|
|
| News Update May 1999 | |
Environmental Health Committee By Mark Miller, CoChair The Food Quality Protection Act (FQPA), passed unanimously by Congress in 1996, is an important new law that for the first time explicitly protects infants and children by setting health-based standards for pesticide residues in food. It was motivated in part by a National Academy of Sciences report which found that the current regulatory process for pesticides did not account for children’s differing exposures and vulnerabilities. The U.S. Environmental Protection Agency is now reassessing its pesticide tolerances (allowable residues on food) to comply with the FQPA. The FQPA incorporates four major child-protective provisions in the setting of pesticide tolerances. These include: 1) An explicit requirement that EPA assure a “reasonable certainty that no harm will result to infants and children” from exposure to pesticides; 2) Consideration of the cumulative effects of chemicals with a common mechanism of toxicity; 3) Consideration of aggregate pesticide exposures from multiple sources; 4) In the absence of complete and reliable data on fetal and children’s exposure and toxicity to pesticides an additional safety factor (10-fold) be applied to the level allowed in food. Currently little data exists on children’s exposures to pesticides at home or in schools. Most of the tests performed on pesticides don’t look at the effects of the chemical on children. Despite these data gaps less than 10% of EPA decisions under FQPA have required the full 10-fold safety factor be used. Child health advocates are encouraging full implementation of the act, including the extra safety factor for children. Routt Reigart MD, FAAP testified before the U.S. Senate, representing the AAP in support of the FQPA, “ It is my own view... that many families and physicians are very concerned that there is so little information regarding the safety for infants and children of pesticides in our food.” “ The American Academy of Pediatrics believes, given the available information on the risks of pesticides in the diet, that it is prudent to recommend that infants and children be provided a diet rich in fruits and vegetables. No known risk from pesticides presently outweighs the benefits of this healthful diet. At the present time it is clear that it is not possible to state that pesticides have been evaluated for safety to children and their special needs”, said Dr. Reigart. Prior to the passage of the FQPA the industry was not required to provide data on the effects of pesticides to the central nervous system, immune system, or other immature systems in the developing organism. Pesticides, many of which are known neurotoxins, have never been shown to be safe for the developing nervous system. Data is often lacking on children’s total exposures from various sources. A child’s diet contains more fruits and vegetables than an adult’s does. For example, infants consume about 20 times more apple products than adults do. Even if a pesticide in apples had the same effect on a child’s developing nervous system as an adult, his or her risk after a 10-fold safety factor would still be double that estimated for an adult. “They [pediatricians] would like to be able to say, without qualification, “Your infant or child should eat a diet rich in fruits and vegetables. You need not be concerned about hazards of pesticides in your selection of fruits and vegetables for your child”, testified Dr. Reigart. Pediatricians’ voices are important and it will be important for your representatives in congress to hear from you in support of this issue. By Tom Long, President I have said it before and indeed it seems trite. Yet, “Life is a Journey.” I have thoroughly enjoyed these last two years as your Chapter President. It has been a privilege, which I never anticipated. I have come to feel much more connected to our American Academy of Pediatrics. Coming to know so many dedicated pediatricians and unnamed but crucial and committed support staff renewed my energy and resolve many times during my tenure. I will always be proud of our continued recognition for Chapter excellence. But nothing compares with some of the work we’ve started and which still remains unfinished. The harvest still awaits us. Our committee members answered my challenge to take up a definable task. In keeping with the law of the farm, there is still more work to do. Dr. George Monteverdi has stirred the School Health Committee to new life with statewide appeal. Cathy McDonald and now Seth Ammerman have taken us to a more credible level of advocacy for our patients in the world of tobacco and substance abuse. Our Behavioral Pediatrics Committee continues to study the impact of behavioral problems on the classroom. And we continue to explore the role of the pediatrician in the neighborhood school. Our legislative activities brought results vis-à-vis Medi-Cal for the first time in years. We saw the evolution of Healthy Families. I hope that this year’s representatives to the Academy’s Legislative Training Program in Washington, DC will come home charged up to help us deliver our pediatric message in Sacramento. Mika Hiramatsu organized a telephone hot line call in service at the time of the National AAP meeting here in San Francisco. Mark Simonian is our webmaster whose talents have also been noticed at the level of our national organization. The Member-at-Large Chapter Update is a vehicle to keep our Board members current between meetings. Mary Jane Pionk and Myles Abbott, with the assistance of our Education Committee, have continued to develop outstanding annual programs. Service, communication, education are keys to our success. None of this could happen without the resources, understanding, and tireless efforts of our Chapter Executive Director, Beverly Busher. Special thanks are due to so many of you. To each and all, you have my sincere gratitude. I know Paul Jewett, the next Chapter President, will be equally inspired. While it is too soon to reap our rewards, there are still more seeds to sow. We have been working to raise the awareness of our members about CATCH. Yet I am afraid that the prospects of sponsoring or directing a grant project is overwhelming many of you. I believe there is an identifiable project in each and every community. Who better to take up a cause for children than a community pediatrician? We recently met with Arnold Gold, our Chapter 1 CATCH facilitator, and Steve Barrow at the Sierra Foundation Offices in Sacramento. Steve identified resources to help us mobilize pediatricians locally for the benefit of their own communities. Would you like to get trained? Have you got a project in need of a leader? Let us know. Life’s journey takes many twists and turns. We look around every bend carefully picking our way, but looking back what will we see? When the path is out of sight, will we know that we left it a little better than it was before? I look forward to serving children and my pediatric colleagues in some new way. I hope each of you will find your niche in a Chapter project. You cannot put a hand on the plough and look backwards. I also look forward to seeing many of you at our Monterey meeting on Memorial Day Weekend – a true potpourri experience. A few topics include Holistic Medicine, Dermatology, Infectious Disease, and Orthopedics. Come to a great family dinner. Be sure to attend our Annual Business Meeting on Sunday morning, May 30th. We would like to share first hand our many Chapter projects with all of you. Try our web page (www.aapca1.org). Sign up on line. I hope you’ll be there too. By Paul Jewett It looks like spring has finally come, and soon it will be time for our Annual Monterey Meeting. The Educational Committee has done an outstanding job selecting speakers as usual and I hope you are planning to join us again in Monterey. Not only is this an important educational session, but it also affords time for you to discuss your concerns at our annual business meeting. This year the legislative agenda in Sacramento is rather hefty and includes bills on several issues of interest to Pediatrics. Come and learn what are the legislative priorities for our Chapter and District. MICRA, Healthy Families implementation, vaccine compensation, Medi-Cal and Healthy-Families reimbursement rates, and Gun Safety (trigger lock legislation) are the top priorities that have been chosen at the District level. Do you agree or are there other issues you would like to see tackled? Soon the Millennium will be upon us. Are you ready as the Internet ads say? Have you looked into the Y2K (Year 2000) compatibility of your office computer systems, especially billing and appointment systems? Any office equipment with a chip in it should be evaluated. Your hospital administrative folks may be useful in helping decide if any of your office equipment has issues, e.g. oxygen monitors, infusion pumps, EKG machines, etc. Some hospitals around the country are making contingency plans for staffing during late December and early January – has the need for this planning been considered at your hospital and in your practice? Hopefully Y2K is more hype than a real disaster in the making, but prudent planning is still in order. Ballots are in the mail giving us a chance to vote for the new president-elect of the National AAP. We heard both candidates speak at a recent District meeting. Both Dr. Berman and Dr. Sia are extremely well qualified for the role. They can bring different skills, strengths and interests to bear on the job. Dr. Berman has a strong background in Health Care Finance issues. Dr. Sia has had a remarkable career in community service in his home state of Hawaii and has exemplary skills in coalition building and motivating people to come together on community projects. The Academy is indeed fortunate to have two strong candidates, either of whom could easily provide the leadership needed going into the new century. Take some time to read their statements in the AAP news and vote. Finally let me say how much I have enjoyed working with Tom Long, our Chapter President the past two years. He has done an outstanding job setting the direction for our Chapter and supporting your efforts at doing all that you do to promote better health and care for Children. His enthusiasm for and admiration of your efforts at making our Chapter one of the best in the country have been obvious and infectious. Most recently we met with the Sierra Foundation to open an initiative to provide help and training for Pediatricians in our Chapter who are interested in writing grants for CATCH or other funding sources that can help you start projects in your local communities. We hope you will take advantage of this opportunity for free training if you have an idea how to better provide service in your area. Tom has a strong interest in school health, and we plan to continue supporting efforts to get Pediatricians involved with the schools in their area. I know I will continue to benefit from Tom’s advice and knowledge over the next two years as I enter my term as President. See you in Monterey and best wishes for a wonderful spring and summer. First, here is the good news. Effective February 15, the firm of California Advocates and principals Peter Kellison and Robert Walters assumed lobbying duties for the California AAP District. This experienced and well-respected Sacramento based firm represents a breadth of clients ranging from architects to educators to manufacturers to law schools and judges, and we look forward to our association. For the not so good part, given the limitations of our budget and the reality that we cannot afford to monitor all the bills and legislative issues which might be relevant to children and pediatricians, our District Board and State Government Affairs Committee set priorities which limit our active involvement to bills addressing five major issues. We currently are addressing the following issues as priorities:
Then, there are the postscripted crucial issues of child care, vaccine carve out, school bus seat belts, early brain development, and child mental health parity which cannot be forgotten. By press time, there may be another 3 or 4 issues not even included above, some of which might potentially displace our previously agreed upon ranking. Fortunately, we have built strong coalitions with California Children’s Lobby, the California Medical Association, and other groups which may become more actively involved than the District in lobbying issues still of great concern to the District. It promises to be yet another busy legislative session, with many new legislators as well as a new gubernatorial administration needing much education about child health issues. As our new lobbyists address some of these issues, let’s not forget our individual responsibility to communicate with our state and federal legislators and to help them to be better informed on child health issues. Before you take your legislator to lunch, phone the District office to discuss protocol if you wish to represent the AAP, and request information on your legislator and relevant bills, which he/she may have introduced. Phone the national AAP’s DC office and request copies of the new packet of “white papers” on important child health topics. You may also want to request a copy of the Government Affairs handbook, which gives an excellent overview of the legislative process, as well as impressive discussions of lobbying and advocacy. Look at term limits as an opportunity for pediatricians to do a better job of education for legislators – every two years. Let your Chapter President know if you’re interested in becoming more politically active, and help will be forthcoming from the AAP to assist you in becoming a well-informed and effective key contact. If you’re already involved, let your Chapter President know your areas of interest, and keep up the good work. By Jeff Berman Telemedicine is one of the most difficult and confusing areas with which to deal. The AAP Committee on Medical Liability (of which I am a member) has reviewed this issue for the last three years. Recently the Health Care Financing Administration (HCFA) has decided to pay for telemedicine exams in rural areas for the Medicare population. Of course, we all know that whatever happens to Medicare eventually happens to Medi-Cal in our state. Many of us are using telemedicine every day. Some feel that a consultation over the telephone is telemedicine. I use it frequently to contact specialists at UCSF Department of Pediatrics or the Lucile Salter Packard Children’s Hospital at Stanford. It is much easier for me to send messages over the Internet, via e-mail, than to chase people around on the telephone. The broadest definition of telemedicine is the best one in my opinion. The American Telemedicine Association (ATA) describes telemedicine as “the use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or the health care provider for the purpose of improving patient care.” Unfortunately HCFA’s definition is very narrow. Their definition involves real time communication, real time video and imaging equipment, which allows the consulting physician (off-site) to examine patients while in contact with the on-site physician and the patient. At the present time this is what will be paid. In addition, the way they are paying for Medicare is one payment. Of that payment 75% would go to the specialist and 25% would go to the primary care physician. They envision paying the specialist who will kick back to the primary care physician 25% of the fee. This of course has many complications, including being against the law in California. HCFA’S conceptual paradigm is that the patient would be transported to the specialist. I strongly disagree with this approach. As a primary care physician you and I will be responsible for the patient, the patient’s medical record, the video tape, making sure that informed consent has been obtained from the patient, that the technicians who run the equipment have confidentiality, etc. In other words, no matter what happens, the responsibility will fall on the primary care physician to set up the telemedicine conference and not the specialist. The only other academy that agrees with this position at the present time is the American Academy of Family Practice. The ASIM-ACP and ACOG presently do not have a position on this, and in essence, the ATA has no position on the paradigm either. State licensing is a major issue. The only way to have some type of disciplinary control over the physician giving the advice and the physician accepting the advice is for state licensing to occur. There are four different options. One, most states at the present time are requiring full licensure in order to practice telemedicine in that state (28 states presently). Two, national licensing is a possibility. I oppose this because every state has its own requirements and its own needs. The third possibility is the consultation, which goes on presently. The fourth possibility, which I feel is the most acceptable, is partial licensing. This is the position of the Federation of State Medical Boards (FSMB). Partial licensing would be easy to accomplish. The consultant could have a license to practice in the state where he is presently located, he could be a member in good standing, and hopefully he could have a reasonably good record for the national data bank. Hospital credentialing would also be an issue because at times a consultation could take place in the hospital, your office, the ER, a skilled nursing facility, or an outpatient surgical facility. Confidentiality is almost as big an issue, in my mind, as licensure. We have to remember how this will work. The patient must understand that when the interview takes place there will be technicians in the room who know very little medicine. In addition, it is possible that the video image will be sent through a control station to the specialist. There will be technicians in that control station and they must be sworn to confidentiality. There will be a medical record, which you, the primary care physician, will be responsible for, and probably some type of videotape record. All of these must be kept confidential. Finally, malpractice is a major issue for the practicing pediatrician. Let us assume that the specialist is in Ohio and you are in California. Ohio does not have a MICRA law as we have in California. According to the Center for Telemedicine Law, it is possible to have a malpractice action take place both in California and/or Ohio. How will your malpractice carrier look on this issue? My guess is they will have a rider on your policy and some type of blended rate. This blended rate could be very expensive. Technology for telemedicine is very expensive at the present time. It requires a very broad band (able to transfer large amount of data quickly), which essentially requires fiberoptics and a T-1 line. These lines are expensive to install and maintain. HCFA refuses to pay this cost. I doubt most of us will be able to afford telemedicine equipment in our offices, and the equipment is presently too expensive for most rural hospitals. In the future though, 10-15 years from now, telemedicine will probably take place via satellite. In essence, these are some of the major issues concerning telemedicine. If you have any questions please give me a call at (831) 422-9001 and I would be glad to talk to you. For Your Immediate Action and Attention Forwarded by George Monteverdi The announcement reproduced below appeared in a message to County Medical Society Executives and Specialty Society Executives at the beginning of the New Year from the Special Legislative Assistant/Political Liaison counsel of the California Medical Association. The County Commissions described will be appointed no later than May 1999. Regretfully, this announcement is late but please investigate any opportunity you as a pediatrician may have to serve in this capacity. Your local medical society or specialty organization may be your best source of information and support. Announcement Regarding: Implementation of Proposition 10 State and County Commission Appointments With the passage of Proposition 10 in November, came the creation of a nine member California Children and Families First Commission and the ability of counties to establish their own Children and Families First commissions. The effective date of the initiative is January 1, 1999. Proposition 10 established a new 50 cents per pack tax on cigarettes. It is estimated that the revenues from this tax will be $700 million per year. This initiative has created an excellent opportunity for organized medicine around California to have a significant impact in the development of programs at the local level, which will improve the health of children who do not currently have access to medical services. Organized medicine has the opportunity to be heavily represented on the commissions created by this initiative. Specifically, the state medical association, county medical societies and the state medical specialty societies have been identified as those groups from which some members of the state and county commissions must be selected. Medical specialty groups identified include public health, pediatrics, obstetrics, behavioral health specialists (psychiatry) and would extend as well to family physicians, who are not specifically identified, but provide many of the above noted services. Action Requested: If you have not already done so, now is the time to start identifying physicians within each of your organizations who could represent medicine on the commissions. You may also want to contact your County Board of Supervisors to let them know you want to be involved and will be forwarding physician nominations for their consideration. It will take some time for start up, but you need to be prepared when each of your counties decide to create their own commissions, which they may do after January 1, 1999. Every Chapter, District and the National AAP must track membership information including address, participation and dues. In an era of increasing information there are expectations that the Academy and its affiliate Chapters are successfully coordinating and updating our data regularly. Unfortunately every Chapter has adopted different methods of maintaining and communicating their own membership information. Inconsistencies in the process has led to misinformation and delay, so a task force of representative Chapters has met to develop a standard interface to upload information and create accurate reports for the Chapter membership. The Internet and the World Wide Web will be used as the medium to collect and distribute information in a secure system that all will find easier to use. Analysis will be done daily so the information will continue to stay current. The first model application was available at the Chicago Spring Meeting and a working program is planned at the Chapter Forum in September 1999 so that Executive Directors can view and comment on the interface and reporting features. As a member of the task force I have had a chance to express our unique issues. We will be the first beta site for the implementation of this new tool. The website implementation for the entire membership should be released in early 2000. Neurofibromatosis 1 – Old and New By Ronald Bachman Neurofibromatosis 1 (NF1), one of the most common genetic disorders (1/4000) is frequently not diagnosed because of mild symptoms, but rarely can have devastating symptoms. Early diagnosis is important in order to prevent severe complications. NF is inherited as an autosomal dominant condition, so there may be a positive family history. If affected, there is a 50% risk for each offspring. The degree of severity is variable within families. On the other hand, an affected child may have no family history of NR1. This “new spontaneous mutation” occurs in 50% of affected children. The gene for NF1 is located on the long arm of chromosome 17 (band q11.2), and gene sequencing can be done (with difficulty). No easy molecular test has been developed because it seems that each family has its own specific mutation within the gene. The clinical diagnosis of NF1 is based on two or more of the following features: (1) 6 or more café-au-lait spots ( 1.5 cm in postpubertal and 0.5 cm in prepubertal) (2) Two or more neurofibromas of any type or one or more plexiform neurofibroma: (3) Axillary or inguinal freckling (4) Optic glioma (5) Two or more Lisch nodules (iris hematoma) (6) Congential bone defects (sphenoid bone dysplasia, bowing of long bones) (7) A first-degree relative with NF-1. Sometimes a child has only one of the above findings, and other features may become apparent later. Clinical management of a child with NF1 (or possible NF1) is not complicated and is well described in an article entitled “Health Supervision for Children with Neurofibromatosis” (Pediatrics, 96:368, 1995). Health supervision should include: 1. Skin evaluation for neurofibroma – most neurofibromas require no attention unless they are growing rapidly. 2. Eye evaluation by an ophthalmologist – optic pathway tumors occur in 15% of NF1 individuals. The risk for these decrease after age 7. 3. Hypertension – do blood pressure on each pediatric visit. 4. Monitor for learning disabilities – Attention Deficit Disorder with or without hyperactivity is common (40-50%). 5. Monitor for symptoms of CNS involvement – Routine MRI evaluation is controversial but should be done if symptoms are present. 6. Monitor for scoliosis The National Neurofibromatosis Foundation (NNFF) is an outstanding resource, both for professionals and families with MF1, and also has links to many related web sites. (web site) Http://www.nf.org; (e-mail) NNFF@aol.com; (phone) (212) 344-NNFF; (address) 95 Pine St., 16th Floor, New York, NY 10005 The California chapter of NNFF can help families and also provide names of physicians with experience in NF1. In addition, there is a Northern California support group for NF1: (phone) (310) 470-3888 or (650) 473-4229; (e-mail) NFCAL@aol.com; (Northern California Support Group) (510) 923-9314 Ronald Bachman, MD & Edgar Schoen, MD; (510) 596-6571 or (510) 596-6585; ronald.bachman@ncal.kaiperm.org Pediatrician Referral Service Online The American Academy of Pediatrics’ Pediatrician Referral Service, an exciting new benefit of your Academy membership. This service, designed for patients and health care professionals alike, will enable users to search a database to find a pediatrician by name, specialty, or location. But only Academy members who sign up for this service will be included, so don’t delay; complete the form recently sent you by the National office and send it in today. If you have any questions or would like additional information regarding the Pediatrician Referral Service, contact the Academy at (800) 433-9016, ext. 6753 or visit the Academy’s Web site at http://www.aap.org. The Community Health
The Spring Chapter Meeting is about here but it is not too late to register. Conference Location The conference hotel this year is the DoubleTree Hotel in Monterey. The conference itself will be held at the Monterey Convention Center adjacent to the DoubleTree Hotel. The DoubleTree is located in downtown Monterey at Two Portola Plaza. Fisherman’s Wharf, the Cannery, the Monterey Bay Aquarium, the factory outlets and other points of interest are very close to the hotel, many within walking distance. Educational Objectives : Upon completion of this course, participants should:
|
|
|
Created 6/1/99
Last Updated January 08, 2004
