage, developed with support from theArmy was approved by the F.D. A. to control severe bleeding andis in battle field tests at present.
CONSUMER Outlook: Presently available byprescription for $139, and emergency personnel are next on the listas soon as military demand is met. Smaller, less costly bandages,intended for first aid kits, and a bandage for internal medicine isscheduled for later sale.
RED CROSS WOUND DRESSING
HOW IT W ORKS: The four-inch-square wound dressing,coated with the plasma-clotting proteins fibrin and thrombin is stillin early trial phase. Army and Special operations forces use theproduct in Iraq as part of clinical trials to treat severe injuries.
CONSUMER outlook: Although FDA approval ispresently expected no predictions for civilian uses are available.When available, cost would likely be in the range of $1,000.
Page 28
RDH BANDAGEHOW IT WORK S: A four-inch square bandage, coated
with a micro-algae polymer, attracts platelet and red blood cells tospeed up clo tting. The Rapid Deployment Hemostat, developedthough a grant from the Office of Naval research is designed towithstand extreme temperatures and for easyportability. It is a battle field variation of the Syvek Patch, adressing with the same clotting agent. It was approved by the FDAin 1997.
CONSUMER outlook - The ‘seaweed bandage' costsabout $100 and is used mostly in trauma situations at hospitals. By2004, smaller and less-expensive variations may become available.
SONOSITE 180 AND 180 PLUSHOW IT W ORK S - Hand -held portable ultrasound
devices allow surgeons to detect internal bleeding, basic heartmotion and internal objects such as shrapnel. These devices,developed with assistance from the Defense Research P rojectsagency, or Darpa* and the Office of Naval Research, wereapproved by the FDA in 1997.
CONSUMER Outlook - The costs are not minuscule,$30,000, but they are in hospitals nationwide.
TERASON PROBEHOW IT W ORK S : An ultra sound device, when hooked
up to a laptop or computer, acts as a portable probe that can viewimages and detec0t internal injuries, was developed with fundingfrom Darpa*.
CONSUMER outlook - Has been used in hospitalsnationwide to identify tumors, fetuses and hearts since early 2000.Cost $26,000.
LIFE SUPPORT FOR TRAUMA AND TRANSPORTHOW IT W ORKS: An entire intensive-care unit is
miniaturized to fit in a five-inch platform underneath a stretcher.The units, which were developed with support from Darpa*, sawaction in Kosovo and are in Iraq.
CONSUMER Outlook - Integrated Medica Systemsexpect the $165,000 units in the next several years to be used intrauma rooms when hospitals are over capacity and extra intensivecare beds are needed . It also expects use in transferring patientsbetween hospitals and in emergency-trauma situationssuch as highway accidents.
[This article was edited from the original in an attempt to avoid specificreference to any specific company or manufacturer. The purpose of editingwas to also attempt to avoid endorsement of any product. The originalentitled, "Medical Advances Follow a Path from War Front to HomeFront" was originally published in the Wall Street Journal, April 22, 2003.It was reviewed as a continuing medical education effort in keeping withthe purpose of the FPS/FCAAP Newsletter. The reviewer presents nopersonal views.]
President(= continued from page 3)
As I begin my tenure as your President, I’m reminded of the wordsstated in the FCAAP mission: to promote the health and welfareof Florida’s children and support and promote the pediatrician asthe best qualified provider of their healthcare. Though we aspediatricians have managed to forge paths to excellent healthcarefor all American children, there is still much room forimprovement. The following areas still pose significant challenges.
First, we must facilitate better access to care for children and theirfamilies. Most people in our country believe that all Americansshould be given access to a system of healthcare that is efficient,practical, and non-wasteful, but many of our citizens are being leftbehind and are unable to access a healthcare system they mightdesperately need. Although many Americans believe that societyhas the obligation to provide access to care for every citizen andthat each citizen should compensate for those services in someway, be it through insurance or healthcare programs or othermeans, the unfortunate truth is that thousands of Americans are stilluninsured and underinsured and not receiving appropriate andefficient healthcare.
Simply ensuring that every American is appropriately insured orenrolled in a healthcare program won’t completely solve theproblem. To effectively hit the problem head-on, all necessaryprimary care and specialty services must be adequately distributed;community-based healthcare infrastructures must be designed andimplemented to deliver, coordinate, and integrate services; andculturally aware and competent providers must be available toaddress the unique needs of their diverse populations.
Most importantly, we must listen to and involve those who knowthe most about accessing the healthcare system – the patients andfamilies who use our services. Although it is very easy to discussand debate policy and ultimately decide on a solution that we thinkis right for others, it is my opinion that communities should beinvolved from the start. I believe that to create a robust nationalvision, answers and solutions must be solicited from localcommunities first. Only then can we develop a clear and focusedunderstanding of how best to tackle this issue.
Another challenge facing us today is re-thinking and improving thequality of care we are providing for our patients and their families.There is a startling lack of consistency. Various studies have shownthat there is a considerable gap between the care we think we’readministering and the care actually received by our patients.According to NICHQ, children and families report that care they’rereceiving is not “well-coordinated”, and most alarmingly, that“communication and support” are not meeting their definition andexpectations of quality pediatric healthcare. Putting ourselves inthe place of our patients and their families and looking at thehealthcare system from their perspectives may help us listen totheir needs better. We need to always remember that there arecountless other things a child would rather do than see a doctor.
An ideal environment, as stated by NICHQ, would be evidence-based, responsive to the needs of children and families, and wouldresult in excellent outcomes. As pediatricians, we have theresponsibility to do our best to provide superlative care to thechildren and families in need of our help. And we have theresponsibility to ensure that care is delivered in a consistent,reliable, and effective manner.
Our next challenge involves facilitating great changes in healthcareon a national scale. In conjunction with the Wye River Group
Project, entitled “Communities Shaping a Vision for America’s 21st
Century Health & Healthcare” and several other like-mindednational organizations, the FCAAP will endeavor to improvehealth and healthcare in the United States by addressingdeficiencies in our current system, protecting and preserving itsadvantages, and working toward constructive change. The WyeRiver Group project will not only involve public policy groups andnational experts, but also the community, who will offer advice andopinions through a series of “listening sessions.” By targetingselected communities around the nation and meeting with localopinion leaders to gain a better understanding of each community’sunique cultural aspects and healthcare system dynamics, we hopeto develop an agenda that goes far beyond politics and sectorcompetition and fosters positive change in the American health andhealthcare system.
Finally, another task we need to accomplish is to invite morepediatric subspecialists into our ranks. A recent NACHRI studyfound that “a shortage of pediatric subspecialists during the nextdecade may become the number-one strategic and operational issuefacing children's hospitals” and a study in PEDIATRICS found that“pediatric subspecialists (report) levels of stress and burnout thatraise significant concerns” for the future pediatric subspecialistworkforce. Since 1986, the proportion of pediatric residentschoosing advanced training has declined from 33 percent to 21percent – mainly due to managed care's focus on primary care,which has guided reduced support for specialist fellowships andreduced reimbursement income for specialists. As a result,physicians within specific subspecialties are predicted to "age-out"within the next 15 years. Thus, it is extremely important to seekmore pediatric subspecialist involvement in the FCAAP andwelcome their views and opinions.
I consider it a privilege to serve you as President. There are greatchallenges to face in the next two years, and we will meet thesechallenges together. As leaders in pediatric healthcare, we havebeen given an extraordinary responsibility. We have been entrustedwith the rare honor and gifts to advance and improve the health andwell-being of children, in the state of Florida – and given ourgeographic location even the international community. Thougheach of us has gathered individual accolades and accomplishments,we should never lose sight of the fact that we work for the mostvulnerable and the most wonderful members of our population –the infants, children, adolescents, and young adults who come tous seeking help, with hope in their hearts and faith in our abilities.
With sincerest regards,
Deborah Ann Mulligan-Smith, MD FAAP FACEP
Page 29
Region 8( = continued from page 6)
encouraging young families to read to their infants and children byproviding books, brochures, and other reading materials in doctor’soffices and other accessible areas. The program also provides appropriatebooks as gifts for children and their families, and recruits mentors to readto children. This is an exciting new program in Florida with potential,significant impact on the development of a very fragile population ofinfants and children.
This past fall, Dr. Charles R. Bauer gave a presentation to thePediatric Residents in training at the University of Miami-JacksonMemorial Medical Center regarding the goals and advantages ofmembership in the Florida Pediatric Society and the Florida Chapter ofthe American Academy of Pediatrics.
Dr. Kimberly Schwartz welcomed Jonah, a healthy baby boy,into the family in July 2002. Mother and son are thriving, as is District8.Submitted by: Charles R. Bauer, M.D.
District 8 Representative (retired)
Chairmen(= continued from page 7)
principles. Currently, our students have a written examination that mustbe passed after completing both the hospital and ambulatory pediatricrotations. In the future, this examination will be modified to incorporatethe subjects presented in these web-based areas.
The most exciting event to occur this year is our approval tostart a new pediatric residency at Palms West Hospital. The firstresidency class will begin training July 1, 2004. The new program atPalms West Hospital was established to provide training for new primarycare pediatricians in both a general ambulatory pediatric practice and thecare of hospitalized pediatric patients. The program was developed tomeet the special criteria of a “Fast-Track” training program. A “Fast-Track” program meets the unique licensure requirements needed forosteopathic physicians in many states that require a physician to havecompleted a traditional internship prior to applying for a license topractice. After completion of the three-year pediatric residency, theresident will be considered to have completed both an internship and apediatric residency in the three-year time span.
I look forward to the academic year that is about to begin. Thistime next year, I will be able to report on the events of the 2003 – 2004academic year, and the beginning of our new postgraduate program.
Risk ( = continued from page 17)
regard to each, there is recognition that the patient’s right to know andchoose may be outweighed by other considerations. These categories areemergency, therapeutic privilege, patient waiver, and governmentalaction.Emergencies
It is generally recognized that emergencies may create situationswhere it is often impractical to obtain the consent of the patient or thepatient’s legal representative. In situations where a patient is unable toprovide consent and the representative cannot be reached in a timelyfashion, the physician may proceed to administer medical therapy. Thelaw recognizes an implied consent in these circumstances and it appliesequally to both adults and children. However, some difficulty does arisein determining when an emergency exists.Therapeutic PrivilegePage 30
As noted in the landmark decision: “It is recognized that
patients occasionally become so ill or emotionally distraught on disclosureas to foreclose a rational decision, or complicate or hinder the treatment,or perhaps even pose psychological damage to the patient” Where that isso, the cases can be interpreted to provide a physician with a privilege tokeep information from the patient. However, a critical inquiry is whetherthe physician responded to sound medical judgment that communicationof the risk information would present a threat to the patient’s well-being.
As explained in this case, the therapeutic privilege is thought ofas being applicable where the patient’s condition is such that fulldisclosure of information would significantly worsen the condition. Thecases that have discussed this issue are in disagreement as to whether thespouse or next of kin must be provided the full disclosure when it iswithheld from the patient for therapeutic reasons. It would seem that theprudent course would be to give the spouse, next of kin, or patient’srepresentative the full disclosure that would have been presented to thepatient.
One final caveat is in order with regard to this privilege. Itshould not be utilized if the physician is only concerned that the patientwill not agree to the procedure if a full disclosure is provided. The patienthas the right to choose and only in those circumstances where thecondition would be significantly worsened should this exemption beconsidered.Waiver
A third recognized exception is a waiver by the patient. If anadult patient insists upon not being informed of the nature of the procedureor risks attendant to it, then the patient relieves the physician of theobligation to obtain an informed consent.
Obviously, if a patient has the right as a competent adult todemand information upon which to make a decision, the patient also hasthe right to forego receipt of that information. However, the exception isfraught with danger. One can easily envision a situation where a patientprovides a waiver and later claims, upon the occurrence of a complication,that a waiver would never have been signed if the patient had known ofthat particular risk.
The physician, in most instances, is unprotected in thiscircumstance. As a result, it is recommended that the physician not relyupon a patient waiver and instead obtain the informed consent of thepatient. The one exception might be where the therapeutic privilege isinvolved. If the physician realizes, after consulting with the patient, thata full disclosure would actually increase the risks of danger to the patient,the physician would be on firmer ground in accepting the patient’s waiver.In all such circumstances, the waiver should be completely documentedand the form signed by the patient.
One practical concern in this regard is that the physician shouldnot be the one to recommend a waiver of information. The physician is ina fiduciary relationship with the patient and, as such, the courts willimpose upon the physician a duty to protect his/her charge. If thephysician has been the one to suggest the waiver and the patientcomplains, a court or jury might hold that the physician’s suggestion wasoverreaching and in violation of their position of trust.Governmental Action
Courts have recognized the rights of the state in somecircumstances to have a medical act accomplished in spite of a lack ofconsent or even refusal by a patient. In these circumstances, public interestoutweighs the right of the individual. Physicians most commonlyexperience this in civil or criminal cases where the court has ordered anexamination of a patient. Even in this circumstance, however, thephysician should endeavor to provide the appropriate information to thepatient. If the patient refuses to consent, the court order is sufficient toallow the procedure. On the other hand, if the patient actively resists sothat harm may result, the physician should refer the matter back to thecourt.
In addition to court orders, state statutes may authorize medicalacts without patient consent. For this reason, seek risk management orlegal guidance whenever uncertainty may arise.[Information in this article does not establish a standard of care, nor is it asubstitute for legal advice. The information and suggestions contained here aregeneralized and may not apply to all practice situations. FPIC recommends youobtain legal advice from a qualified attorney for a more specific application to yourpractice. This information should be used as a reference guide only.]
Managed(= continued from page 15)
More from the AAP(= continued from page 19)
autism. < The authors claim falsely that children in the United States in 2003 may
be exposed to higher levels of mercury from thimerosal contained inchildhood immunizations than any time in the past, when in fact, allroutinely recommended infant vaccines currently sold in the UnitedStates are free of thimerosal as a preservative and have been for morethan 2 years ( www.fda.gov/cber/vaccine/thimerosal.htm#1 ). No scientific data link thimerosal used as a preservative in vaccines
with any pediatric neurologic disorder, including autism. Despite this, the Centersfor Disease Control and Prevention, American Academy of Pediatrics, NationalInstitutes of Health, and US Public Health Service have continued to investigatethis issue to put theoretic concerns about this mercury-containing compound torest. Thimerosal continues to be used widely as a vaccine preservative in manyother parts of the world where economics and sanitation concerns mandate aneffective means to safeguard vaccines from contamination when stored in bulk inmultidose vials. Any scientific article that can prove a thimerosal link to significantadverse events in children must be published in respected and widely read journalsbecause of the great general interest today in vaccine safety. These journals can beexpected to apply the highest standards of critical peer review to the results of anyresearch that purports the existence of these associations and claims of causality.1. Geier MR, Geier DA. Thimerosal in childhood vaccines, neurodevelopmentdisorders and heart disease in the United States. J Am Physicians Surg.2003;8:6-11 2. Institute of Medicine, Immunization Safety Review Committee. ImmunizationSafety Review: Thimerosal-Containing Vaccines and NeurodevelopmentalDisorders. Stratton K, Gable A, McCormick M, eds. Washington, DC: NationalAcademies Press; 2001 3. Nelson KB, Bauman ML. Thimerosal and autism? Pediatrics. 2003;111:674-679
Posted May 16, 2003
Primary Care Disclaimer:
Patient Last Name: __________ _________________________________
Patient First Name: _________________________________
Preparticipation physical exams cannot guarantee or accurately predict thatyour child is risk free. It is well known and understood that certain sportsproduce injuries and that some cardiac anomalies may be present even with“normal” results from a routine screening test. Therefore, normal results fromroutine screening tests should not be interpreted as indicating that he/she is freefrom risk or that all potential cardiac anomalies have been ruled out.
I have read and agree with the above statement.
Signature Relationship to Patient Date
Cardiology Disclaimer
Patient Last Name: _________________________________
Preparticipation cardiovascular evaluation cannot guarantee or accuratelypredict that your child is risk free. It is well known and understood that certainanomalies may be present even with “normal” results from examinations,electrocardiograms (EKGs), cardiac ultrasounds (Echocardiograms), and othercardiac tests. Therefore, normal results from the various tests that your childtakes should not be interpreted as indicating that he/she is free from risk or thatall potential cardiac anomalies have been ruled out.
THE FLORIDA PEDIATRICIAN will publish Upcoming Continuing Medical Education Events planned. Please send notices to the Editor as earlyas possible, in order to accommodate press times in February, May, August, and November.
Program: Practical PediatricsDates: August 29-31, 2003Place: Seattle, WashingtonCredit: Hour for hour (up to 16.5 hours), for Category 1 for
AMA Physician Recognition AwardSponsor: American Academy of PediatricsInquiries: American Academy of Pediatrics, (800)433-9016, ext
6796 or 7657
Program: Practical PediatricsDates: October 10-12, 2003Place: Toronto, Ontario, CanadaCredit: Hour for hour (up to 16.5 hours), for Category 1 for
AMA Physician Recognition AwardSponsor: American Academy of PediatricsInquiries: American Academy of Pediatrics, (800)433-9016, ext
6796 or 7657
Program: Practical PediatricsDates: November 14-16, 2003Place: Tempe, ArizonaCredit: Hour for hour (up to 16.5 hours), for Category 1 forAMA Physician Recognition AwardSponsor: American Academy of PediatricsInquiries: American Academy of Pediatrics, (800)433-9016,
ext 6796 or 7657
Page 32
The Florida Pediatrician c/o USF Department of Pediatrics12901 Bruce B. Downs BoulevardMDC Box 15CETampa, FL 33612
Program: Practical PediatricsDates: December 12-14, 2003Place: San Antonio, TXCredit: Hour for hour (up to 16.5 hours), for Category 1 for AMA
Physician Recognition AwardSponsor: American Academy of PediatricsInquiries: American Academy of Pediatrics, (800)433-9016, ext
6796 or 7657
Program: Practical PediatricsDates: January 15-18, 2004Place: Keystone, COCredit: Hour for hour (up to 16.5 hours), for Category 1 for AMA
Physician Recognition AwardSponsor: American Academy of PediatricsInquiries: American Academy of Pediatrics, (800)433-9016, ext
6796 or 7657
Program: Hematoopoietic Growth Factors and Specific AntibacterialAntibody Preparations in Neonatology
Dates: October 7-9, 2004Place: Coronado Springs Resort, Orlando, FLCredit: To be announcedSponsor: University of South Florida and All Children’s
HospitalInquiries: Continuing Professional Education, (813)974-4296
