Ohio Peds Winter 2012

33127_Peds Winter 2012_Ped Spring 2007copy 4 co copy 2 2/27/12 9:26 PM Page 1 STANDING BEHIND OHIO’S CHILDREN Ohio AAP...

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STANDING BEHIND OHIO’S CHILDREN

Ohio AAP Open Forum May 10-11 in Cleveland Pediatric injury and Bike Helmet Safety Awareness Week activities to be discussed.

The next Ohio AAP Open Forum will be held on May 10-11 at the Center for Families and Children in Cleveland. A networking reception will kickoff the two-day event on Thursday, May 10 from 5-8 p.m. CATCH grant information will be shared and “Advocating for Our Mission” will be presented by representatives from Rainbow Babies & Children’s Hospital, Metro Health and the Cleveland Clinic. The Ohio AAP’s bike helmet awareness campaign continues with another educational campaign May 7-11 to coincide with National Bike Month, and ending with the Open Forum on Friday, May 11 from 8 a.m. to noon. You will also learn about a marketing campaign for mothers and caregivers on the importance of safe sleep practices.

WINTER 2012

Pediatrician of the Year Award   

Toledo pe      diatrician  Pamela       Oatis, MD,  received     the 2011 Elizabeth Spencer Ruppert Outstanding Pediatrician of Pamela Oatis, MD the Year award from the Ohio AAP. Dr. Oatis was unable to attend the Chapter’s Annual Meeting in August, so she received the award at the Open Forum meeting Feb. 21 in Cincinnati.



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Dr. Oatis was recognized for her distinguished achievements and outstanding contributions to the advancement of pediatric care and education for patients and physicans in Ohio.

For more information visit the Ohio AAP website at www.ohioaap.org.

Look inside! What is the Ohio AAP Foundation up to?

In a special report Ohio AAP Foundation President James Duffee, MD, MPH, explains the quiet, but significant change the Foundation has undergone in the past year. Find out about the Foundation’s signature programs, and how you can support its efforts to better the lives of children for whom you care.

See Oatis...on page 19

In This Issue 





 

• Sports Shorts - Staph infections H

• Immunizing adults for pertussis • Pound of Cure program

• Coding Corner: Developmental screening code 96110

Newsmagazine of the Ohio hio Chapter Chapter,r,, American Academy of Pediatrics



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Update from the Statehouse

Important Medicaid changes will impact care of patients The arrival of a new year marks the half way point of the Ohio 129th General Assembly. The first year was one of unprecedented change and activity. The year began with the swearing in of Gov. John Kasich and new legislative leaders in both the House and Senate, and progressed rapidly with state budget deliberations and the legislative activity. In 2011, the members of the Ohio General Assembly introduced more than 650 bills for consideration, and passed 47 into law. By all metrics, 2011 was a busy year in the Ohio General Assembly, and 2012 looks to be a similarly busy year for the advocacy efforts of Ohio AAP. Last year the Ohio General Assembly, under the leadership of Gov. Kasich, passed a state operating budget unlike budgets in recent memory. House Bill 153, the state operating budget was unique because it contained not only appropriations to keep the state and local government operating, but also significant policy changes. Many of these policy changes will impact the Ohio Medicaid program and the physicians who care for patients in the Medicaid program. Three of these policy changes are of significant interest to Ohio AAP members: 1. The transition of the Medicaid pharmacy benefit from the feefor-service (FFS) side of Medicaid to the managed-care plans,

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2. The development of pediatric accountable care organizations (ACO); and 3. Medicaid managed-care reprocurement.

Many of the policy changes will impact the Ohio Medicaid program and the physicians who care for patients in the program. The purpose of this update is to inform the Ohio AAP membership of these important changes to the Ohio Medicaid program. House Bill 153, the state operating budget, called for the transition of the Medicaid pharmacy benefit from the FFS to the managed-care plans. Recent federal policy changes contained in the Affordable Care Act, allow states to capture the pharmaceutical rebates, whether the state, or a managed-care plan, operate the pharmacy benefit. This new federal policy change and the promise of additional savings when the pharmacy benefit was moved to the managed-care companies led to inclusion of this policy in the state budget. During the budget, Ohio AAP raised concerns about the transition of the pharmacy benefit and the potential problems that could be created for patients and providers. Instead of one statewide Medicaid pharmacy formulary and preferred drug list, pre-

scribers would be interacting with two to three formularies in any given Medicaid region, and seven different formularies statewide. While the state did work to bring some uniformity to the seven different formularies, there is still significant variation. During the initial transition of the pharmacy benefit in October of last year, Ohio AAP began to receive comments from their members. Concerns focused on the administratively burdensome nature of working with numerous formularies and an unexpectedly high number of prior authorizations for patients who had already been prior authorized and stable of medication. Ohio AAP leadership has met with both the Ohio

See Legislation...on page 13

A Publication of the Ohio Chapter, American Academy of Pediatrics

Officers

President....Gerald Tiberio, MD, FAAP

President-Elect....Judith Romano, MD, FAAP Treasurer....Andrew Garner, MD, PhD, FAAP Delegates-at-large: Jill Fitch, MD, FAAP Allison Brindle, MD, FAAP Robert Murray, MD, FAAP Executive Director: Melissa Wervey Arnold

450 W. Wilson Bridge Road, Suite 215 Worthington, OH 43085 (614) 846-6258, (614) 846-4025 (fax)

Lobbyist: Dan Jones

Capitol Consulting Group 37 West Broad Street, Suite 820 Columbus, OH 43215 (614) 224-3855, (614) 224-3872 (fax)

Editor: Karen Kirk

(614) 846-6258 or (614) 486-3750

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President’s Message

Supporting Ohio AAP Foundation is an opportunity to give back cided to expand board membership to include diverse disciplines throughout the state. That decision was pivotal. The board is much stronger with increased experience, expertise, and newfound enthusiasm.

President Gerald Tiberio, MD In this article, I will focus on the Ohio AAP Foundation. Libby Ruppert, MD, was President of the Ohio Chapter in 1997. Dr. Ruppert asked John Duby, MD, and Robert Needlman, MD, to work with her to promote Reach Out and Read (ROR) across Ohio. At the time, there was one ROR site in Ohio and the three pediatricians felt there was a tremendous opportunity to spread the program in our state. The idea for the Ohio AAP Foundation grew out of their commitment to raise funds to support the expansion of Reach Out and Read. There was a need for a 501 (c) (3) organization to be able to solicit grants and contributions. The fledgling Foundation began in 2000. Initially, the board consisted only of Chapter members. About six years ago, it was de-

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Many readers will recall multiple efforts sponsored by the Foundation in previous years. These included a conference for families of pre-teens, the My Story Foster Care Program, Breakfast for Books, numerous golf outings, and fundraisers at the Annual Meeting. One recent success was “Brunch, Baseball and Books” held at Huntington Park this past summer. Karen Kasich, wife of Gov. John Kasich, spoke and Jeff Hogan from WBNS 10-TV emceed the event. The guest reader was Ken Schnacke, General Manager of the Columbus Clippers. It was a great success, and fun for all. Another first-time fundraiser, and also successful event, was Casino Night at the Annual Meeting in August. The mission is clear: The purpose of the Ohio AAP Foundation is to support the Ohio Chapter, American Academy of Pediatrics to advocate for the physical health, mental health, safety and education, and prevention of cruelty of Ohio’s infants, children, adolescents, and their families; and advance the education and research to benefit infants, children, adolescents, and their families. This fundraising entity is solidly aligned with the Ohio Chap-

ter’s mission and is poised to help fund Chapter initiatives. Three pediatrician leaders have served as president of the Foundation. Libby Ruppert’s vision created it. John Duby’s diligence sustained it through a number of years. Jim Duffee’s foresight and talent will carry it into the future. In this issue of Ohio Pediatrics you will find a Foundation Annual Report for all members to view. Jim Duffee has outlined current programs in more detail and discusses some major changes in funding streams. Jim is a visionary with a solid list of accomplishments. Lastly, I believe John Duby’s recent communication to me concerning the Foundation serves as a true inspiration to all of us: “The Ohio AAP Foundation continues to be one of the main charities that my wife, Sara, and I support. We believe that as pediatricians we have been given a special gift to gain the trust of children and families, and that it is our responsibility to give back to support the needs of those who have given us so much professionally.” Gerald Tiberio, MD Ohio AAP President

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Adding Chocolate to Milk Doesn’t Take Away Its Nine Essential Nutrients All milk contains a unique combination of nutrients important for growth and development. Milk is the #1 food source of three of the four nutrients of concern identified by the 2010 Dietary Guidelines for Americans: calcium, vitamin D and potassium. And flavored milk contributes only 3% of added sugars in the diets of children 2-18 years.

Reasons Why Flavored Milk Matters KIDS LOVE THE TASTE! Milk provides nutrients essential for good health and kids drink more when it’s flavored.

NINE ESSENTIAL NUTRIENTS! Flavored milk contains the same nine essential nutrients as white milk - calcium, potassium, phosphorus, protein, vitamins A, D and B12, riboflavin and niacin (niacin equivalents) – and is a healthful alternative to soft drinks.

HELPS KIDS ACHIEVE 3 SERVINGS! Drinking low-fat or fat-free white or flavored milk helps kids get the 3 daily servings* of milk and milk products recommended by the Dietary Guidelines for Americans.

BETTER DIET QUALITY! Children who drink flavored milk meet more of their nutrient needs; do not consume more added sugar or total fat; and are not heavier than non-milk drinkers.

TOP CHOICE IN SCHOOLS! Low-fat chocolate milk is the most popular milk choice in schools and kids drink less milk (and get fewer nutrients) if it’s taken away.

www.nationaldairycouncil.org/childnutrition

©National Dairy Council 2011®

REFERENCES: 1. National Health and Nutrition Examination Survey (2003-2006), Ages 2-18 years. 2. Johnson RK, Frary C, Wang MQ. The nutritional consequences of flavored milk consumption by school-aged children and adolescents in the United States. J Am Diet Assoc. 2002; 102: 853-856. 3. National Dairy Council and School Nutrition Association. The School Milk Pilot Test. Beverage Marketing Corporation for National Dairy Council and School Nutrition Association. 2002. Available at: http://www.nationaldairycouncil.org/ChildNutrition/Pages/SchoolMilkPilotTest.apx. 4. National Institute of Child Health & Human Development. For Stronger Bones…for Lifelong Health…Milk Matters! Available at: http://www.nichd.nih.gov/publications/pubs/upload/strong_bones_lifelong_health_mm1.pdf Accessed on June 21, 2011. 5. U.S. Department of Health and Human Services. Best Bones Forever. Available at: http://www.bestbonesforever.gov/ Accessed June 21, 2011. 6. Frary CD, Johnson RK, Wang MQ. Children and adolescents’ choices of foods and beverages high in added sugars are associated with intakes of key nutrients and food groups. J Adolesc Health. 2004; 34: 56-63.

7. American Academy of Pediatrics, Committee on School Health. Soft drinks in schools. Pediatrics. 2005; 113: 152-154. 8. U.S. Department of Health and Human Services and U.S. Department of Agriculture. Dietary Guidelines for Americans, 2010. 7th Edition, Washington DC: U.S. Government Printing Office, December 2010. 9. Greer FR, Krebs NF and the Committee on Nutrition. Optimizing bone health and calcium intakes of infants, children and adolescents. Pediatrics. 2006; 117: 578-585. 10. Murphy MM, Douglas JS, Johnson RK, et al. Drinking flavored or plain milk is positively associated with nutrient intake and is not associated with adverse effects on weight status in U.S. children and adolescents. J Am Diet Assoc. 2008; 108: 631-639. 11. Johnson RK, Appel LJ, Brands M, et al. Dietary Sugars Intake and Cardiovascular Health. A Scientific Statement From the American Heart Association. Circulation. 2009; 120: 1011-1020. 12. 2010-2011 Annual School Channel Survey, Prime Consulting Group, May 2011. 13. Patterson J, Saidel M. The Removal of Flavored Milk in Schools Results in a Reduction in Total Milk Purchases in All Grades, K-12. J Am Diet Assoc. 2009; 109: A97.

*DAILY RECOMMENDATIONS – The 2010 Dietary Guidelines for Americans recommends 3 daily servings of low-fat or fat-free milk and milk products for those 9 years and older, 2.5 for those 4-8 years, and 2 for those 2-3 years.

www.ohioaap.org

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Case Study: MRSA Editor’s note: The author of this case study, Katalin I. Koranyi, MD, is a professor of Clinical Pediatrics at the College of Medicine and Public Health at The Ohio State University.

History You are seeing a 13-year-old boy with his mother in your office for a follow-up visit from an Urgent Care. He had a 3 cm abscess drained from his right knee four days prior which grew Methicillinresistant Staphylococcus aureus (MRSA). He is doing well and completing a five-day course of Bactrim. On exam, the incision is slightly crusted but dry and measures 0.5 cm in length.

Advice to parents/guardians You notice that mom appears distraught. She tells you that she has been worried about her son getting very sick because of MRSA infection. She heard in the news recently that a young person lost his legs from MRSA. You tell mom that although the MRSA epidemic has not abated in more than 20 years, fortunately almost all MRSA infections are relatively minor skin and soft tissue infections.

reliable way to prevent spread of this bacterium. You also discuss with mom that MRSA and Methicillin-susceptible Staphylococcus aureus (MSSA) infections can be equally troublesome and clinically indistinguishable. The major difference is the kind of antibiotics that the physician can use to treat these infections. Katalin I. Koranyi, MD Nationwide Children’s Hospital Division of Infectious Diseases Department of Pediatrics

You acknowledge that so far we have not eliminated MRSA infections and emphasize that hand hygiene is the most important and

The patient is a wrestler and his next competition is the following day. He tells you that he “really” wants to participate. What is your advice? • You should tell him that the abscess area needs to remain covered with clean dressing and he is not allowed to return to sport activities until it has healed completely. • You will remind him and the family that handwashing with soap or alcohol-based waterless gel needs to be done often and especially after changing the dressing. • You should also advise his school that the sports equipment including the mats need to be cleaned. • You will also tell your patient that he should not share towels with his teammates.

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Bike helmet awareness campaign continues

Building off the success of last year, the Ohio AAP is pleased to announce ‘Put A Lid On It!’ – the Chapter’s bike helmet awareness campaign – will continue this year from May 7-11, 2012. The Chapter will be partnering with safety advocates throughout Ohio during this week. The goal is to organize events in Ohio’s major cities using the marketing materials created by the Chapter. The Ohio AAP will also be working to gain the support of legislators and law enforcement. The decision to expand the campaign was based on feedback from organizations in the community. In November, the Ohio AAP invited injury prevention specialists including the Ohio Public Health Association, the Ohio Department of Health, Safe Kids, TriHealth Think First Injury Prevention as well as law enforcement officers from Dublin, Ohio, to a meeting to discuss injury prevention. The purpose of the meeting was to collaborate efforts and resources in order to make a greater impact. The meeting was a great success and the Chapter looks forward to continuing these partnerships. The Ohio AAP welcomes you to join our preventative injury initiatives. We have toolkits, fliers, stickers and other resources that can be distributed in your community. If you would like to get involved with the campaign, please contact Lee Ann Henkin at the Chapter office, (614) 846-6258 or email lhenkin@ohioaap. org.

SAVE THE DATE Medical Opportunities in Ohio (MOO) www.ohmoo.org – serves hospital employers and private practices with an online recruitment program, designed to connect Physicians, Physician Assistants, and Nurse Practitioners with jobs in Ohio. Job seekers register for FREE! Our database of Physicians spans more than 85 specialties! Employers, contact us today to learn more about how the MOO program can work for you!

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Ohio AAP’s Annual Meeting

Sept. 27-29, 2012 Embassy Suites, Dublin, Ohio

• Poster presentation • Opening reception awards ceremony • Casino Night

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Ohio AAP pilots “A Pound of Cure” obesity management program In 2007, the Ohio AAP, along with several partners, introduced the Ounce of Prevention is Worth a Pound toolkit to provide primary care practitioners with anticipatory guidance for families on the topic of obesity prevention. Five years later, the Ohio AAP has launched the coordinating obesity management toolkit, called A Pound of Cure. The prevalence of childhood overweight and obesity has steadily increased over the past 30 years, and Ohio is not immune. A 1997 article by Whitaker et al. in the New England Journal of Medicine outlines what has been learned about obesity: 1. A child of normal weight at age 5 years, who remains normal at age 10 years, has only a 10% risk of being an obese adult; 2. A child who is obese at 5 years of age, has a 50% risk of being an obese adult; and 3. A child obese at 10 years of age has an 80% risk of adult obesity. Like other chronic diseases, childhood obesity has lasting, compounding consequences over time, and it is less likely to be reversed. Compared to children of healthy weight, Anderson and Whitaker detailed in 2009 that obese children are reported to be: • 4.6-fold more likely to have diabetes, • 2.0-fold more likely to have poor health status, • 1.9-fold more likely to have limited ability to do things, • 1.8-fold more likely to have asthma, and • 1.6-fold more likely to have poor

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mental health.

Obesity also markedly increases the use of health services by Ohio children. Compared to healthy weight children, obese children are reported to be more Robert Murray, MD, FAAP, chair of the Home llikely to have had two or more hospital- and School Health Committee, informs attendees at The Pound of Cure Learning izations in the past year, to have had two Collaborative Learning Session about available resources to aid clinicians in evaluator more Emergency Department (ED) visits ing, interviewing, educating, tracking and following up with overweight and obese in the past year, to children, and their families. have special health care needs, and to use chronic medication. 8. Limiting screen time to two hours In 2007, The American Academy per day, or less of Pediatrics, and 14 other collab9. Participating in at least 60 minorating organizations, provided utes of physical activity Expert Committee Recommendations Regarding the Prevention, “Developed as a series of office Assessment, and Treatment of modules, A Pound of Cure is Child and Adolescent Overweight based on the nine Expert Comand Obesity that guide clinicians mittee Recommendations,” exin very specific terms about how to plains Samantha Anzeljc, Pound of screen for, assess, and manage Cure Project Manager, and PhD excess weight that may occur in Candidate in the Interdisciplinary the early years of life. The nine PhD Program in Nutrition (OSUN) at Expert Committee RecommenThe Ohio State University. “The dation around behavior modificaintervention is presented as a set tion are: of succinct modules for use within 1. Encouraging exclusive breast a brief 15-20 minute time frame in feeding during the first six months a busy practice. These modules of life are structured to guide physicians 2. Having breakfast daily in identifying a child’s overall obe3. Encouraging family meals sity-related health risk by collecting 4. Limiting fast food consumption a comprehensive history – includ5. Increasing fruits and vegetables ing family, diet, and physical activ6. Limiting sugar-sweetened bever- ity history – as well as a physical ages exam and laboratory evaluation. 7. Eating age-appropriate portion sizes See Pound...on page 17

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Coding for asthma care discussed at Learning Session 2 webinar On January 20, practice leadership of the CQN2 Asthma program, were able to take a break from their busy day seeing patients to participate in Learning Session 2 covering a wide range of topics. This webinar carefully planned by the leadership team which was comprised of National AAP, Ohio AAP, Partners for Kids, the Alabama AAP, and Quality Improvement consultant Jen Powell.

and generated interest for the next action period.

Coding for optimal asthma care was presented by Wes Stubblefied, MD, Alabama AAP. Dr. Stubblefield reviewed documentation requirements for codes 99213 and 99214, as well as billing for complex asthma pa- This chart represents the progress MuskinAfter introductions, Kim Giuliano, tients, including ancillary gum Valley Health Center has made in its asthma program since Learning Session I. MD, Ohio AAP, celebrated the services. William Long, program’s successes with a data MD, representing Partreview from across the collaboraners for Kids, taught attendees The last agenda item covered tive from the past four months, realiability principles to care delivthree practice level presentations which determined key successes ery to achieve target goals. on specific case studies with detailed information on how a practice created a reliability system that could be used by others in ""The The Secret Secret T o Growing To Growing Wealthy Wealthy Without Without Losing Losing the collaborative. The Ohio Chapter was well represented by Y Your our M Money oney IIn n The The Wall Wall Street Street Roller Roller Coaster” Coaster” Gerald Tiberio, MD, Ohio AAP Th This is free free book w will ill show show you you how how to: to : president, speaking of his experience at the Muskingum Valley Enjoy upside growth off tthe market • En joy tthe he u p s id e g rowth o he m a rk e t Health Center. In the presentawithout ever risking money wi th o u t e ver ri sking yyour our m oney tto o tion, Dr. Tiberio identified areas of market ma rket llosses! osses! key learning, including: • Pr o te c t a gainst tthe he rravages avages o ncreasing Protect against off iincreasing 1) Recognizing the need for imta xe s! taxes! nterest p aid to duce o liminate iinterest • Re Reduce orr E Eliminate paid provement at provider/staff level rd companies! companies! banks and ccredit redit ca banks card 2) NHLBI Guidelines TO FINANCE FINANCE • PROVIDE PROVIDE CAPITAL CAPITAL TO 3) Knowledge of community reYOUR PRACTICE! PRACTICE! YOUR sources 4) Fine-tuning referral patterns our 100% F REE Viisit TODAY TODAY to claim c l a im y Visit your FREE 5) Teaching families/patients paperback paperback co copy py mailed mailed to to your your door! doorr!! about what is good control

www. www.OhioFreeBook.com OhioFreeBook.com Completely Co mp p le t e ly F FREE: REE: There There iis sN NO O COST COST - NO NO Shipping Shipping - NO Fees Fees (Why Free? We've been by the author give away (W hy F ree? W e 'v e b een ccommissioned o m m is s io n e d b y th ea uthor to g iv e a w ay number books help a llimited imited num ber of book s and cconsultations onsultations tto o hel p rresidents esidents grow grow their money securely). th e ir m oney safely safely and and se curely).

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This learning session was both informative and inspiring; the Ohio CQN2 is looking forward to many more successes in Action Period 2. For more information, please contact Project Manager Elizabeth Dawson at (614) 846-6258.

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GUIDELINES FOR PHYSICIANS AND SCHOOL NURSES

Staph and skin infections

Methicillin-resistant Staphylococcus aureus (MRSA) remains a serious and common community acquired (CA) skin and soft tissue infection. These strains differ from the more resistant MRSA acquired in health-care settings. CA-MRSA is susceptible to 2 or 3 classes of antibiotics. Because some MRSA strains may carry virulence factors, infections caused by any of these Staph strains are potentially life-threatening. The prevalence of CA-MRSA varies geographically but definitely is on the rise worldwide. In one report MRSA accounted for half of the Staphylococcus aureus hospitalizations in children in the U.S.

Risk factors for CA-MRSA

1. Skin trauma (abrasions, body shaving, body piercings, tattoos and lacerations) 2. Skin-to-skin contact 3. Sharing contaminated personal items and sport equipment (razors, towels, etc.) 4. Crowding 5. Poor personal hygiene

Clinical spectrum of Staphylococcal infections

1. Soft tissue abscesses or boils (most common) 2. Impetigo and cellulitis 3. Invasive infections including osteomyelitis, pneumonia, sepsis and endocarditis

Many individuals are colonized with Staphylococcus aureus and serve as a reservoir. The most common site for colonization is the anterior nares but consider vaginal, rectal areas and skin sites also. Attempts to decolonize individuals have been only partially successful; many individuals get recolonized. There is no way to successfully eliminate these infections. The most important measure is to practice scrupulous and frequent hand hygiene to avoid infections and recurrences of these infections in the same individual and family members. Coaches, trainers and parents need to be vigilant to limit exposure to MRSA. Athletes should not be allowed to participate in sports while lesions remain open and draining. Regular, thorough cleaning of all sporting equipment with antibacterial solutions is critical to reducing the spread of infection. Sports trainers should discourage sharing of sports equipment or personal items.

For recurrent Staphylococcal infections

There is no clear and well-accepted strategy. Decolonization may be effective, but unfortunately in many cases are only temporary, due to repeated contact with a carrier (family member or classmate). Consider the following strategies: • Cover the area with clean bandages • All household members wash their hands frequently • Always wash after coming in contact with the lesion • Fingernails kept clean and short

Management of skin abscesses

• Drain pus incision and drainage (I&D) and submit it to the laboratory for culture and susceptibility testing. • For abscesses less than 5 cm in size, l&D often is sufficient to treat. • If the physician prefers, l&D can be followed by a short course of an appropriate oral antibiotic. • Appropriate antibiotics include: clindamycin, doxycycline (for > 7 years of age) and trimethoprim/sulfamethoxazole (TMP/SMX). Methicillin sensitive Staph strains can be treated with the “old” antibiotics: cephalexin, or trimethoprim/ sulfamethoxazole, doxycycline or clindamycin. Cellulitis or abscess caused by Group A Streptococcus cannot be treated with TMP/SMX. • Follow up is suggested within 48 hours. • For large abscesses both surgical l&D and oral antibiotic therapy are necessary. • If a child is febrile or a good follow up cannot be assured, hospitalize and start on empirical intravenous clindamycin. Keep in mind that some strains of MRSA and even methicillin sensitive Staph are resistant to clindamycin. In more severe cases add vancomycin until susceptibilities become available. • If the patient has severe infection (limb-threatening infection, toxic-appearing), the patient needs to be hospitalized, surgery performed promptly, and vancomycin plus nafcillin started intravenously.

With repeated recurrences, consider placing the patient on a 5-day course of TMP/SMX plus rifampin following completion of your therapy for the acute infection. • Soiled linens, pjs and all clothing should be washed in hot water and separate from the rest of the family • No contact sports should be allowed until all lesions are healed • Sites of new skin trauma should be cleansed and mupirocin (Bactroban) ointment applied 3 times daily • Once infection has cleared, the patient may take bleach baths • All household members should apply mupirocin ointment into the anterior nares 2 times a day for 5 days

This information is available on the Ohio AAP website www.ohioaap.org

www.ohioaap.org

Author: Katalin Koranyi, MD

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GUIDELINES FOR PARENTS

Staph and skin infections Infections of the skin and soft tissues, such as abscesses (boils) are most commonly caused by bacteria known as Staphylococcus aureus. In recent years many of these strains of bacteria have become resistant to the common antibiotics we used in the past. This is a serious development. Both the methicillin-susceptible (MSSA) and the methicillin-resistant (MRSA) forms of Staphylococcus are highly contagious; can spread readily among family members and schoolmates; and under certain circumstances, can be a very dangerous, and even fatal, form of infection. Everyone associated with the active child, particularly those participating in sports where skin-to-skin contact is common (wrestling, football, basketball, lacrosse, etc.), need to be watchful about skin infections, and take the right steps to limit them right away.

Tips for preventing spread of MRSA/MSSA

1. Wash hands frequently throughout the day. 2. Always wash hands after touching infected skin or touching an item that was in direct contact with a draining wound. • Soap and water (the brand of soap in not important) or • Alcohol-based gels 3. Do not share clothes/towels/linens or personal items such as razors. 4. If possible, avoid shaving in skin areas that are frequently infected. 5. If shaving those areas cannot be avoided, change razor blades frequently. 6. When washing laundry, add bleach (if color permits) and use hot water. 7. Dry clothes on the hottest possible setting (bleach and heat can kill MRSA/MSSA). 8. Keep hands washed and fingernails clean and cut short to prevent scratches to the skin. 9. Cover any draining infected area with a clean, dry bandage. 10. Environmental surfaces that have frequent contact with bare skin (door knobs, countertops, bath tubs, and toilet seats) should be cleaned frequently with any commercially available cleaner or detergent.

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The following recommendations from the physicians of the Ohio Chapter, American Academy of Pediatrics can help you to decrease the chances of an infection getting worse, or an isolated infection becoming a recurring problem due to the spread of the MRSA and MSSA type infections. If your child is involved in sports, discourage any sharing of personal or sports equipment with other kids. Be sure all equipment is kept clean and clothing and towels are washed frequently. Keep a close eye on your child’s skin, looking for skin wounds or infections that may signal early problems and treat them right away. If your child has multiple recurrences, try using a soap with chlorhexidine (Hibiclens) to bathe, three times per week for four weeks. This, plus the above recommentions, may help limit reinfection. Also: • Apply Bactroban ointment just inside the nose using a Q-tip twice a day for five days. • Use bleach baths two times a week for about 1-3 months with 1 teaspoon of bleach per gallon of water (or a cup of bleach in a tub of water = 13 gallons). Soak in the bleach water up to your neck for 10-15 minutes, then rinse thoroughly with plain water afterwards. • Recurrent pus-filled skin infections after trying these routine measures merits a visit to your doctor. Antibiotics may be needed to control the infections. Finally, if your child is involved in school sports and has had a problem with skin infections, remind the coaches and athletic trainers to be vigilant about keeping those students with open lesions out of direct contact with others until the wounds heal completely. Controlling MRSA is an issue for the whole community. Author: Katalin Koranyi, MD

This information is available on the Ohio AAP website www.ohioaap.org

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Immunizing adults for pertussis A recent technical report published in the January edition of Pediatrics suggests a new strategy pediatricians may consider using to protect our youngest patients. Should we Ryan Vogelgesang, MD consider immunizing adults in our practices? After years of decreased pertussis disease and despite high primary vaccine rates among children, rates of pertussis have been increasing. Multiple factors are likely responsible and may include poor adolescent and adult pertussis vaccination rates, clustering of non-vaccinated disease-susceptible infants and children and possible decreased immunogenicity of the acellular pertussis vaccine compared to whole-cell vaccine. Pertussis caused 12 infant deaths nationwide in 2009. Up to 70% of pertussis cases in infants and young children are from contact with a family member with the disease, one who is often unvaccinated. Vaccination remains the most effective means of preventing pertussis disease. The 2010 National Immunization Survey reported 84.3% of Ohio’s children received all four recommended doses of a pertussis containing vaccine by age 2 years. Unfortunately, national data show that only 56% of adolescents are up to date on pertussis vaccination and only 6% of

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adults. With this in mind recommendations have been made regarding routine use of Tdap in children and adolescents starting at age 11. Use of Tdap is recommended in children 7-10 years-old who are behind on recommended pertussis vaccines, and adults 1964 years-old in need of Tetanus vaccination, and especially pregnant women during the late second or third trimester of pregnancy. All recommendations may be viewed in detail at CDC.gov.

Pediatricians may be in a unique position to improve adult vaccination rates. Office encounters with infants and their adult caregivers may give us an opportunity to counsel and offer other immunization vaccines to adults.

The technical report describes many factors contributing to the poor vaccination rates in adults and suggests that, while more study is needed, pediatricians may be in a unique position to improve adult vaccination rates. Our focus on primary prevention and our experience with logistical issues regarding purchasing, counseling, administering and obtaining reimbursement for vaccines make us all experts in vaccination. These factors, combined with the frequent office encounters with infants and their adult caregivers may give us an opportunity to counsel and offer immunization with Tdap and influenza vaccines. To some extent this is already happening as a recent survey regarding influenza vaccine reported

51% of pediatric offices had offered vaccine to some adult caregivers of their patients. Any practice considering expanding vaccination to adults would have to consider significant issues involving logistics of purchasing adult vaccines and how to handle the liability, legal and financial barriers that may make such a process challenging. We should continue to promote vaccination as a means of disease prevention. The arrival of a new baby in the home should be cause for us to review any older sibling’s vaccination status and get them up-to-date if needed. We should be talking to our OB/GYN colleagues and promoting appropriate vaccination of their pregnant patients with both Tdap and flu vaccines. If they are unable or unwilling to provide such vaccination in their offices, they should be providing their patients with resources to get vaccinated. Increasingly hospital labor and delivery units are stocking and providing these vaccinations after delivery to new moms. Pediatricians should be aware of their local hospital protocols and encourage such practices. We can direct parents, grandparents and others who will have significant exposure to unprotected infants to their own primary care provider, or to local health departments for vaccination, and we can consider whether to offer vaccinating them in our own offices. Ryan Vogelgesang, MD MOBI Director

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Importance of implementing Preschool Vision Screenings Vision is the primary sense used for learning in the early years. Approximately 80 percent of what a child learns is learned visually. Early detection and treatment of vision disorders are important to maximize a child’s visual potential.

Prevent Blindness Ohio and Ohio AAP have partnered together since 2003 to raise awareness and educate primary care providers about the value of vision screening, training and certification and the importance of conducting a vision assessment and vision screening for children ages 3-6 years in a primary care setting. With funding from the Ohio Department of Health, Bureau of Child and Family Health Services, Save Our Sight Program, a one-hour in person educational program and webinar have been developed. During the program, participants learn about: • common children’s eye problems that can lead to amblyopia • the AAP and AAFP recommendations for preschool vision screenings at well-child visits • the equipment that is used to screen for visual acuity and ocular alignment during a preschool vision screening • case studies in children’s eye diseases and disorders All participants receive an assortment of children’s eye health and safety brochures as well as the Preschool Vision Screening for Health-Care Professionals manual which was co-written by Prevent Blindness Ohio, the American Academy of Pediatrics and the Ohio Department of Health. CME’s are available to the first 100 attendees at no cost! For additional information, or to register for a program, contact Elizabeth Dawson at Ohio AAP at (614) 846-6258 or email [email protected]. For those individuals who would like to implement preschool vision screenings into their practice, Prevent Blindness Ohio offers a FREE four-hour training that provides instruction on how to perform preschool vision screenings, as well as the equipment needed to conduct the screenings, including:

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• Instruction on how to perform stereopsis and distance visual acuity screening, • Detailed information on childhood eye diseases and disorders • Preschool Vision Screening Guide for Health-Care Professionals published in partnership with Prevent Blindness America and American Academy of Pediatrics • Preschool Vision Screening Guidelines published by the Ohio Department of Health • Sample referral and follow-up resources and access to no cost eye exams and eyeglasses for qualifying families Upon successful completion of the training, as well as a two-hour homework component, participants will be certified with Prevent Blindness America. Prevent Blindness America is the only organization offering a national certification program for pediatric vision screening and vision screening training. Participants are also eligible to receive free vision screening equipment (a $300 value) that includes: • Lea Symbol Chart for Screening for visual acuity • Model A Good-Lite Visual Acuity cabinet • Random Dot E stereopsis test • Assorted children’s vision care resources and brochures For more information, or to register for a training to implement preschool vision screenings into your practice, please visit Prevent Blindness Ohio’s website at WiseAboutEyes.org or call 1-800-301-2020.

Upcoming webinar dates Friday, March 2 from noon to 1 p.m. Tuesday, March 20 from 3:30-4:30 p.m. Friday, March 23 from noon to 1 p.m. Friday, April 13 from noon to 1 p.m.

To register online go to: http://www.ohioaap.org/program-initiatives/ pediatric-vision-screening

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Legislation...from page 2

Association of Health Plans and staff at the Ohio Department of Job and Family Services (ODJFS) to discuss these concerns. Another important policy change in the state budget is the creation of pediatric ACOs to care for children in the Medicaid Aged, Blind and Disabled (ABD) program. The language included in the budget calls for the children in the ABD population to be placed into a

2012 Ohio AAP Annual Meeting

The Ohio AAP is very excited to announce a re-energized 2012 Annual Meeting being held at Embassy Suites Dublin on Sept. 2729.

managed-care program beginning in July 2012, and then later into a pediatric ACO. During 2012, the staff at ODJFS will be working to develop the model for pediatric ACOs in Ohio. What is clear is that senior staff in the Kasich administration often cite the Partners for Kids Program as a successful example of an ACO-like care delivery system. Finally, on Jan. 11, the Department of Job and Family Services launched the Medicaid managed-care procurement process. Managedcare procurement is the process through which Ohio Medicaid restructures the program. This year the restructuring will bring about many changes to the managedcare program as we have come to know it. These changes include

the reduction in the number of Medicaid regions from eight down to three, the implementation of new expectations for enhanced case management by the plans, and the implementation of pay for performance requirements requiring the managed-care companies to hit certain performance indicators to receive full compensation. The restructured Medicaid managed-care program is scheduled to be implemented on Jan. 1, 2013. Ohio AAP will work with ODJFS to provide Ohio AAP members with additional information as this process develops. Charlie Solley, Lobbyist Capitol Consulting Group

• New topics – Exciting new topics that include a state and national legislative/advocacy update, safe sleep, early brain and much more • New reception format – This year, the award ceremony that is typically a luncheon event on the last day of the meeting, will be held during the opening reception. The second annual Casino Night will be held immediately following the reception.

• New Opportunities – For the first time, Ohio AAP will incorporate a poster session into the reception on Friday evening. Posters will remain in the exhibit hall throughout the entire meeting. Be prepared to learn, network, make positive office changes, and have some FUN!

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Planning, resident CATCH grants available in 2012

The Community Access To Child Health (CATCH) will have two funding programs available – Planning Funds and Resident Funds – beginning May 1 with a due date of July 31, 2012. Planning Funds program provides grants from $5,000 to $12,000 to pediatricians to develop innovative, community-based initiatives that increase children’s access to medical homes or to specific health services not otherwise available. Resident Funds program supports pediatric residents in the planning and/or implementation of community-based child health initiatives. Grants of up to $3,000 are awarded twice each year on a competitive basis for pediatric residents to address the needs of children in their communities. Your Chapter CATCH co-facilitators, Jonna McRury, MD, ([email protected]) or Heng Wang, MD, ([email protected]) are available to help from proposal development to project implementation. For more information, or to apply for a grant, visit National AAP’s website http://www2.aap.org/catch

Don’t Think Alike Small, highly-structured classes

Rolling admissions

Assistive T Teechnology

TEACH | IGNITE | INSPIRE

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SERVING STUDENTS IN GRADES K-12 WITH LEARNING DIFFERENCES

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District V Report

Enhancing chapters’ membership is seeing positive results An assignment when my daughter was in the third grade was to write a poem about how she felt during the first snowfall of the season. She wrote “I have a blizzard of excitement in my mind” and went on to elaborate the details of the event.

This is very much how I feel this month as the wintry blast Marilyn Bull, MD hit the Midwest and I review what is happening in our AAP in the midst of challenges that face our chapters and members. Several areas are exciting to share at this time. First, chapters including Ohio have been participating in several endeavors to enhance chapter membership with positive results. Your own Jerry Tiberio is the District V representative to the national work group and the National AAP has responded to help with modified reporting systems for the chapters. The battle is not won, and the work is not done, but our strength lies in collaboration and cooperation and the process is in place to address this challenge. Another change that I hope you have seen is the revised AAP website. When you visit you will experience the greatly enhanced organization and power of the site. By logging on you may enter “My AAP” where your data and your interests are displayed and you may take advantage of an even more enhanced and direct connection for CME credit to the American Board of Pediatrics. In just a few minutes of exploration you will feel comfortable with this new resource. AAP.org also is a work in progress, but even now is working for you. Washington, D.C. is never without excitement and this month was no exception. The preservation of appropriations for children’s interests has been an ongoing endeavor of the Washington staff in the financial mindset of cuts. While significant reductions were made, direct appropriations through September 2012

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for Labor, Health, Human Services and Education have been established. For details see the AAP Federal Affairs website. One happy note is that the Graduate Medical Education (GME) funding has been largely preserved at least for now. It is critical that for this, and all funding issues, we remain vigilant and supportive of the Washington staff as the issues arise. These are only a few of the issues that affect everyone and I hope we all can see through the blizzard and stay the course toward our goals. Please contact me with questions and/or concerns [email protected]. Marilyn Bull, MD District V chair

Ohio AAP welcomes new members Lisa Kay Abate, Findlay Marisha Agana, Warren Amber Ellis Anastasi, Cincinnati Lauren Canton Bar-lev, Columbus David Alan Burke, Wooster Matthew William Byers, Kettering Moira Aileen Crowley, University Heights Marian Liu DelVecchio, Lebanon Ann Marie Dietrich, Dublin Gina Marie Fedel Sparvero, Lewis Center Lisa N. Gelles, Cleveland Julie Regal Gooding, Powell Catherine Ann Kelly-Langen, Norton John Seyerle, Cincinnati

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Coding Corner

2012 brings challenges, victories The new year has brought with it some new coding challenges and victories. These include a recent resolution of a concern with the developmental screening code 96110, increased published relative values for preventive medicine and newborn services; and Medicaid recognition and payment for medical nutrition services Richard Tuck, MD and tobacco counseling.

which should translate into comparable increases in payment for each of the 11 CPT codes, is as follows:

A CPT coding change for 2012 was to change the descriptor for 96110 from Developmental Testing, limited, to Developmental Screening, more accurately reflecting the intent and application for this important service. This code helps support the work of providing the developmental initiatives the Ohio Chapter has championed. With the language change, CMS changed their relative value assignment to 0, consistent with their policy not to cover screening services. This raised great concern with the AAP and all pediatricians, recognizing that CMS payment policy often extends to Medicaid and private payer policy. Thanks to a massive effort by the AAP Washington office and pediatricians everywhere, CMS has now changed their position and has published a relative value of .28 for 96110. Using the current Medicare conversion factor, this would translate into a Medicare equivalent payment of approximately $9.53. With this recent controversy, pediatricians should continue to monitor recognition and payment for this important code. Thanks to the efforts of the AAP Committee on Coding and Nomenclature, working with the Bright Futures Steering Committee, 2012 has also brought us increased relative values and associated payments for Preventive Medicine Services and Newborn Services. This represents a long awaited improvement to payment for pediatric services that have long been undervalued. As a result of the Academy’s work, the higher wRVUs

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CPT Code 99381 99382 99383 99384

2010 wRVU 1.19 1.36 1.36 1.53

2012 wRVU 1.50 1.60 1.70 2.00

% Increase 26% 18% 25% 31%

99391 99392 99393 99394

1.02 1.19 1.19 1.36

1.37 1.50 1.50 1.70

34% 26% 26% 25%

99460 99462 99463

1.17 0.62 1.50

1.92 0.84 2.13

64% 35% 42%

Medical Nutrition Codes This year has also delivered an Ohio Medicaid victory, with official recognition and payment for the Medical Nutrition Codes (97802-97804). These codes would provide for payments to a registered dietician providing services in a pediatrician’s office. This helps pediatricians provide more complete services for conditions such as obesity, failure to thrive, and diabetes in their medical home. Use of these codes does require the AE modifier and should be billed under the NPI of the supervising physician, physician assistant, or advanced practice nurse. If medical nutrition services are provided by a physician or advanced practice clinician, providers should use the appropriate evaluation and management or preventive medicine code. In addition, Ohio Medicaid has also published coverage for tobacco cessation counseling codes (9940699407) for children under the age of 21. All of these changes enhance the payments we can receive by providing increased services in our medical homes. Richard Tuck, MD, Zanesville Ohio AAP Coding Expert

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Pound...from page 7

This information is used to prompt physicians to address fundamental behaviors that fuel excess weight gain.” On Wednesday, January 18, the Pound of Cure Learning Collaborative kicked off with a Learning Session designed to offer training and resources to aid clinicians in evaluating, interviewing, educating, tracking and following up with overweight and obese children, and their families. The learning collaborative is designed to support primary care providers with a specific counseling process and the resources to make them optimally effective by providing behavior change techniques as a component of education about core messages.

The 10 primary care practices participating in the Pound of Cure Learning Collaborative, and piloting these materials and techniques, are: • Ashtabula Health Department

• Cincinnati Children’s Hospital Medical Center – Fairfield Primary Care • Child and Adolescent Specialty Care of Dayton

• Health Partners of Western Ohio • Ironton Lawrence CAO Family Medical Centers • Kenton Hardin Health Department • Pediatric Associates, Inc.

• Primary Health Solutions – Hamilton West

• Wheeling Hospital Center for Pediatrics

• Wilmington Medical Associates “At the conclusion of the Pound of Cure Learning Collaborative, our goal is to see children who are overweight receive guidance and counseling from their physician, in addition to stabilizing their weight trajectory and blood pressure,” says Anzeljc, who originally created the Pound of Cure materials with advisor, Robert Murray, MD, chair of the Ohio AAP Home and School Health Committee. “We also want those physicians to have greater confidence in the messages they are giving to families; it will be a win-win situation for both physicians and patients.”

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Safe sleep campaign for caregivers

As many of you already know, in October the American Academy of Pediatrics released an updated policy on infant sleep. The full article in Pediatrics is available at http://pediatrics.aappublications.org/content/early/2011/10/12/peds.2011-2284. Some of the additions include: • Breastfeeding is recommended and is associated with a reduced risk of SIDS. (http://www.healthychildren.org/English/agesstages/baby/breastfeeding/Pages/default.aspx)

• Infants should be immunized Evidence suggests that immunization reduces the risk of SIDS by 50 percent. (http://www.healthychildren.org/english/safety-prevention/immunizations/Pages/default.aspx) • Bumper pads should not be used in cribs There is no evidence that bumper pads prevent injuries, and there is a potential risk of suffocation, strangulation or entrapment. A significant number of infant suffocations occur when the infant is sleeping in bed, or on the couch with adult caregivers or siblings. It is important to remind families that room sharing, but not bed sharing, is an important way to decrease the risk of infant suffocation. (http://www.healthychildren.org/English/safety-prevention/at-home/Pages/New-Crib-StandardsWhat-Parents-Need-to-Know.aspx) The Ohio AAP is working on a collaborative statewide effort to develop a unified marketing campaign for mothers and caregivers on the importance of safe sleep environments and practices. Bike Helmets In other injury news, we are continuing our statewide bike helmet awareness campaign and will have another educational campaign May 7-11 to coincide with National Bike Month and ending with the Ohio AAP Open Forum in Cleveland May 10-11. We will be targeting communities in Columbus, Cleveland, Cincinnati, Dayton and Akron with marketing materials, media outreach and school activ-

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ities. If you are interested in learning more or would like to get involved, please contact Lee Ann Henkin at (614) 846-6258 or email lhenkin@ohioaap. org.

As you do your injury prevention anticipatory guidance this winter, please continue the discussion about helmets. A recent study in the Journal of Trauma looked at bicycle and sledding injuries and found that head injuries accounted for the largest percentage of sledding-related injuries. Another article in Pediatrics found that traumatic brain injury was more likely to occur on snow tubes compared to other types of sleds. There are multiple studies in the literature illustrating the importance of helmet use during sledding, skiing, ice skating and snowboarding activities. Free downloadable patient handouts on winter safety for your office are available at: http://injuryresearch.net/resourcelibrary.aspx http://www.healthychildren.org/English/news/ pages/Winter-safety.aspx Injury Prevention Legislative Update During the “Put a Lid on It” public awareness campaign that focused on the importance of wearing bike helmets, the Ohio AAP worked with various legislators across the state to hold events in their districts where helmets were fitted and distributed. Additionally, many of these legislators also promoted the campaign by including information in their constituent newsletters and/or by writing columns in their local newspapers. The Ohio AAP is looking for a legislative champion who will introduce legislation mandating that children under age 14 wear helmets; similar to legislation that has been passed in local communities/ cities and in 27 other states. As the Injury and Violence Prevention Committee continues to work to make injury prevention easier for you, we welcome your comments/feedback at [email protected] or sarah.denny@ nationwidechildrens.org. Sarah Denny, MD Committee on Injury and Violence Prevention

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Dr. Oatis...from page 1

Dr. Oatis is “a brilliant person with a deep commitment to children especially the underserved,” says Libby Ruppert, MD. “I first met her when she was a medical student at the then Medical College of Ohio. She was a stand out then, and I knew she would accomplish much. She was very well informed, logical in her thinking and was already showing that she was not a person to accept the status quo,” says Dr. Ruppert. Dr. Oatis’ parents were highly respected in the community. Her father was a topnotch lawyer and her mother was a leader in the volunteer world. After completing her pediatric residency Dr. Oatis became a generalist in pediatrics which was soon followed by her deep interest in palliative care. “She has been productive and creative in her work and her most recent huge grant confirms that she competes successfully,” says Dr. Ruppert. “When I retired from clinical care I asked Pam if she would like to serve on our Lucas County Family Council a responsibility that I had enjoyed for many years. She accepted and I was so grateful for I knew she would represent pediatrics and children's needs very well,” adds Dr. Ruppert.

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Child Mental Health Learning Collaborative

The Ohio AAP will soon begin recruitment for a new Part IV MOC-approved Quality Improvement program to address screening, diagnosis and treatment of mental health from ages birth to 18 years. Please contact Lee Ann Henkin at the Chapter office, (614) 846-6258 or email [email protected], if you are interested, or would like more information.

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Ohio Chapter American Academy of Pediatrics 450 W. Wilson Bridge Rd. Suite 215 Worthington, OH 43085

Calendar of Events

The Ohio AAP announces the following meetings and events.

May 10-11, 2012 – Ohio AAP Open Forum Center for Families and Children, Cleveland Thursday, May 10, 2012 5 p.m. Registration 5:30-6 p.m. Networking Reception 6-8 p.m. Program

Friday, May 11, 2012 8-9 a.m. Registration 9 a.m. Pediatric Injury and Bike Helmet Safety Awareness Week Activities 12:15 p.m. Executive Committee Meeting

Sept. 27-29 – 2012 Ohio AAP Annual Meeting Embassy Suites, Dublin

• First-ever poster presentation • Opening reception with awards ceremony • Casino Night • Topics: State and national legislative/advocacy update, safe sleep, early brain

PRESORTED STANDARD Permit No. 156 U.S. Postage PAID DUBLIN, OH

Dues disclosure statement

Dues remitted to the Ohio Chapter are not deductible as a charitable contribution, but may be deducted as an ordinary and necessary business expense. However, $40 of the dues is not deductible as a business expense because of the Chapter’s lobbying activity. Please consult your tax adviser for specific information. This statement is in reference to fellows, associate fellows and subspecialty fellows.

No portion of the candidate fellows nor post residency fellows dues is used for lobbying activity.