ohio pediatrics

Gerald Tiberio, MD, FAAP, direc-tor of the Muskingum ValleyHealth Centers, received the2013 Ohio AAP Chapter’s Eliza-beth Spencer Ruppert Outstand-ing Pediatrician Award. This isthe Chapter’s highest awardgiven for distinguished achieve-ments and outstanding contribu-tions to the advancement ofpediatric care and educationfor patients and physicians ofOhio. See Award..on page 10

The Ohio AAP is one of the mostactive and visible health-care pro-vider organizations at the State-house. Members of the Legislatureoften reach out to us to seek ouropinion on a bill or policy idea,and many of our fellow health-care provider groups look to us tolead the charge on issues. As a re-sult, we have had a lot of successin passing legislation and regula-tions that have improved thehealth of Ohio children. Here aresome highlights from the lastdecade:

• Newborn Screening Require-ments: Over the years, we haveworked with legislators and offi-

cials atthe De-partmentof Healthto addandchangerequirednewbornscreenings. Most recently, we weresuccessful in adding screenings forcritical congenital heart defectsand a universal hearing screening.

• Booster Seat Requirements: TheOhio Chapter led a prolongedfight to enact legislation requiring

In This Issue• Sports Shorts - Winter Sport Injuries

• Case Study: TFCC Tear

• Challenges of spirometry in asthma management

• Annual Meeting photos

In the next several issues of OhioPediatrics, we will be featuringarticles highlighting one of theChapter Pillars.

Advocacy is the theme of this is-sue. You will not only read aboutthe major legislative gains of theChapter in the past decade, butalso about school safety bills, theChapter’s push for legislation toenact a statewide youth bike hel-met mandate in Ohio, teen driv-ing update, and the epinephrine-in-schools bill.

Authors for these articles aremembers of the Chapter Pillars.The Advocacy Pillar leaders areWilliam Cotton, MD, FAAP, andJonathan Thackeray, MD, FAAP.Contributors to this issue includedour lobbyists, Dan Jones andDaniel Hurley of Capitol Consul-ting Group.

See Gains...on page 6

Themed articlesfeature Ohio AAPChapter Pillars

Newsmagazine of the Ohio Chapter, American Academy of Pediatrics

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S T A N D I N G B E H I N D O H I O ’ S C H I L D R E N F a l l 2 0 1 3 / W i n t e r 2 0 1 4

Ohio Chapter makesmajor gains in advocacy

Dr. Tiberio receivesChapter’s Pediatricianof the Year Award

Elizabeth Ruppert, MD, FAAP,with award winner GeraldTiberio, MD, FAAP.

Prior to serving as Chapter Pres-ident, Dr. Tiberio served asChapter Treasurer, President-

37265 Ohio Pediatrics.qxp_Ped Spring 2007copy 4 co copy 2 12/20/13 3:54 PM

www.ohioaap.org Ohio Pediatrics • Fall 2013/Winter 2014

A Publication of the Ohio Chapter, AmericanAcademy of Pediatrics

OfficersPresident....Judith Romano, MD

President-Elect....Andrew Garner, MD, PhD

Treasurer....Robert Murray, MD

Delegates-at-large:Jill Fitch, MDJonathan Thackeray, MDMike Gittelman, MD

Executive Director:Melissa Wervey Arnold94-A Northwoods Blvd.Columbus, OH 43235(614) 846-6258, (614) 846-4025 (fax)

Lobbyist:Dan Jones Capitol Consulting Group37 West Broad Street, Suite 820Columbus, OH 43215(614) 224-3855, (614) 224-3872 (fax)

Editor:Karen Kirk(614) 846-6258 or (614) 486-3750

Medicaid Expansion takes big leapforward following series of eventsThe yearlong drama overwhether or not Ohio will expandMedicaid coverage appearsheading for a resolution followinga series of events in October. Ori-ginally, Gov. John Kasich pro-posed Medicaid Expansion in hisbudget proposal earlier this year.Citing concerns related to cost,and facing pressure from TeaParty groups, legislative Repub-licans stripped Expansion fromthe budget. In addition to remov-ing Expansion, the General As-sembly also added languagethat explicitly prohibited OhioMedicaid from covering the Ex-pansion population. Prior to sign-ing the budget in June, Gov.Kasich exercised his line-itemveto power to strike languageprohibiting Medicaid Expansion.

In Ohio, the director of Medicaidis authorized to file a state planamendment (SPA) with the Cen-ters for Medicare and MedicaidServices (CMS) to cover any eligi-bility category defined in Title XIX,including group 8. Using this au-thority, Ohio filed an SPA andgained approval from CMS onOctober 11 to expand Medicaidcoverage. Since the ACA pro-vides for 100% federal coverageof the cost of Expansion from cal-endar years 2014 to 2017 (even-tually the federal share will de-cline to 90%), Ohio will receivebillions in federal funds over thenext few years. Executive Agen-cies including the Ohio Depart-ment of Medicaid are prohibitedfrom spending any money,whether state or federal, without

appropriation authority. This au-thority is granted in the budget,which does not account for Ex-pansion adults; therefore OhioMedicaid does not have the abil-ity to spend new federal dollarsand would be at risk of exhaust-ing its appropriation authority.

Recognizing that appropriationsmay need to be adjusted withinbudget cycles, the General As-sembly created the Ohio Con-trolling Board in 1975 and em-powered the board to approvenew spending and transfer fundsbetween line items. On October21, the Ohio Department ofMedicaid went before the Con-trolling Board to request an ap-propriation increase totalingmore than $2.5 billion. The Con-trolling Board is made up ofseven members – the chair ofeach chamber’s Finance Com-mittee, a member of each partyfrom each chamber, and a presi-dent who represents the gover-nor. The Speaker of the Houseand President of the Senate areresponsibly for appointing mem-bers from their respective cham-bers.

Prior to the Oct. 21 hearing, thetwo House Republicans on theControlling Board were Represen-tatives Ron Amstutz (R-Wooster)and Cliff Rosenberger (R-Clarks-ville) – both are opponents to Ex-pansion and both are vying toreplace House Speaker WilliamG. Batchelder (R-Medina), who isterm limited. The morning beforethe Controlling Board hearing,

Speaker Batchelder replacedboth of the House Republicans onthe board with RepresentativesJeff McClain (R-Upper Sandusky)and Ross McGregor (R-Spring-field). Representative McGregor isa vocal Expansion supporter;combined with Gov. Kasich’s rep-resentative, and the two Demo-crats, this gave Ohio Departmentof Medicaid the majority it need-ed to move the appropriationincrease. Sen. Chris Widener (R-Springfield) also voted in favor;the final vote was 5-2.

Unfortunately, the issue is still notresolved. The 1851 Center forConstitutional Law, a conservativeadvocacy group, filed a com-plaint with the Ohio SupremeCourt; six Republican members of

Update from the Statehouse

2

See Legislation...on page 15


www.ohioaap.org Ohio Pediatrics • Fall 2013/Winter 2014

President’s Message

2013 Annual Meeting delivered valuewith MOC and CME opportunities

3

The Ohio Chapter AAP prides it-self on delivering value to itsmembers. Two of these areas areMOC and CME, in which OhioAAP excels. Traditionally, thehighlight for Ohio pediatricians togather and learn is the Ohio AAPAnnual Meeting, while the Na-tional Conference and Exhibition(NCE) is the premier gathering forall pediatricians in the UnitedStates, as well as many fromabroad.

Ohio AAP’s Annual Meeting 2013was extremely successful due tothe hard work of the planningcommittee which involved staffand board members, as well asexecutive committee membersand experts. In a time when mostpediatricians obtain CME fromsources other than meetings, it isa challenge to present a pro-gram that will attract pediatricprofessionals from those in train-ing to those with senior status.The kickoff for the meeting was a

pre-conference Advocacy Daywith legislative updates, an inter-active advocacy experience,and presentations by Represen-tatives Mike Duffey and JohnPatrick Carney. Participants wereable to experience firsthand thechallenges that lawmakers andlobbyists face in addressing issuessuch as Medicaid Expansion andgun control.

The Annual Meeting itself hadsomething for everyone includingOhio AAP Asthma CollaborativeMOC Program Learning Session;the Executive Committee/ExpertMeeting where participantslearned not only about currentprojects but had an opportunityto brainstorm and make sugges-tions for future work; Speed Men-toring for residents; a first-ratePoster Session; and educationalsessions on hot topics.

The highlight of the 2013 AnnualMeeting was definitely the Part 2,MOC workshop. Physicians en-rolled in MOC were afforded anopportunity to complete an ac-tivity for MOC credit. Our moder-ator for the session on SportsMedicine was Kelsey Logan MD,FAAP, who introduced and dis-cussed each article, highlightingthe important information andleading the discussion; each par-ticipant then entered the an-swers to the questions on theirown laptop, and by the end ofthe session, participants hadcompleted the activity. Dr. Lo-gan’s expertise in the area madethis an extremely enjoyable

learning experience. Attendeeshad a great time, and are anx-ious to do this again next year.Whoever thought MOC could befun?

The 2013 NCE held in Orlando,Fla., had many Ohio AAP mem-bers serving as faculty. We werevery proud to see Andrew Gar-ner, MD, FAAP, and John DubyMD, FAAP, on the podium forfeatured speakers for the Peds 21Symposium on Early Brain andChild Development. Both aretrue leaders and were featuredspeakers throughout the entireNCE. Other Ohio faculty mem-bers included: Andrew Hertz, MD,Jonathan Thackeray MD, JosephTobias, MD, Caroline Kercsmar,MD, Richard Tuck, MD, RobertMurray, MD, Kelsey Logan MD,Alan Brown MD, Stacy Ishman,MD, Elaine Schulte, MD, CarloDeLorenzo, MD, William Cotton,MD, and yours truly. There weremore than 50 Ohio presenters.

I would also like to congratulateRick Tuck MD, FAAP, who wasawarded the prestigious Abra-ham Jacobi Award at the NCEannual business luncheon (seestory on Page 15).

We have much to be proud ofand I am thankful to all of theindividuals who give tirelessly tobetter the profession of pedi-atrics and thus better the lives ofchildren. OHIO AAP ROCKS!!!!

Judith T. Romano, MD, FAAPOhio AAP President

President Judy Romano, MD


www.ohioaap.org Ohio Pediatrics • Fall 2013/Winter 2014 4

Legislators are united in thegoal to improve school safety

The tragic events in Chardon,Ohio, and Newtown, Conn., haveraised the issue of school safetywithin the halls of the Ohio State-house. And, while there is dis-agreement over policy, membersare united in their goal to improvethe safety of Ohio’s schoolchildrenand address gaps in mental healthtreatment. The Ohio AAP has re-mained engaged throughout thisprocess and offered testimony andinsights into what can be done toaddress the causes and outcomesof school-related violence.

Citing the high profile and priorityof this issue, House Republicans in-troduced a school safety bill asone of their first 10 pieces of legis-lation. House Bill 8 seeks to addressthe physical security of a school byallowing employees with appropri-ate training to carry a concealedfirearm. A school board would de-cide which employees would beallowed to carry weapons. Thosenames and the protocol for carry-ing a weapon would be part ofeach school’s safety plan and re-main confidential. The bill passedthe House Education Committee inearly November with some biparti-san support, though law enforce-ment advocates expressed someconcerns with the bill.

Another lower chamber bill, HB

215,wouldallowschools tocontractwith cur-rent andretiredlawenforce-ment officers to provide volunteersecurity services. This bill hasreceived a couple of hearings, buthas not received a vote. Severalother pieces of legislation relatedto gun control have sparked someheated debate in the House ofRepresentatives, which tends tobe more conservative. The focusfor House Republicans appears tobe physical security, with a heavyfocus on arming teachers andother school employees torespond in an active shooter situa-tion.

The Ohio Senate has taken a morecomprehensive approach to theissue of school violence, examiningboth the physical security aspect,as well as the broader mentalhealth debate. In a series of hear-ings earlier this year, SenatorsPeggy Lehner (R-Kettering) andFrank LaRose (R-Copley Twp.)heard from dozens of witnessesincluding Ohio Attorney GeneralMike DeWine, Geauga CountyBoard of Mental Health DirectorJim Adams, and the Ohio Chap-ter’s own Mike Gittelman, MD. Thetestimony was powerful and, attimes, very emotional.

Senators Lehner and LaRose areexpected to publish their findingsin a report and, following that, un-

veil legislation to address issuesraised during these hearings. Atimeline for both the report andlegislation has not been devel-oped. It’s also unclear how thisapproach will interact with HB 8and other House-supported mea-sures. The Senate also passed legis-lation earlier this year sponsored bySenators Gayle Manning (R-NorthRidgeville) and Randy Gardner (R-Bowling Green) that would allowschool districts to put a levy on theballot for school safety purposes.

While the legislature continues itsdeliberations, Ohio Gov. JohnKasich created a $5 million crisisstabilization fund to pioneer strate-gies to identify and help childrenwho may be in crisis or consideringa violent action. Ohio AttorneyGeneral Mike DeWine has also de-veloped a number of resourcesand tools for schools to improvetheir physical security and re-sponse plans for an active shooterscenario. This is an issue that willcontinue to garner attention andwe need to remain engaged.While there isn’t a consensus onwhat steps Ohio will take to avoidanother tragedy, there are a num-ber of policy suggestions that meritour review and insight.

Daniel Hurley, LobbyistCapitol Consulting Group

While there is disagreementover policy regarding schoolsafety, all parties do agreethat school violence andgaps in mental health treatment are high priorityissues.


Over the last three years, the Put a Lid On It! cam-paign has distributed thousands of bike helmets andconnected with many Ohio children and parents.The goal has always been to get as many kids as pos-sible to wear their helmets. We have held hundreds ofevents throughout the state and involved elected of-ficials and community leaders in nearly every one.Not only have we successfully worked toward ourstated goal, but we have also developed an extraor-dinary grassroots network of advocates and havegotten this issue on the radar of many members ofthe Ohio General Assembly.

We will need this network and awareness as we beginour push for legislation to enact a statewide youthbike helmet mandate in Ohio. As you know, numer-ous municipalities in Ohio have bike helmet ordinan-ces; while there is no real consistency in terms ofages covered, we estimate that 430,841 Ohio kids(15%) live in a jurisdiction that requires bike helmets.These requirements cover large urban areas like Cin-cinnati and Columbus, and small communities likeMarietta and Waynesville. Our legislation would en-sure all Ohio children are under the same require-ments and are protected.

The legislation is simple – any child under the age of18 would be required to wear a helmet when riding abike (or as a passenger) if they are on a road, side-walk, bike path, or other public right of way. Addi-tionally, the bill requires bike-rental companies to fur-nish information on the law and provide helmets forindividuals to rent. A $25 fine is assessed for a first of-fense; each offense after that can come with a pen-alty up to $100. A court can waive a fee if an offend-er shows evidence they have a helmet and intend touse it in the future. All fines assessed will be creditedto the state and used to provide bike helmets to lowincome families. States that have enacted similarlaws have seen an increase in bike helmet usage and

a corresponding decrease inthe number of bike-relatedinjuries and deaths.

Bike helmets can reduce therisk of head injury by 85%and severe brain injury by88%; additionally, an estimat-ed 75% of all bike-relatedfatalities among childrencould be prevented with a bike helmet. From a costperspective, a $10 bike helmet can generate $41 insavings across Ohio’s health-care system by mitigat-ing a fatality or serious brain injury. Our best estimateis that 10-20% of Ohio kids currently wear their hel-mets; more than 70% of all children ride their bike reg-ularly. According to data from the Ohio Departmentof Health, emergency department visits from bikeaccidents more than doubled over the last decade.

Despite our strong grassroots support and the over-whelming amount of data supporting this bill, we stillface an uphill battle in the General Assembly. Manyconservative Republicans oppose “mandate” billsand will argue that parents should decide whether ornot their child wears a helmet. Some will also raiseconcerns over the cost of helmets. Given the highvolume of health care and Medicaid bills already in-troduced, and the shortened legislative calendarnext year (an election year), we simply won’t have alot of time for hearings. That being said, we havestrong support from key legislators including StateSenator Shannon Jones (R-Springboro), the chair-woman of the Senate Medicaid, Health, and HumanServices Committee. This won’t be an easy fight, andit may take several years to get this passed, but thetime is now to take the next step in bike helmet safe-ty.


5www.ohioaap.org Ohio Pediatrics • Fall 2013/Winter 2014

Push is on for legislation to enactyouth bike helmet mandate in OhioAccording to data from the OhioDepartment of Health, emergency department visits from bike accidentsmore than doubled over the last decade.



children to be secured in a proper booster seat. Afternearly a full decade of work, this bill was signed intolaw by Gov. Ted Strickland.

• Private Insurance Well-Child Benefits: The OhioChapter successfully lobbied to require health insurersin Ohio to provide parity coverage for well-child visitsoffered through Medicaid. This law ensures all Ohiokids have access to comprehensive primary and pre-ventive care services, regardless of their insurancecoverage.

• Vaccine Requirements: Over the years, Ohio AAPhas worked successfully with the Ohio Department ofHealth and the General Assembly to add immuniza-tions to the required list for children. Most recently, wesecured the addition of the Hepatitis B and Varicellavaccines.

• Concussion/Return-to-Play Law: Last year, Gov.John Kasich signed into law a comprehensive youthsports concussion law that put in place requirementsfor children to be removed from play and evaluatedafter showing signs of a concussion.

• Primary Care Rate Increase: The Affordable CareAct allowed primary care providers to receive Medi-care rates for certain Medicaid services provided in2013 and 2014. The Ohio AAP led the charge in im-plementing this policy in Ohio and ensuring all eligiblemembers had adequate time to sign up. We contin-ue to work with Ohio Medicaid to resolve issues.

The Ohio Chapter has also been active during con-sideration of state budgets, which not only fundMedicaid and other critical health-care programs,but often contain sweeping policy changes. We ex-pect to fight for a statewide youth bike helmet man-date and the restoration of the vaccine requirementfor children entering daycare. Additionally, a flurry ofMedicaid reform bills and controversial issues such asschool safety and gun rights will merit our attention.

Thank you to Ohio AAP members for their efforts anddedication, whether in testifying before a committee,attending an interested-party meeting, or simply mak-ing a phone call to your legislator.


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In 2011 eight teenagers died each day in U.S. from motor vehicle collisions Scope of the problemBy now, you are probablywell aware that motor vehi-cle collisions are the leadingcause of death in teen-agers. In fact, in 2011, eightteenagers died a day in theU.S. from motor vehicle colli-sions.1,2 The fatality rate istwice as high for teens 16-17years old, compared to 18-19 years of age,3 andalmost 9 times that of the general population.4 Intheir first year on the road, teens are almost 10 timesmore likely to be in a crash.5

Why are teenage drivers so dangerous?There are multiple factors that contribute to the highrate of fatalities in teen drivers, but inexperience andrisk-taking behaviors are predominant factors in thesetragedies. The prefrontal cortex, responsible for “exe-cutive function,” allows us to think before we act, rec-ognize consequences of actions or choices, and con-trol impulses. This part of the brain is not fully matureuntil the 20s, putting teen drivers at increased risk ofacting on impulse and engaging in risky behavior, in-cluding driving without a seatbelt, speeding, and sub-stance use or abuse without recognizing the potentialnegative consequences.

Teenagers are more likely to take chances, drive inhigh-risk conditions, succumb to peer pressures, andoverestimate their abilities compared to older drivers,especially when first starting to drive unsupervised, in-creasing their risk for crashes. Some of the conditionsthat make teens more likely to be involved in a colli-sion include: an increased number of passengers inthe car, more nighttime driving, unsafe vehicles beingdriven, less use of safety restraints, and the use ofdrugs and alcohol during vehicle operation. Alsoadded distractions such as eating, listening to theradio, and cell phone use, in combination with inex-perience, only puts the teen driver at greater risk forcrash and ultimate injury.

Proposed changes to Ohio’s Graduated LicensingLawState Rep. Rick Perales, from Ohio House District 73,

recently introduce House Bill 204, with proposedchanges to the current teen driving legislation. Someof the proposed changes, and the data to supportthem are included below.

• Nighttime restriction for probationary license holdersfrom 10 p.m. to 5 a.m.Studies repeatedly show that the risk for fatal acci-dents increase with additional teen passengers andwhen the teen is driving at night.2,3,4 Review of crashdata indicates that more than 40% of teenage motorvehicle crash deaths occur between 9 p.m. and 6a.m., with the most being from 9 p.m. – 3 a.m.1 Stateswith laws that restrict nighttime driving have seen a60% reduction in fatal crashes during the restrictedhours2 and states with nighttime driving restrictionsstarting at 10 p.m. or earlier were associated with 19%lower 16 year-old fatal crashes.3 A study done by theInsurance Institute for Highway Safety found that forevery hour nighttime driving was restricted, fatalcrash rates were reduced.3

• Passenger restrictions for drivers with a probationarylicenseAccording to the American Academy of Pediatrics’Policy Statement on Teen Driving, the chance of be-ing involved in a car crash is directly proportional tothe number of teenaged passengers being transport-ed.4 Fatal crash rates for 15-17 year olds dropped by21% when new drivers were not allowed to carry teenpassengers, compared to those states that allow twoor more teen passengers, and 7% when new driverswere allowed to transport one passenger.

The proposed change to Ohio’s current legislation willhelp to strengthen the existing law and effectively re-duce teen driver fatalities by increasing the nighttimedriving restriction and expanding on the passengerrestrictions. As we counsel our teen drivers in the pri-mary care setting, it is also important to remind themof the dangers of distracted driving. The Allstate Foun-dation reports that sending a text is the equivalent ofdrinking four beers, and that in the time it takes tosend that text at 55 mph, the teen driver has essen-tially driven the length of a football field with theireyes closed.8 In Ohio, the law prohibits a person who

See Teen driving...on page 8


Sarah Denny, MD, FAAP, Ohio AAPCo-Chair of the Injury PreventionCommittee, joined Ohio House Bill296 sponsors Rep. Mike Duffey (R-Worthington) and Rep. Terry John-son (R- McDermott) at a newsconference prior to a vote on theepinephrine-in-schools bill.

HB 296, which passed the OhioHouse unanimously on Nov. 20,would allow schools to stock epi-nephrine to reverse the symptomsof anaphylaxis. School districtsand day-care centers will de-velop protocol on how to storeand use epinephrine.

The bill removes the legal barriers


Teen driving...from page 7is less than 18 years of age fromusing in any manner, an electronicwireless communications devicewhile driving, and prohibits textingwhile driving.9

In a recent survey by the AllstateFoundation, teen drivers were sur-veyed on their attitudes towardmore restrictive graduated licen-sing laws. Key points from that sur-vey include:• The vast majority of teens (78%)approved of night restrictions. • The majority of teens (57%) werein favor of passenger restrictions. • Bans on hand-held and hands-free cell phones and texting foryoung beginners were stronglyendorsed.10

A study published in Traffic InjuryPrevention in 2011 surveyed par-ents of teenagers ages 15-18 ontheir feelings toward more restric-tive licensing laws and found that

parents were supportive of legisla-tion that included higher permitand licensing ages, longer learnerperiods with high practice hour re-quirements, plus strong and long-lasting night and passenger restric-tions.10

The Ohio AAP is actively support-ing this proposed legislation as itmakes its way through committeehearings. If you would like to be-come more involved in this effort,please contact Lea Barker at theOhio AAP at [email protected] (614) 846-6258.

Sarah Denny, MD, FAAP, Co-ChairInjury Prevention Committee

References1. Insurance Institute for Highway Safety,Fatality Facts 2011: Teenagers website,http://www.iihs.org/iihs/topics/t/teenagers/fatalityfacts/teenagers

2. Graduated Driver Licensing Laws,SaferRoads.org/graduated-driver-licens-ing.org

3. Graduated Licensing Laws and FatalCrashes of Teenage Drivers: A NationalStudy, Insurance Institute For HighwaySafety, June 2010.www.iihs.org/research/topics/pdf/r1122.pdf

4. The Teen Driver, American Academy ofPediatrics Policy Statement, Pediatrics.2006;118(6):2570-2577.

5. StateFarm, Teen Driving facts and Stats,http://teendriving.statefarm.com/learning-to-drive/preparing-to-drive/teen-driving-facts-and-stats

6. Traffic Safety Facts: Laws, NHTSA, January2008, DOT-HS-810-888W, www.nhtsa.goc/DOT/NHTSA/Communication%20&%20Consumer%20Information/Articles/Associated%20Files/81088.pdf

7. Teen Safe Driving: Teen Licensing Survey,Allstate Foundation, www.allstatefounda-tion.org/teen-licensing-survey

8. http://www.allstatefoundation.org/sites/default/files/Teen_Driving_Facts.pdf

9. Ohio Department of Motor Vehicles,http://bmv.ohio.gov/texting_ban.stm

10. Views of parents of teenagers aboutlicensing policies: a national survey. WilliamsAF, Braitman KA, McCartt AT. Traffic Inj Prev.Feb;12(1):1-8. doi: 10.1080/15389588.2010.515631.

House Bill 296 allows schools, day-carecenters to stock doses of epinephrine

to a drug that can save lives andis safe to use. It allows schools to

use an EpiPen when it’s a non-patient-specific dosage.

Sarah Denny, MD, with HB 296 supporters at a news conferenceprior to a vote on the epineprine-in-schools bill.



foundation

O H I O

Pediatricians Standing Behind Ohio’s Children focus

“As an attendee to many Ohio AAP Foundation Fundraisers, I can say they keep getting better! Casino Night was a great time, and it was a good opportunity to support important programs like early literacy. I also had fun networking with other Ohio AAP members.” –Dr. Judy Romano

Don’t miss your chance to support the Foundation at next year’s events!

Lions, Literacy, and Lunch May 17, 2014

Casino Night at Annual MeetingSeptember 5, 2014

Save the Date!

Annual Meeting’s Casino Night 2013

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Part 2 MOC to return at 2014 Annual Meeting

10www.ohioaap.org Pediatrics • Fall 2013/Winter 2014

On Saturday, Sept. 21 more than65 Ohio AAP members attendedthe Part 2 MOC Workshop at An-nual Meeting 2013. This sessionwas the most highly attended ofthe meeting, but record-settingattendance and interest wasrecorded across the three daysof learning and networking atthe Sheraton Columbus Hotel onCapitol Square.

Many popular features, includ-ing the Part 2 MOC Workshop,will return, or be expanded, forAnnual Meeting 2014, scheduledfor Sept. 4-6, 2014 at the DublinEmbassy Suites.

This year, the Part 2 MOC Work-shop moderated by KelseyLogan, MD, allowed participantsto leave with 20 points of credittoward Part 2 MOC, as well asCME, in the two-hour session. Dr.Logan, director of the Division ofSports Medicine at CincinnatiChildren’s Hospital Medical Cen-ter, walked participants throughthe 2012 Sports Medicine Self-Assessment by providing dualpresentations of the test ques-tions and resources revealinganswers.

“The MOC session on Saturdaywas excellent,” said TaraWilliams, MD, hospitalist at Fire-lands Regional Medical Centerin Sandusky. “It was highly inter-active and clinically useful.”

Dr. Williams was not the only at-tendee to thoroughly enjoy thesession; overwhelmingly positivefeedback has already lead to

discussion of featuring two similarsessions at the 2014 AnnualMeeting. This option would allowphysicians who attend both ses-sions to complete their entirePart 2 MOC requirements in oneweekend.

In 2014, a practice mangementworkshop will be held on theThursday prior to the AnnualMeeting at the Ohio AAP Of-fices. This year, an advocacyworkshop was held prior to theAnnual Meeting. RepresentativesMike Duffey and John PatrickCarney attended to answerquestions from members. Later,members participated in an in-teractive advocacy experience.Attendees broke into two groupsand debated and passed mocklegislation on immunization re-quirements.

Annual Meeting 2013 introduc-ed dual sessions on Friday, andwill be expand into tracks in2014. Potential tracks will be de-cided using the feedback pro-vided by attendees at this year’smeeting. A large numbers of re-quests have been made for ses-sions focusing on mental healthand patient-centered medicalhomes. Special sessions are inthe works for residents, hospital-ists, and practice administrators.

The changes to the AnnualMeeting format broke severalrecords including highest num-ber of residents, poster presen-ters, and exhibitors. Friday alsoset a record daily attendance ofmore than 150 people!

Award...from page 1

Elect, and Treasurer of the OhioAAP Foundation Board. National-ly, he has served as District VCATCH facilitator, recently com-pleting his term as chair of theCATCH program. During his termas president, Dr. Tiberio led theChapter to the second sequentialselection as the national Out-standing Very Large Chapter ofthe American Academy of Pedi-atrics. In presenting the award,Elizabeth Ruppert, MD, said, “Dr.Tiberio’s holistic approach to life isnot only laudable but successful.His leadership in the Ohio AAP hasbeen never failing and an integralpart of our success. His long-stan-ding vision of pediatrics as a com-munity endeavor to enhancehealth shows his foresight.”

A new advocacy award wasnamed in honor of William Cotton,MD. As advocacy chair for theOhio AAP, Dr. Cotton oversawwork concerning legislation onbooster seats and concussions.Under his expertise, the Chapterhas become a valuable part ofthe Ohio legislative process.

Other awards winners were:• Gov. John Kasich – AntoinetteParisi Eaton Advocacy Award forhis many actions to improve thelives of Ohio’s children. • Jonathan Thackeray, MD –William H. Cotton PediatricianAdvocate Award for his commit-ment to Ohio’s foster children.• Sarah Denny, MD, and MichaelGittelman, MD – Leonard P. RomeAward for their work on the BikeHelmet Safety Awareness project.• Bill Long, MD – Arnold FriedmanCommunity Pediatrician for hislong-time commitment and dedi-cation to the children and familiesof the Central Ohio area.

See Annual Meeting photos pg. 24



Are your patients and their families struggling with emotional, developmental or behavioral issues?

The Ohio Chapter, American Academy of Pediatrics Building Mental Wellness Learning Network can help!

The Building Mental Wellness (BMW) Learning Network is seeking primary care practices in Ohio who want to help patients and families cope with mental wellness issues in children and youth.

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GUIDELINES FOR PHYSICIANS

Winter Sport InjuriesThe winter months bring more than just snow. As winter sports gainmore and more popularity, people are spending more time partici-pating in various recreational activities throughout the winter sea-son. Winter sports injuries are getting a great deal of attention athospital emergency rooms and doctor’s offices. In 2007, the U.S.Consumer Product Safety Commission reported:• 139,332 injuries from snow skiing

• 164,002 injuries from snowboarding

• 133,551 injuries from ice skating

• 53,273 injuries from ice hockey

Preventing winter sports injuries

SKIINGLower extremity:• MCL injuries are the most commonly reported lower extremityinjury.

• ACL injuries have increased and now account for almost 20% ofskiing injuries.

• Commonly described mechanisms include:º Valgus external rotation occurs when the ski edge catches.º The “phantom foot” is the most common mechanism for ACL

injuries. This occurs when the skier’s weight is posterior and the hips drop below the level of the flexed knees, resulting in greater edge pressure causing an abrupt internal rotation force on the knee and the ACL usually gives. Teaching skiers to fall forward can prevent this.

Upper extremity:• “Skier’s thumb”(ulnar collateral ligament tear or “Gamekeeper’sthumb”)

º Most common single injury of the upper extremity.º Occurs when the thumb is forcefully hyperextended or

abducted, usually when the skier falls on a planted ski pole and hyperabducts the thumb that is caught in the strap.

º Treatment typically includes short arm thumb spica splint/cast. The main complication is failure of the ligament to heal resulting in instability of the joint and potential requirement for surgery.

ICE SKATINGLower extremity:• Tendonitis of the tibialis anterior and toe extensors also known as“lace bites” can happen when the tongue of the skate is improperlypositioned.

• Malleolar bursitis can occur when friction from the skate againstthe medial or lateral malleolus takes place.

• Haglund’s deformity or “pump bumps” is a bony enlargement ofthe back of the heel where the Achilles tendon attaches and caus-es a painful bursitis. Occurs when the back of the skate fits improper-ly and causes repeated friction with the back of the heel.

• Patellofemoral syndrome is a common problem in figure skating.

SNOWBOARDINGUpper extremity:• The shoulder is particularly vulnerable in snowboarding and com-mon injuries include subluxations, dislocations, clavicle fractures andacromioclavicular joint separations.

• Wrist injuries are involved in 20% of all snowboarding injuries. º Fractures of the distal radius are common. Almost two-thirds are

intra-articular or comminuted fractures and require surgery.

º Carpal fractures of the scaphoid and lunate are also frequently seen and present with point tenderness over these bones.

Lower extremity:• There are fewer pediatric knee injuries seen in snowboarders vs.skiers due to less torsional forces. ACL injuries are uncommon. • Fracture of the lateral process of the talus, also referred to as“snowboarder’s ankle/fracture” is fairly unique to snowboarding.

º Occurs as a result of sudden dorsiflexion and hind foot inversion with axial loading. Often while landing a jump.

º Present similar to lateral ankle sprains and are often missed. º Important to obtain a mortise view with X-rays.

ICE HOCKEYHead injuries:• Concussions account for 8% to 14% of all hockey injuries. Almosthalf of these occurred after collision with another player.

Upper extremity:• “Skier’s thumb” can also be seen in hockey when a player falls onan outstretched hand with the hockey stick still in possession.

• Metacarpal fractures occur due to “slashing” or stick trauma.

Authors: Danielle Greco, DO and Chris Liebig, MD – Akron Children’s Hospital

Injuries vary from sprains and strains to fractures and dislocations.Head injuries are also a frequent concern in all winter sports.Many of these injuries can be prevented when taking the properprecautions prior to participation. The following information canbe followed and adhered to in order to prevent injuries sustainedduring the winter season: • Develop and maintain a good general fitness level.

• Warm up prior to participation

• Helmets should be encouraged for all snowboarders and skiers.Children should wear appropriate-sized helmets and not just onethat they will “grow into” as they mature.

• Protective equipment is recommended. Wrist guards are espe-cially useful in snowboarders.

• Check all equipment to be certain it is in good working order.

• Appropriate winter clothing should be worn to prevent frostbiteor hypothermia. Wear several layers of water- and wind-resistant



GUIDELINES FOR PARENTS

The winter months bring more than just snow. As winter sportsgain more and more popularity, people are spending moretime participating in various recreational activities throughoutthe winter season. Winter sports injuries are getting a great dealof attention at hospital emergency rooms, doctor’s offices, andclinics.

SKIING• Lower extremity injuries are the most commonly reported andoutweigh upper extremity injuries by a ratio of 2:1.

• The majority of these injuries are to the knee.º Teaching skiers to fall forward instead of leaning back or

squatting can help prevent knee injury.• Head injuries account for a small portion of injuries, however,they represent the majority of severe injuries sustained.

º Concussions are common, especially in adolescents.• Upper extremity injuries do occur with the most commonbeing called a “skier’s thumb” or “gamekeeper’s thumb.”

º Occurs when a child falls on a planted ski pole or when the child’s thumb is caught in a strap causing the thumb to be bent awkwardly away from hand.

ICE SKATING• Many injuries in ice skating are the result of overuse or im-properly fitting skates. • Friction from the skate against the inside and outside anklebones may result in swelling and irritation.• A painful enlargement on the back of the heel or “pumpbump” occurs when the back of the skate fits improperly andcauses repeated friction.

SLEDDING• Many items are used to perform this activity, ranging fromsleds with runners and toboggans to inner tubes and card-board boxes. All share common design flaws such as little to nosteering and no restraint system.• Collisions with stationary objects account for at least half ofmajor injuries.• Head injuries are common, particularly in “head-first riding”and carry an increased risk for poor outcomes.• Children younger than 6 have three times the number ofhead injuries as compared to those older than 12 years.• Icy conditions increase both the speed of the sled and thenumber of injuries. • Adult supervision has a profound effect on safety when sled-ding, as it prevents hill overcrowding and collisions.• Ensure a proper run-out area (an area of sledding coursethat allows for deceleration and safe stopping) away fromroads and frozen water• Proper lighting should be provided for evening sledding toavoid collisions with stationary objects or other sledders.• Sledding should be done in open, well-groomed areas thatare free of obstacles.• The safest sledding position is sitting while facing forward.

SNOWBOARDING• Snowboarding is one of the fastest growing sports worldwide.• Compared with skiing, there is a higher incidence of upperextremity injuries.

º Wrist injuries are the most common, making up 20% of all snowboarding injuries. • Head injury rates are three times higher in snowboarders thanin skiers. • Lower extremity injuries do occur with a unique fractureknown as “snowboarder’s ankle/fracture” occuring while land-ing jumps.

MEDICAL ISSUES• 85% of ultraviolet waves reflect off the snow surface, increas-ing the effect of sun on exposed areas of skin and eyes.• Cold injuries such as frostnip (redness, numbness, and burningpain of outermost skin) and frostbite are best treated with pre-vention by minimizing exposure of skin to cold environmentalconditions.

º If concerned about frostbite, place area in warm water or cover with warm washcloth. If numbness continues, call your pediatrician.• There is a known increased prevalence of exercise-inducedairway narrowing or “bronchospasm” in winter sport athletes.

º The prevalence ranges from 11-50% and is thought to be due to the cold and dry air associated with most winter sports/recreation.

º 90% of asthmatics will have exercise-induced bronchospasm (EIB).

º If a child is diagnosed with asthma, wearing a face mask or breathing through the nose will help moisten and warm the air to prevent symptoms.

º Follow your pediatrician’s recommendations for proper use and timing of prescribed inhalers.

Winter Sports Injuries

This information is available on the Ohio AAP website www.ohioaap.org Sports Shorts is provided by the Home and School Health Committee.

Preventing winter sports injuries and medical issues

Injuries vary from sprains and strains to fractures and dis-locations. Futhermore, medical issues may arise with ex-posure to the cold environment. Taking the proper pre-cautions prior to participation may prevent many ofthese concerns.• Helmets should be encouraged for all snowboardersand skiers.

º Children should wear a properly fitted helmet and not one that they will “grow into.”º Children younger than 12 years should wear a fitted

helmet while sledding.• Protective equipment is always recommended.

º Wrist guards are useful especially for snowboarders.• Allow children to skate only on approved surfaces.

Authors: Danielle Greco, DO and Chris Liebig, MD – Akron Children’s Hospital


Ohio AAP member, Richard H. Tuck, MD, FAAP, received the AbrahamJacobi Memorial Award at the American Academy of Pediatrics NationalConference in Orlando, Fla., on Oct. 28. The Jacobi Award, named afterone of the founders of AAP, is one of the most prestigious awards made bythe Academy. It recognizes a pediatrician who has made long-termnotable contributions to pediatrics nationally in teaching, patient careand/or clinical research. Dr. Tuck joins a select group of national pediatri-cians recognized for these achievements.

Dr. Tuck is a general pediatrician who has been in pediatric private prac-tice for 35 years in Zanesville, Ohio. He is a graduate of Cornell UniversityMedical College and completed his residency at Strong Memorial Hos-pital, University of Rochester Medical Center. Dr. Tuck now sees patients atthe Muskingum Valley Health Center, and is medical director of QualityCare Partners, a local physician hospital organization.

Dr. Tuck has been dedicated to teaching primary care physicians practicemanagement, including the complicated coding system they must utilizeto communicate the services they provide to payers and other entities. Hehas worked at both the state and national levels to advance issues of health care to children, having servedon many committees and as an officer of the the Ohio Chapter. He has been recognized in the past with sev-eral Chapter awards including the Outstanding Pediatrician of the Year.


Dr. Richard Tuck receives Jacobi Award

Jacobi Award winner RichardH. Tuck, MD, and wife Cynthia.

Legislation...from page 2

the House joined the suit againstthe Controlling Board and theOhio Department of Medicaid.The complaint argues that theBoard and Ohio Medicaid violat-ed legislative intent by pursuingExpansion over the objections ofthe legislature. While many legalexperts contend this suit is likely tobe thrown out, it may cause fur-ther delays to Medicaid Expansionbeyond Jan. 1, 2014. As a precau-tion, the Healthy Ohioans Workcampaign will continue to collectsignatures for a possible ballot ini-tiative next fall. However, despitelegal challenges and political is-sues, Medicaid Expansion is al-most a reality in Ohio.


www.lawrenceschool.org |


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It is important to make use of everyoffice visit to address the currentimmunization status of the child.Immunization has led to dramaticdecreases in vaccine preventabledisease in the last century. The mostre-cent data from the Centers forDisease Control (CDC) was 67.65%among children 19-35 months old,and ranged from 66-79% for the differ-ent adolescent vaccines for Ohio children who havereceived their vaccines.2,3

There are many challenges to vaccine administrationincluding parental refusal, active illness, and lack ofadherence to a medical home.6 Undervaccination ofa community places both unvaccinated and vacci-nated children at risk for disease. It is not uncommonfor a visit to be in preparation for an upcoming pro-cedure which may involve procedural sedation oranesthesia. This may present the perfect opportunityto ensure that the needed immunizations are given.

What should you do in the event the child is due tohave surgery in the next two weeks? This is especiallypertinent in the adolescent population who may in-frequently visit the practice and may present the onlyopportunity to administer a vaccine. While up-com-ing surgery is not a contraindication to vaccine ad-ministration according to CDC guidelines, receivingblood during the procedure is listed as a precautionfor varicella and measles, mumps, and rubella vac-cines.4

There are many questions that surround this issue: • Is it safe to deliver vaccines in the perioperativeperiod?• Are the vaccines just as effective when given dur-ing a time period close to general anesthesia or pro-cedural sedation (1-2 weeks)?• Will the procedure be cancelled if I give the vac-cine?• Can complications associated with vaccines con-fuse the pre- and post-operative assessment? There is a theoretical risk that vaccines may be lesseffective or ineffective due to concerns about im-munomodulation that can occur during surgery and

anesthesia.5 This effect is thought to be transient.Bone marrow depression, neutrophil activity, T cellresponses, have all been demonstrated to occur withdifferent anesthetics.7 The recommendations in theanesthesia literature deferring procedures surroundingimmunizations varies from a few days up to threeweeks.8 Most of the studies that explore the effect ofsurgery or anesthesia on the immune system are pri-marily observational studies, are small, and, are indi-rect in that they do not look at the immune effect onthe response to vaccination specifically. Studies thatexamine the effect of anesthesia on the response tovaccination consist only of a systematic review andexpert opinion pieces which vary on the need for, orduration of, an interval.

More concerning to the anesthesiologist is the poten-tial for vaccines to cloud what could be a potentialadverse effect from anesthesia since they have simi-lar effects. Most important is potential for fever andirritability which can be associated with vaccines. Afever at the time of elective procedures can lead tocancellation due to concerns about an intercurrentillness. (See table below for other potentially con-founding factors with vaccines and anesthesia.)

Jill Fitch, MD

Are immunizations safe prior to anesthesia/sedation procedures?

Immunization (50)

LocalInflammationPainGranuloma an necrosis

(uncommon)Lymphadenopathy and

abscess (exceptional)

SystemicFeverIrritabilityExanthemaProlonged inconsolable crying (>3 h)NeurodeficiencyThrombocytopenic purpuraAnaphylaxis with shock like

state

Surgery (nonexhaustive list)

LocalInflammation (wound infection)Postoperative pain

SystemicFever (sepsis)IrritabilityAnesthesia-induced rashCryingPostanesthesia agitation and confusionSeptic petechiaeSeptic shock

Side effects or complications of immunization and surgery

See Anesthesia...on page 19


Mary Ann Sprauer Abrams, MD, MPH, ColumbusKhalid Abulaban, MD, LovelandJohn Conrad Alfes, MD, WestlakeElizabeth DeFrancis Allen, MD, ColumbusBrit Anderson, MD, CincinnatiMichael R. Anderson, MD, LyndhurstAdjoa Andoh, ColumbusArmand H. Matheny Antommaria,MD, PhD, CincinnatiCatherine Dowe Arora, MD, Avon LakeMarcus Aram Baratian, MD, StreetsboroDonald P. Barich, Broadview Hts.Jessica S. Bates, AkronRebecca Beesley, BeavercreekPaul S. Bellet, MD, GlendaleSharie Alison Benoit, DO, GahannaBanarikammaje Narayana Bhat,MD, DCH, LisbonAnisha Bhatia, CortlandSamina Bhumbra, Ottawa HillsJennifer Biber, MD, Cleveland Hts.Marianne Marzen Black, MD, PerrysburgEunice E. Blackmon, MD, FairfieldTerra Blatnik, MD, LyndhurstNiyati Bondale, FairbornSharon Maria Bout-Tabaku, MD, ColumbusCassie M. Brady, MD, CincinnatiAmy L. Brown, MD, ColumbusMorgan Elise Brown, LovelandMelissa M. Burgett, MD, WoosterCathy L. Cantor, MD, Maumee

Lindsay Cary, WarrenThomas James Catalanotto, MD, FairfieldRachel-Marie Cazeau, MD, ColumbusJulie Cernanec, MD, Cleveland Hts.Christopher Chiu, MD, South CharlestonValerie T. Coats, MD, Shaker Hts.Bridget C. Combs, MD, MadisonJoseph Anthony Congeni, MD, AkronJennifer Mickle Cooper, MD, WorthingtonRebecca Currier, CincinnatiRoseAnn L. Cyriac, MD, CincinnatiIngrid M. Daoud, MD, CincinnatiKatherine J. Deans, MD, ColumbusAnthony Loren DeRoss, MD, ClevelandErica Renee Schmidt DeVries, MD, PerrysburgKaren A. Diefenbach, MD, ColumbusMarita D'Netto, MD, WestlakeJulia Marie Eckert, MD, CelinaJennifer Alyson Ehrhardt, MD, WyomingSharon Sarah Ehrman, CincinnatiMoussa El-hallak, MD, AkronCarrie Oklota Fadell, MD, YoungstownGregory Faris, MD, MadeiraJennifer Feldman, MD, CincinnatiTodd A. Florin, MD, CincinnatiLuke Thomas Fraley, RavennaPatricia A. Francis, MD, ColumbusSteven Lee Friesen, MD, AshlandTanya Elizabeth Froehlich, MD, CincinnatiKathleen Fulop, MD, WestervilleAaron Howard Gardner, MD, Liberty Township

Kimberly Giuliano, MD, WestlakeRichard Philip Golden, MD, ColumbusBryan Howard Goldstein, MD, CincinnatiMichael Aaron Goodman, MD, CincinnatiLindsay M. Gould, MD, ClevelandAmanda E. Graf, MD, ColumbusJacqueline Graham, AkronRebecca Greaves, CincinnatiJonathan Marc Grischkan, MD, ColumbusIsh Kumar Gulati, MD, ColumbusVineet Kumar Gupta, MD, IndianapolisMatthew Glen Hardwick, MD, Spring ValleySharon Lee Harp, MD, CincinnatiBrenda M. Hartley, MD, SylvaniaPatrick Stanley Hein, MD, CincinnatiDrisana Henry, ClevelandDaniel Herchline, CincinnatiAndrew R. Hertz, MD, Shaker Hts.NancyJ. Hesz, MD, XeniaCheryl Ilene Huffman, MD, FindlayKaren Marie Hummel, MD, SevilleSrikant Balachandran Iyer, MD, MPH, CincinnatiBryan John Jacobs, DaytonPrakruti Reddy Jambula, MD, MasonKristie Michelle Jetter, Odessa, FLCatherine Jin, CincinnatiEvelyn Jones, MD, CincinnatiJordan Jones, DO, CincinnatiKerwyn Charles Jones, MD, AkronCatherine Olson Jordan, MD, ColumbusEneni Hazel Kanu, MD, Liberty TwpRamakrishna Kasindula, MD, ZanesvilleKathi J. Kemper, MD, MPH, BlacklickEllen Daniel Kempf, MD, AkronNancy A. Kessler, MD, Ottawa HillsKimberly Cook Khosla, MD, SpringboroAnne Chung-Wha Kim, MD, Cleveland Hts.Ingrid Karen Kraus, MD, Cleveland HtsSimmi Dogra Kulkarni, DublinJennifer Kusma, ColumbusJennifer Lyn Lail, MD, CincinnatiPhilip Lamptey, MD, TroyMartine Lamy, CincinnatiLibeth Lazaron, MD, CincinnatiCandice Star Eva Lengyel, MD, CincinnatiMegan Little, BeavercreekJulia Lloyd, MD, ColumbusNicolas L. Madsen, MD, CincinnatiMatthew Magyar, ToledoCandice Marie Maietti, ClevelandParevi Majmudar, MorrowPrashant Solanki Malhotra, MD, ClevelandJennifer Manning, DO, CanfieldAlessandro Lorenzo Maranzana, MD, ChillicotheJennifer Christina Marcy, MD, LakewoodNatalia Martinez-Schlurmann, MD, ClevelandDerek Armand McClellan, MD, ColumbusCharlotte Currie McCumber, MD, SolonMary Antenen McIlroy, MD, ColumbusDavid P. Meagher Jr., MD, BeavercreekMary Ann Merling, MD, WilmingtonAshley Renee Miller, DefianceChristopher Miller, MD, ColumbusPeter C. Minneci, MD, Columbus


See New members...on page 27

Ohio AAP welcomes new members

Physicians across the country turn to ChildLab because we care about your patients as much as you do.

For a complete list of our pediatric laboratory tests and pathology services, visit www.childlab.com or call 800-934-6575.



Anesthesia...from page 17

Summary While there are certainly a potential for interactions with anesthesia andthe immune system these appear to be mild and transient. Vaccinationshould not be delayed in children who are to undergo an elective pro-cedure. Discuss the plan with the anesthesiologist as well so he/she isaware of the need for the vaccine prior to the procedure. This canpotentially prevent any cancellation of the procedure due to recentvaccination, family dissatisfaction, and poor utilization of resources. Youneed to know what your hospitals/surgery center’s guidelines are forimmunizations before surgery. If they require immunizations being heldprior to surgery, you should question the need and encourage them todiscontinue this unnecessary delay.

Special thanks to William Cotton, MD, Medical Director Primary CareNetwork, and Joe Tobias, MD, Chief of Anesthesiology, NationwideChildren’s Hospital, for review and input on material. If you have anyquestions please contact me at [email protected]

Jill Fitch, MDClinical Associate Professor of PediatricsNationwide Children’s Hospital

References1. Imdad A, Tserenpuntsag, B, Blog, DS, et al. Religious exemptions forimmunization and risk of pertussis in New York State, 2000-2011 Peds2013;132(1) :37-43

2. http://www.cdc.gov/vaccines/stats-surv/nisteen/tables/11/tab02_iap_2011.pdf accessed July 23, 2013

3. http://www.cdc.gov/vaccines/stats-surv/nis/tables/1112/tab02_anti-gen_iap_1112.pdf accessed July 23, 2013

4. http://www.immunize.org/catg.d/p3072.pdf accessed July 23 2013

5. Pietrini D, Pusateri, A, Tosi E et al. Infectious diseases of childhood andtheir anesthetic implications. Minerva Anesthesiol 2005; 71 (6) :385-389

6. Robison, SG. Sick Visit Immunization and delayed well baby visits. Peds2013;132 (1): 44-48

7. Siebert JN, Posfay-Barbe KM, Habre W and Sigrist CA. Influence ofanesthesia on immune responses and its effect on vaccination in chil-dren: review of evidence. Pediatr Aneth 2007; 17:410-420

8. Short JA, Van der Walt JH, Zoanetti JD. Immunization and anaesthesia– an international survey. Paediatr Anaesth 2006; 16(5) :514-522

The Ohio AAP Foundation has an-nounced scheduled events for2014. Mark your calendars to par-ticipate!• Bike Helmet Safety AwarenessWeek – May 9 – 18, 2014Join the Ohio AAP in promotingbike helmet safety awareness byhosting an event at your organiza-tion, distributing helmets, or writinga letter to the editor.• Lions, Literacy and Lunch – May17, 2014The 8th Annual Foundation Fund-raiser returns to the Columbus Zooand Aquarium for upclose animalencounters, food, and fun whileraising funds to support the Foun-dation’s programs.• Glow Ball – A new type of golfouting coming in JulyGlow Ball will begin at sundown,with nine holes of golf played onan illuminated course with, ofcourse, glowing golf balls!• 4th Annual Casino Night at OhioAAP Annual Meeting – Sept. 5,2014 at the Dublin Embassy Suites.Casino Night in 2013 introducednew games, dancing, and oppor-tunities to win real cash! All of thefun will return for this marqueeevent and fundraiser.

CorrectionIn the last issue of Ohio Pedi-atrics, some authors wereomitted from the Sport Shortsarticle on Pre-ParticipationEvaluation. The authors are:Pamela Lachniet, MD, PhD,Teri McCambridge, MD, andKate Berz, DO.

Save the date!Ohio AAPFoundation2014 events


Editor’s note: The authors of this case study are MichaelDonaworth, MD; Kate Berz, DO; Kelsey Logan, MD; TeriMcCambridge, MD, of Cincinnati Children’s HospitalMedical Center Division of Sports Medicine, Cincinnati,Ohio.

Chief Complaint: Wrist Pain

Subjective: A 13-year-old female, right-hand dominant vol-leyball player, presents to clinic with right wrist pain for 10days. She has a history of Ehlers-Danlos Syndrome (EDS)Type III and has a history of knee pain and foot pain. Herwrist pain is constant in nature and localizes to the dorsaland ulnar side of her wrist. Her pain worsens with move-ment, especially dorsiflexion and palmarflexion and im-proves with rest and naproxen. She has tried an OTC wristsplint to help with the pain, but she feels that this adds in-creased pressure and pain to the affected area of thewrist. She plays volleyball, but does not remember a specif-ic traumatic event that precipitated the pain. She is havingmost of her pain with serving. She endorses symptoms ofpainful popping with wrist movements, but does not haveany catching sensations. She denies any weakness or swel-ling, but does state that the pain radiates to her shoulderunpredictably at times. She is also having some pain whileplaying basketball.

Physical Exam: This is a healthy appearing young female inno acute distress. She has a Beighton score of 7. Examina-tion of the right wrist reveals tenderness to palpation overthe distal ulna. There is a click felt with wrist rotation. Shehas full active range of motion, but pain with passive radialdorsiflexion and palmarflexion. Her grip strength is very mild-ly diminished (4+ compare to 5/5 on the left) but thestrength of her intrinsic hand muscles is preserved. She hasnormal sensation over the entire hand and wrist. She has nopain with compression over the triangular fibrocartilagecomplex (TFCC). Resisted ulnar deviation causes pain.There is no pain with Watson’s click testing.

Differential Diagnosis: TFCC injury, ulnar styloid fracture,hamate hook fracture, Keinbock’s Disease, lunotriquetralinstability, extensor carpi ulnaris (ECU) subluxation, distalradioulnar joint (DRUJ) arthritis, juvenile idiopathic arthritis,ulnar impaction syndrome, interosseous ganglion, ECUtenosynovitis, epiphysitis, enchondroma, Madelung deformi-ty.

Treatment: The patient was trialed with an OTC wrist brace,rest and NSAID’s for treatment. She has an underlying histo-ry of EDS, hypermobile type, and this made her treatmentand pain control difficult. Her hypermobility has led to issueswith chronic joint pain. She was also referred to Occupa-tional Therapy for hand exercises and activities. She contin-

ued to have pain with minimal improvement with these in-terventions. When conservative measures failed, an injec-tion into the TFCC area was provided using 0.5mL of kena-log and 0.5mL of marcaine. She continues to have pain inthe area, and she is awaiting a visit with hand surgery. Shecontinues to participate in volleyball and perform all activi-ties of daily living despite the pain.

Discussion: The TFCC is located in the distal radioulnar joint(DRUJ) and functions to stabilize the joint. It is formed by theunion of the palmar and dorsal radioulnar ligaments, themeniscal homolog, the ulnar collateral ligament, and thesubsheath of the extensor carpi ulnaris tendon. Injuries tothe TFCC are usually caused by a traumatic force, but de-generation and overuse also plays a role. The peripheralmargins of the TFCC are well-vascularized; however, thecentral area, as well as the radial attachment site is rela-tively avascular. The mechanism of injury for most TFCClesions is typically that of hyperpronation with axial loading

Wrist Radiograhs: Mild ulnar minus variance with no acuteabnormality

MRI (MPGR T2 images):

1. Findings suspicious for partial ulnar attachment tear of the trian-gle fibrocartilage2. Small linear area of hypointense signal distal to the styloidprocess likely represents fracture fragment off of the ulnar styloid(Middle Image)


Case Study: TFCC Tear

See Case Study...on page 21

Triangular Fibrocartilage Complex



Case study...from page 20

in a patient with ulnar positive anatomy. The wrist bearsapproximately 80% of the axial load through the radius and20% through the ulna. The function of the TFCC is to transferthe load of the ulnar carpus to the ulnar shaft. This is whatmakes the injury much more common in patients with anulnar positive variance, compared to the ulnar negativeanatomay that our patient demonstrates. With ulnar nega-tive patients, the TFCC tends to be thicker than in ulnar pos-itive patients.

The physical exam of the wrist iscritical in evaluation of TFCC in-juries. There is typically tendernessto palpation in the soft spot bor-dered by the extensor carpiulnaris, flexor carpi ulnaris, ulnarstyloid, and triquetrum. The sensi-tivity of this exam for a TFCC tearis 95.2%, with a specificity of 86.5%(See Figure 1). The examinershould also look for a test for anulnar impaction sign. With thismaneuver, the examiner placesthe patient in forced ulnar devia-tion in an attempt to bring thelunate and the TFCC into contactwith one another and reproducepain. The piano key test looks forinstability at the DRUJ. The ex-aminer presses the distal ulna withthe wrist in a pronated position. Apositive test, indicating instability,is reported with increased move-ment or pain of the distal ulna-compared to the unaffectedside. Ironically, our patient did nottest positive for these on initialexam, however, her follow-upexams became positive for TFCCtenderness.

Treatment generally begins with immobilization of the wristin a position of slight flexion and ulnar deviation for 4 weeks.If there is a tear to the peripheral portion of the TFCC, thevascularity of the area will allow healing in that time frame.If either physical exam or radiology demonstrates instability,there is increased concern for a complete disruption of theTFCC. These cases should be referred for surgical evaluationby a hand surgeon initially as conservative therapy will likelynot be beneficial. If the patient fails to make progress withprolonged immobilization and therapy over the course ofseveral weeks, a steroid injection and/or surgical referralshould be considered.

The type of surgical procedure that is pursued is generallyguided by the location of the injury. A tear in the centralportion of the TFCC, which is avascular, will need to be de-brided as opposed to repaired. Studies have shown thatremoval of the central portion of the TFCC does not signifi-cantly alter ulnar loading of the risk. If the tear is located

along the more vascular border, surgical repair is favoredover debridement.

Michael Donaworth, MD; Kate Berz, DO; KelseyLogan, MD; Teri McCambridge, MD Cincinnati Children’s Hospital Medical Center Division of Sports Medicine, Cincinnati, Ohio

References• Cannon NM (ed.). Diagnosis and Treatment Manual forPhysicians and Therapists: Upper Extremity Rehabilitation 4thed. The Hand Rehabilitation Center of Indiana. Indianapolis.2001:163-165

• Lindau T, Adlercreutz C, Aspenberg P, “Peripheral tears ofthe triangular fibrocartilage complex cause distal radioulnarjoint instability after distal radial fractures” J Hand Surg, 25A(2000), pp. 464–468.

• May MM, Lawton JN, Blazar PE, “Ulnar styloid fracturesassociated with distal radius fractures: Incidence and impli-cations for distal radioulnar joint instability”, J Hand Surg,2002; 27.6:965-971.

• Nagle DJ. Triangular fibrocartilage complex tears in theathlete. Clin Sports Med. 2001;20(1):155-66.

• Palmer, Andrew K. "Triangular fibrocartilage disorders:Injury patterns and treatment." Arthroscopy 6.2 1990, 125-132.

• Park MJ, Jagadish A, Yao J. The rate of triangular fibro-cartilage injuries requiring surgical intervention. Orthopedics2010;33:806.

• Sachar K. Ulnar-sided wrist pain: evaluation and treat-ment of triangular fibrocartilage complex tears, ulnocarpalimpaction syndrome, and lunotriquetral ligament tears. JHand Surg Am. 2012;37:1489–500

• Tay SC, Tomita K, Berger RA. The “ulnar fovea sign” fordefining ulnar wrist pain: an analysis of sensitivity andspecificity. J Hand Surg 2007;32A:438–444.

Figure 1Surface anatomy of the ulnarfovea sign. The ulnar styloidprocess is easily palpated withthe forearm in neutral rota-tion. The fovea lies betweenthe ulnar styloid (US) processand the flexor carpi ulnaris(FCU) tendon. Distally, it isbounded by the pisiform (P)bone and proximally by thevolar surface of the ulnarhead, which in this photo isunder the examiner’s indexfinger pulp. The tip of theindex finger points to thelocation of the fovea.



Meeting the challenges of spirometry in asthma managementThe 2007 NHLBI Guidelines for the management ofasthma recommends the use of yearly spirometry forpatients with asthma. Spirometry can diagnose asth-ma and follow lung function over time. Here is a briefreview of this key tool to help manage asthma:

What spirometry tells usSpirometry measures the speed and volume of amaximal expiratory effort. It can detect abnormalflow to detect airflow obstruction from asthma. Im-portantly, when done annually, spirometry can mea-sure changes in lung function over time. Of note, nor-mal spirometry does NOT rule out a diagnosis of asth-ma. The 2007 NHLBI tables for control and severity in-clude FEV1/FVC measurements as one objective toolto help classify asthma.1

The maneuverThe test is physically demanding, but children asyoung as age 5 years can be coached to performthe test correctly. The patient seals their moutharound a mouthpiece, taking care to keep theirtongue out of the way. They then take several easytidal breaths into the machine to ensure that no air isleaking. The patient then takes the biggest, deepestbreath possible, filling their lungs to total lung capaci-ty. They then very quickly BLAST the air out, continuingto exhale forcefully for several seconds (ideally sevenseconds) to residual volume. From this maneuver theForced Vital Capacity (FVC) and Forced ExpiratoryVolume in 1 second (FEV1) can be calculated. Re-sults can be displayed graphically in a flow volumeloop and/or volume time curve. Results are also pre-sented as absolute volumes (Liters) and as percentpredicted based on age, gender, height, and race. Ifairflow obstruction is present, a bronchodilator canbe administered and the test repeated to determineif the obstruction is reversible.

Keys to ensuring a good testAdequate coaching to exhale forcefully and for anadequate duration is necessary for the test to provideaccurate information. Many spirometers come withsoftware for visual incentives and “video games” thatencourage kids to exhale by blowing a piece of toastout of the toaster, blowing up a balloon, or making a

red line go to the top of a bar. The test must be repro-ducible, or done at least three (up to eight) times toensure there is little difference between tests.

Spirometry in general pediatric practiceOne barrier to obtaining spirometry is the lack of ac-cess to a pediatric spirometry lab and making familiesshow up to yet another appointment. To overcomethis barrier, many practices include in-office spirome-try as part of routine care for asthmatics. Many fac-tors must be considered when implementing routinespirometry, including spirometer cost, maintenance,calibration, office flow, and reimbursement.

Spirometers are available as portable, hand-held de-vices, although these often lack pediatric norms andequations. Spirometers that connect to laptop com-puters are also somewhat portable, and are oftensold with software that includes both pediatric normsand incentive graphics in order to ensure quality tests.In CQN, practices have trained nurses, medical assis-tants, and respiratory therapists to be able to obtainquality tests from children. Many practices haveworked to incorporate spirometry into routine officeflow.

Attendees from Star Pediatrics at the Ohio AAPCQN3 Asthma Collaborative Learning Session atthis year’s Annual Meeting learn about spirome-try.

See Asthma...on page 23



District V

The excitement in Orlando atNCE was exceptional withmore than 15,000 attendees,a dazzling opening session,hundreds of educational pro-grams, Section and Councilmeetings, and so many op-portunities to reconnect withfriends and colleagues. EvenMickey made a visit.

The exhilaration of the experi-ence lasts long after the flighthome. The breadth anddepth of the American Academy of Pediatrics andthe benefits it provides for its’ members and the chil-dren of the world is inspiring.

Several new developments have been announced. First, for the subspecialist, is the new web site “Spe-cialty Pediatrics” accessed from the home page ofaap.org. The site connects the specialist directly totheir area of interest, assistance with MOC, coding,and getting involved with the Academy.

Another new member benefit – EQIPP Modules thatare appropriate for Part 4 of MOC will be a memberbenefit beginning next year. This will be a great helpin maintaining certification with the American Boardof Pediatrics.

The greatest benefit of your AAP membership howev-er, remains your advocacy voice for children. TheAAP staff in Elk Grove Village and Washington D.C. –along with the strength of AAP pediatricians – contin-ue to speak for the issues of children on topics rang-ing from lead poisoning to payment for services. Thestrength of our numbers pays back and the strengthand credibility of the AAP is unequaled in our coun-try.

Thank you for all you do, and remember that yourAAP leaders are only an email or phone call away.

Marilyn Bull, MD, FAAP District V [email protected]

Website designed for subspecialist

Marilyn Bull, MD

Working with a local pulmonary function testing labSome practices choose to work within their local hos-pital system or local pulmonary function lab to im-prove scheduling processes as well as the communi-cation of results.

Quick reference spirometry interpretation 1. Check the quality of the test 2. Check the height, age, gender for accuracy 3. Look at the flow volume loop for general patternrecognition of obstruction 4. Check FEV1/FVC.

a. If it is low (<80), there is obstruction. b. If it is normal, check both the FEV1% predicted

and the FVC % predicted to make sure both are nor-mal. If both are low, this suggests restriction and fullpulmonary function testing with measurement of lungvolumes is recommended. 5. Check the FEV1% predicted to determine theseverity of obstruction.

a. >70% mild

b. 60-69% moderate c. 50-59% moderately severe d. 35-49% severe e. <35% very severe

6. If obstruction is present, give one unit dose of abronchodilator and repeat test.

a. A 12% or 0.2L increase in FEV1 is considered asignificant improvement.

Kimberly Spoonhower, MDAsthma Expert for CQN3

References:NIH. National Asthma Education and Prevention Program:Expert panel report 3: guidelines for the diagnosis and man-agement of asthma. Bethesda (MD): National Heart, Lung,and Blood Institute. NIH Publication No. 07-4051. NIHPublication No 07-4051; 2007.

Pellegrino, R. et al. Interpretation strategies for lung func-tion tests. European Respiratory Journal. 2005; 26: 948-968.

Asthma...from page 22



Ohio AAP 2013 Annual Meeting



Two FREE Opportunities for PRESCHOOL VISION SCREENING in a Primary Healthcare Setting from Prevent Blindness Ohio!

1. TRAINING: Attend (or send nursing/allied health staff) a training to learn how to perform stereopsis and distance visual acuity screening for your preschool age patients. Receive FREE equipment ($300+ value), educational materials and certification! Log onto www.WiseAboutEyes.org for more information.

2. ON-DEMAND WEBINAR: Pediatricians Dr. Chris Peltier and Dr. Jeffrey Jinks provide information on children’s eye diseases and disorders and discuss the importance of conducting screenings for ocular alignment and visual acuity. FREE patient education materials! Register at https://oh.train.org. (search Preschool Vision Screening or Course ID 1035426).

Funded by the Ohio Dept. of Health, Bureau of Child and Family Health Services, Save Our Sight Program



New members...from page 18Tal Aaron Minuskin, MD, OrientAlisha E. Moreno, ColumbusKatherine Moyer, DO, Gahanna

Robert P. Myers, DO, CentervilleRobert D. Needlman, MD, Pepper PikeEdith M. Nieves-Lopez, MD, CincinnatiChristopher Ryan Nitkin, MD, Shaker Hts.Muhammad Farrukh Noor, MD, CambridgePatricia Olivia O'Brien, MD, CincinnatiGregory James Omlor, MD, AkronOlutoye Olunuga Osunbunmi, MD, DaytonNora Oulad Daoud, ClevelandBrian Pan, MD, CincinnatiNithiyakalyani Panneerchelvam, KentAarti Patel, MD, CincinnatiCarol Lynn Patterson, MD, ChesapeakeJeffrey Pence, MD, SpringboroConnie Marie Piccone Sankaran, MD,University Hts.Giovanni Piedimonte, MD, ClevelandSandra M. Pinkham, MD, Upper ArlingtonJackie Lee Quach, MD, DelawareGilbert A. Ratcliff Jr., MD, ProctorvilleJessica Ray, Winder GADavid Roy Repaske, MD, ColumbusAmanda Christine Reyburn, DO, WestlakeEmmanuel Reyes-Cortes, CincinnatiJamie Rhodes, RaylandJuli Mari Richter, MD, DublinLisa Rickey, CincinnatiBethany D. Roell, Toledo

Montiel Teresa Rosenthal, MD, CincinnatiChayatat Ruangkit, MD, ClevelandGrace Young Ryu, MD, ColumbusShehzad Ahmed Saeed, MD, CincinnatiColin J. Salle, Port ClintonScott Schachinger, DO, AkronJosh Klughaupt Schaffzin, MD, PhD, CincinnatiSharon A. Schell, MD, MaumeeBradley Joseph Scherer, BeavercreekKari Lynn Schneider, MD, CincinnatiMeri Le Schrader, MD, CincinnatiRuth Barron Seabrook, MD, ColumbusPratima Shanbhag, CincinnatiHani Siddeek, CincinnatiRobert Michael Siegel, MD, CincinnatiPhillip Neal Simon, MD, ColumbusKirsten Simonton, MD, CincinnatiLindsay Marie Smith, Pine Grove CADane A. Snyder, MD, ColumbusGary Edward Snyder, MD, ColumbusMargaret Somple, DO, ZanesvilleKathy Peccatiello Sorger, MD, MontgomeryKathryn Spectorsky, CincinnatiSandra Patrice Spencer, MD, WorthingtonMark Louis Splaingard, MD, ColumbusAnthony Stallion, MD, Charlotte, NCKasey Rae Strothman, MD, DublinEmily Anne Stuart, MD, ColumbusKaren Diane Sullivan, MD, CincinnatiHurikadale P. Sundaresh, MD, SolonPatcharapong Suntharos, MD, Cleveland

Nicholas Szugye, CincinnatiMaria Margarita Talavera, DO, DublinMagdalino Maraguinot Tatad, MD, LimaIra Barry Taub, MD, University Hts.Lauren Taylor, BeavercreekTiffany Christine Thomas-Lakia, MD, MentorRenee Peta-Gae Thompson, MD, HilliardJennifer Treasure, CincinnatiThaddene O'Connor Triplett, MD, XeniaMark H. Tucker, MD, HollandCharles P. Van Tilburg, MD, MedinaPatricia Vega Fernandez, MD, CincinnatiJohn O. Vlad, MD, CortlandNeha Vyas, MD, ClevelandShannon Wagner, Ann Arbor, MIGregory Walker, MD, CincinnatiJennifer Walton, MD, MPH, ColumbusCarmen Maria Weeber-Morse, MD, PerrysburgAshleigh Welko, BeavercreekOlivia Kay Wenger, MD, WoosterSteven Sanford Wexberg, MD, Pepper PikeDerek Scott Wheeler, MD, CincinnatiElizabeth R. Whitaker, MD, ColumbusEric Thomas Whitney, CincinnatiGary David Williams, MD, Broadview Hts.Stephen E. Wilson, MD, CincinnatiKelly Wiseman, CopleyChristina Bezon Wu, ColumbusNeha Yakhmi, ToledoDebra Zauner, North OlmstedRachel Zylberberg, MD, Columbus

We reward loyalty. We applaud dedication. We believe doctors deserve more than a little gratitude. We do what no other insurer does. We proudly present the Tribute® Plan. We honor years spent practicing good medicine. We salute a great career. We give a standing ovation. We are your biggest fans. We are The Doctors Company.You deserve more than a little gratitude for a career spent practicing good medicine. That’s why The Doctors Company created the Tribute Plan. This one-of-a-kind benefit provides our long-term members with a significant financial reward when they leave medicine. How significant? Think “new car.” Or maybe “vacation home.” Now that’s a fitting tribute. To learn more about our program benefits, including the Tribute Plan, call our Columbus office at (800) 666-6442 or visit www.thedoctors.com/tribute.

Tribute Plan projections are not a forecast of future events or a guarantee of future balance amounts. For additional details, see www.thedoctors.com/tribute.

www.thedoctors.com

11:26 AM


The Ohio AAP announces the following meetings and events.

• Jan. 7, 2014 – Preschool Vision Screening Learning Session

Ohio AAP Office

• Jan. 31, 2014 – Expert Roundtable, Ohio AAP Office Topics: ICD-10 Physician Training, Young Physicians/Residents Mentoring Reunion, Teen Driving, Medicaid’s Role in ICD-10 Coding

• Feb. 22, 2014 – BMW Wave 3 Learning Session Cincinnati Children’s Hospital, Liberty Campus

• April 4, 2014 – Expert Roundtable - Topic: Hospitalist

• April 26, 2014 – BMW Wave 3, Sawmill Creek Resort, Huron

• May 9-18, 2014 – Bike Helmet Safety Awareness

• May 17, 2014 – Lions, Literacy and Lunch, Columbus Zoo

• Sept. 4-6, 2014 – Annual Meeting, Embassy Suites, Dublin, OH

Calendar of Events

Dues remitted to the OhioChapter are not deductibleas a charitable contribution,but may be deducted as anordinary and necessary busi-ness expense. However, $40of the dues is not deductibleas a business expense be-cause of the Chapter’s lob-bying activity. Please consultyour tax adviser for specificinformation.

This statement is in referenceto fellows, associate fellowsand subspecialty fellows.

No portion of the candidatefellows nor post residencyfellows dues is used for lob-bying activity.

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