Rang & Dale's Pharmacology Table Of Contents: General principles How drugs act: cellular aspects---excitation, contraction and secretion Chemical mediators Chemical mediators and the autonomic nervous system Other peripheral mediators: 5-hydroxytryptamine and purines Local hormones, inflammation and immune reactions Anti-inflammatory and immunosuppres ant drugs Drugs a
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NEWSLETTER OF THE MASSA o
CHUSETTS CHAPTER AMERICAN A
uCADEMY OF PEDIATRICS
Birth Defects Forms to Fill Out
There have been many coding and pro- probably flag a practice for a chart audit.
health plans in Massachusetts. The fol-lowing is a brief summary of some of the Membership Committee
As of September 1, 2003, BCBS will accept the modifier –25 with a preventive care visit, reimbursing the E&M code at 50% the seven-year limit on Candidate Fellows tation for the complaint is required. Also, as of September 1, 2003, BCBS will accept AAP educational activities, etc. The dues for the Candidate Fellows reach full dues 99050 code for visits after 5 p.m. is still plan for secure e-mail consultations with gram will be the “incentive grants” to local Clerkship Directors and sponsormedical student activities. Please let me number has been decreased 15%.
Patients covered by the SCHIP program list of drugs that require prior authori- took the American Board of Pediatrics(ABP — an organization entirely sepa- zation. If there are medications you feel to task on the issue of proctored recerti- fication exams. This method of recertifi- email@example.com.
children, for instance; 2) We are reporting series of telephone consultation codes.
September, so district officers can pres- recertification issue. Get your questions David Chung, M.D.
In addition to the print copy, there will In the last issue of the Forum, we prom-
insurance plan formularies. By using this www.mcaap.org. If there is sufficient inter-
est, we may also send this tool to you via Chapter President
Boston (617) 414-5202; Fax: (617) 414-4541 first four pages list five insurance plans Vice-President
to these pages for tier information on par- Worcester (508) 752-4511; Fax: (508) 797-4729 each medication and provide formu-lations and standard dosages.
Brockton (508) 894-0618; Fax: (508) 894-0618 Secretary
Arlington (781) 643-7155; Fax: (781) 643-0540 Legal Counsel
examination room for easy reference.
plans that participated for their gracious Kirkpatrick & Lockhart, Boston (617) 951-9143 assistance. Without their help, the MCAAP MCAAP formulary guide — its ease of use, District 1
could not have provided this tool for your Holyoke (413) 536-2393; Fax: (413) 536-1087 use. If you would like to see other major firstname.lastname@example.org.
Reminder from LDAM
Uxbridge (508) 278-5573; Fax: (508) 278-7142 The Learning Disabilities Association of Massachusetts (LDAM) would like to remind you that you should have received materials on learning disabilities in the month of District 4
June. If you have any questions, or would like more information, please contact Teresa Newton (617) 243-6000; Fax: (617) 256-1565 Citro at (781) 891-5009. You can also visit the LDAM website at www.ldam.org.
Chelmsford (978) 256-4363; Fax: (978) 256-1565 MCAAP COMMITTEES & ADMINISTRATIVE APPOINTMENTS
Emergency Pediatric Services
International Child Health
Marblehead (781) 631-7800; Fax: (781) 631-4319 Bylaws Committee
Fetus & Newborn
Boston (617) 638-8000; Fax: (617) 414-3679 Forum Editor
Child Abuse &
Brockton (508) 894-0400; Fax: (508) 894-0618 Continuing Medical
House of Delegates
& Poison Control
Cohasset (781) 383-6800; Fax: (781) 383-6504 2 The Forum
Submissions for the next issue of The Forum should be sent to email@example.com by September 15, 2003. F O R U M J O B L I S T I N G S
LOOKING FOR POSITION:
By Stephanie Schauer
Since the licensure of the varicella vaccine
in 1995, the number of cases of varicella in Massachusetts has significantly decreased.
To gain a better understanding of the epi- demiology of varicella in the post-vaccine Prevention expect all states to have indi- This individual reporting will allow bet- direction and, by early 2004, will initiate ★ A current draft of the one-sided form detect vaccine failures. In addition, break- boards of health, and schools all play an Looking to Hire or Be Hired?
unusual cases or situations involving vari- Job listings are a free service provided by The Forum to cella. For more information, or to make a MCAAP members and residents completing their training.
Nonmembers may submit ads for a fee.
983-6800 or toll-free at (888) 658-2850. If you are looking to fill a position
MCAAP members: Free
Please submit the following information:
MCAAP Committee Updates
function in this age group. It is recognized - Position Title and Description (25-word limit) that the use of this tool will take addi- - Availability (e.g., starting July 2003)- Contact Name - Address, Telephone Number, E-mail Address health services to those identified will be If you are looking for a job
MCAAP members and residents: FreeNonmembers: $50 screening test does not justify additional Please submit the following information: the Greater the Chance the Rest of the reimbursement for your services at a pre- ventive visit. A positive screening test, however, could justify additional charges if coordinating care. This can be billed using Please send text information via e-mail to firstname.lastname@example.org.
Checks may be mailed to the MCAAP office, c/o Cathleen Hag- accept it. Alternatively, you can schedule gerty, Executive Director, P.O. Box 9132, Waltham, MA 02454-9132. All submissions must be received by September 15, 2003, the patient for a return visit to separately to be included in the next issue of The Forum. All submissions are AAP.org address is issued to her/him.
address the mental health dysfunction.
subject to review for appropriateness. For further information, please contact the editor at email@example.com
the June issue of AAP News so be sure to ment in lieu of the usual code for preven- tive services, this will decrease your rate of well-visit compliance when analyzedusing CPT codes.
Children’s Mental Health
Task Force (CMHTF)
setting up a pilot program for pediatric/ Congratulations to the following new
psychiatrists or counselors for children 4 to 16 at preventive health visits. This firstname.lastname@example.org. You may also con-
http://psc.partners.org.The PSC tool is in the
sensitive and specific tool to identify dys- Send your e-mail address to email@example.com for instant notification of issues important to the MCAAP membership. The Forum 3
Pneumococcal Conjugate Vaccine Shortage Is Over! Pneumococcal conjugate vaccine (PCV7) Prioritization of Groups
Since providers may not be able to recall all children simultaneously due to logisti- cal or vaccine supply issues, groups to be recalled should be prioritized in the fol- Vaccine Ordering
During the vaccine shortage, providers in 1) Any infants <12 months of age with <3 doses or high-risk* children of any normal monthly vaccine orders by at least Background
patterns for PCV7 by increasing their next issued an advisory alerting providers that a “moderate” shortage of PCV7 existed in their practice per the guidelines above. We 2) Children <24 months of age with <4 anticipate vaccine orders will need to be 1) defer the fourth dose in children < 24 few months until catch-up is complete. As always, providers are encouraged to order months of age until adequate vaccine sup- plies were available. In Massachusetts, the affect the infant schedule, except possibly References
immunization of all children with medical www.cdc.gov/mmwr/PDF/wk/mm5219.pdf
administration of catch-up doses of pneu- also requested to maintain lists of children It is very important that we identify any mococcal conjugate vaccine. AAP News whose doses were deferred for recall when additional cases due to the vaccine short- www.aap.org/member/pcv0503.htm
demiology of Streptococcus pneumoniae * High-risk groups include children with sickle-cell disease, and its serotypes following PCV7 introduc- asplenia, HIV infection, chronic illness (including cardiac dis- tion. We urge providers to report all cases ease, pulmonary disease, and diabetes), CSF fluid leak, cochlear implant, or other immunocompromising conditions Minors’ Access Cards Available in Massachusetts This important new resource was devel- lescents in Massachusetts.
committed to ensuring that all people have specifically addressing contraceptive care and the American Civil Liberties Union of options counseling, abortion services, sex- calling Crystal Sanford at (646) 366-1890, nated pamphlet is small enough to fit into ext. 11, or by e-mailing firstname.lastname@example.org.
Health is a national, physician-led, not- rounds and visits with patients. The card for-profit organization whose mission is to www.prch.org.
ing the provision of health services to ado- more active and visible role in support of 4 The Forum
Submissions for the next issue of The Forum should be sent to email@example.com by September 15, 2003. (consider OTC cromolyn [Nasalcrom] and nasal saline washes [e.g., Neti pots]) (consider OTC Naphcon A, Opticon A, V Acne, topical
Antibacterial, oral (cephalosporins 1st generation)
Send your e-mail address to firstname.lastname@example.org for instant notification of issues important to the MCAAP membership. The Forum 5
(consider rubbing alcohol/vinegar for mild cases) Antibacterial, oral (cephalosporins 2nd generation)
Antibacterial, oral (cephalosporins 3rd generation)
Antibacterial, oral (macrolides)
Antibacterial, oral (penicillins)
6 The Forum
Submissions for the next issue of The Forum should be sent to email@example.com by September 15, 2003. consider OTC diphenhydramine [Benadryl] (consider OTC fungostatic clotrimazole [Lotrimin] or fungocidal terbinafine [Lamisil]) (consider OTC cimetidine, famotidine, ranitidine [T Antifungal, oral
Antihistamine (sedating —
Asthma therapy (bronchodilators, immediate relief)
Asthma therapy (controller medications)
Send your e-mail address to firstname.lastname@example.org for instant notification of issues important to the MCAAP membership. The Forum 7
(always consider using generics rather than branded steroids) (always consider using generics rather than branded steroids) Gastrointestinal
OCPs, progestin only
Steroids, topical, medium potency
Steroids, topical, high potency
Submissions for the next issue of The Forum should be sent to email@example.com by September 15, 2003. 10 mg/kg on day 1, 5 mg/kg days 2 to 5 for OM, 12 mg/kg/day x 5 days for strep pharyngitis 7.5 mg/kg/dose bid x 7 days — consider alternative to suspension due to poor flavor 10-15 mg/kg/dose tid — higher rate of GI upset (cephalosporins 1st generation)
Antibacterial, oral (cephalosporins 2nd generation)
Antibacterial, oral (cephalosporins 3rd generation)
Antibacterial, oral (macrolides)
cefadroxil (Duricef) 125/250/500 per 5 susp cephalexin (Keflex) 125/250 per 5 susp or cefaclor (Ceclor) 125/187/250/375/500 per cefprozil (Cefzil) 125/250 per 5 susp or cefuroxime (Ceftin) 125/250 per 5 susp or loracarbef (Lorabid) 100/200 per 5 susp or clarithromycin (Biaxin) 125/250 per 5 susp erythromycin 200/400 per 5 susp (EES) or MCAAP Formulary Guide: Drug Formulations and Dosing 50–100 mg po bid — less affected by dairy 0.5 mg/kg qday for 4 doses then 1.2 mg/kg qday Acne, topical
Note: Please consult your own dosing reference and consider drug interactions and contraindications. Doses by weight may not in benzoyl peroxide 5/10% cream, gel, or lotion benzoyl peroxide 5%/clinda (Benzaclin) gel tretinoin (Retin-A) 0.025/0.05/0.1% cream doxycycline 50/100 mg caps or 100 mg tabs methylphenidate (Ritalin) 5/10/20 mg tabs atomoxetine (Strattera) 10/18/25/40/60 mg Send your e-mail address to firstname.lastname@example.org for instant notification of issues important to the MCAAP membership. The Forum 9
10 mg/kg on day 1, then 5 mg/kg per day for oral/esophageal candidiasis or 150 mg po x1 for 200 mg bid x 1 week, repeat qmonth (2 months for fingernails, 3 to 4 months for toenails) 500 mg qday x 1 week, repeat qmonth (2 months 2.5 mg ages 2 to 5, 5-10 mg ages 6 and over 30 mg bid for ages 6 to 12, 60 mg bid or 180 mg 4 mg tid, max 32 mg per day (adult dosing) 400 mg tid x 7 to 10 days for 1st genital herpes, x 5 days for recurrent or 400 bid for suppression 250 mg tid x 7 to 10 days for 1st genital herpes, 125 bid x 5 days for recurrent or 250 bid for 1000 mg po bid x 10 days for 1st genital herpes, 500 bid x 5 days for recurrent or 500-1000 qd for Antifungal, oral
Antiviral (herpes treatment/prophylaxis for adults)
fluconazole (Diflucan) 10/40 per 5 susp or itraconazole (Sporanox) 10 per 5 liquid or Antifungal, topical
ciclopirox (Loprox) 1% cream (fungocidal) ketoconazole (Nizoral) 2% cream (fungostatic) cyproheptadine (Periactin) 2 per 5 syrup or hydroxyzine (Atarax) 10 per 5 syrup, 25 per MCAAP Formulary Guide: Drug Formulations and Dosing, 1-2 gtts q2 hours while awake x 2 days, then 1-2 gtts q4 1-2 gtts q2 hours while awake x 2 days, then 1-2 gtts q4 Start 25 mg qhs, increase by 25 mg in bid dosing Start 150 mg qam; after one week, increase Antibacterial, oral (penicillins)
Antidepressants (dosing for adult patients)
fluoxetine (Prozac) 20 per 5 solution or The Forum
Submissions for the next issue of The Forum should be sent to email@example.com by September 15, 2003. Steroids, oral
Steroids, topical (c = cream, l = lotion, o = ointment)
MCAAP Formulary Guide: Drug Formulations and Dosing, 10 mg/kg/dose q6 hours — Adults: 800 mg Asthma therapy (bronchodilators, immediate relief)
Asthma therapy (controller medications)
albuterol MDI or 0.5% conc soln or 0.083% levalbuterol (Xopenex) 0.31/0.63/1.25 mg fluticasone (Flovent) 44/110/220 mcg inhalers montelukast (Singulair) 4/5 mg chewable or Send your e-mail address to firstname.lastname@example.org for instant notification of issues important to the MCAAP membership. The Forum 11
DEP Resumes, Expands Air Quality Forecasting Reva Levin
high concentrations, they can cause seri- On May 1, with the arrival of warmer
season,” the Massachusetts Department of fine particles appear as haze, dust, or soot.
Airborne particles and droplets also tend daily air quality forecasting for ozone and year-round daily forecasts for fine particles distances. When they eventually settle to the surface, they can soil or damage prop- through Friday, with the Friday reportincluding air quality predictions for the Difference Between Particles
or particles are elevated and expected to ment visits, and hospital admissions.
forecast for the last several years, are simi- general public by updating the forecast on Other Sources of
its toll-free Air Quality Hotline (800) 882- 1497 and its website at www.mass.gov/dep,
2002 issue of The Forum). Each of them Information
as well as by notifying the news media.
What Particles Are and Where They
populations, and fossil fuel combustion is Come From
“Particles” or “particulate matter” are two pollutants is that particles can be a solid particles and liquid droplets in the problem at any time of year, unlike ozone, air we all breathe. Particles are a combina- www.epa.gov/region01/oms/index.html.
tion of fine solids (such as dirt, soil dust, therefore tends to be seasonal in nature.
pollens, molds, ashes, and soot) and liquid For this reason, the DEP issues forecasts droplets that vary greatly in shape, size, available at www.epa.gov/ttn/oarpg/
with a number of harmful health effects.
Air Quality Monitoring
quality with a network of monitors across the state since the 1960s. The primary goal group when particle levels are high. In a quality standards designed to protect pub- polluted with particles, children’s lungs particles in 1999 and currently maintains air as efficiently as children’s lungs in samples on filters that are analyzed in a laboratory with results usually available in basis, providing hourly measurements.
Currently, predictions of particle concen- trations are limited to the cities of Boston, Worcester, and in the near future, Spring- erly, particularly those with or prone to field. The DEP plans to expand its particle- asthma or other existing respiratory ail- casting in other parts of the state in the Health Problems Associated With
themselves during periods of high particle Particle Pollution
quality forecasting, please call Reva Levin The Forum
Submissions for the next issue of The Forum should be sent to email@example.com by September 15, 2003. President’s Message
roles to play, both passive and active.
than ever before; 5) Multivariate statisti- or highly illogical food, toxin, or factor Do you have patients in your practice
might be harmful. The answer is not “You after the fourth DTaP? Is it nearing time idiot, that’s ridiculous”; it’s “We have no Assessment Centers (CISA), in association meticulous studies looking specifically at a wide variety of factors than before. We of reactions after the fifth DTaP in children required, to participate in gathering this reactions after their fourth DTaP. Boston passed legislation last year that requires all physicians to report the presence of a direction of Dr. Colin Marchant in collabo- Adams, M.D.; Elizabeth Barnett, M.D.; andCatherine Fleming, M.D.
respond differently to, chemical and bio- Three Reasons This Research Study Is
accessed by visiting www.state.ma.us/dph/
1. To follow children after the fifth dose it’s a professional and medical one. The don’t, and certain elders get specific can- cognitive factors is for all of us to first accept the likelihood that they exist and not have reactions after the fifth DTaP.
studies that are required to discover the insecticides, food additives, and preserva- that will have real meaning over time.
If You Would Like to Refer Patients
– John G. (Sean) Palfrey, M.D., FAAP 1. Meet the family at your practice or any 2. Enroll patients, complete study proce- dures, and arrange and carry outfollow-up visits. The study visits willconsist of a vaccination/blood test visit, a follow-up visit, and two to three tele-phone calls.
We supply the pediatric physician’s office with nebulizers
To refer patients, please contact
Susan Michalski, R.N., at (617) 414-7423
to be dispensed to patients in need. This program is easy
or by e-mail at firstname.lastname@example.org
for the physician and easy for the patient. Call for details
Information is available at our
Servicing New England
Send your e-mail address to email@example.com for instant notification of issues important to the MCAAP membership. The Forum 13
Ben Scheindlin, M.D.
PROS (Pediatric Research in Office Set- forms on 40 children with injuries. The
practitioner will only be asked to enroll 30 children aged 2 to 11 years coming in for check-ups. This study is easy to work into and six months later. This is a very easy tices in 59 AAP chapters, PROS practition- study to do in the office — confidentiality and fall are ideal seasons to do this health of patient and doctor is assured — and the addressing important child health topics.
ter with 33 practices and 143 practition- the Floating Hospital is one of the princi- Norton of Ware is one of the PROS practi- actively recruiting practitioners now.
pilot test CARES, and he is presently help- Child Abuse Recognition and
ing to recruit practices for the study.
Evaluation Study (CARES)
This descriptive study seeks to understand
Safety Check: A Randomized
how pediatricians assess injuries, distin- Controlled Trial to Prevent Child
manage those injuries in the real world. It This is the first interventional study in with linked educational materials, partici- pating practices will be randomly assigned suspected child abuse, an issue that con- to an innovative violence prevention inter- regular basis. Participating practitioners an unrelated anticipatory guidance inter- Maximize Your Revenues and Minimize Your Costs Receive a Financial Practice Assessment
If you would like an
We will benchmark your vital financial areas against experienced team of
professionals to provide a
financial consultation to
Offer good until September 15, 2003
Submissions for the next issue of The Forum should be sent to firstname.lastname@example.org by September 15, 2003. My “Critical Incident” as a Third-Year Student I’ll never forget my encounter with her at explained to her that she was going to die if
the hospital. Mrs. _____ was a 78-year-old she refused dialysis. Initially I thought that her decision to make. I knew it all along, lady with a history of chronic renal failure she did not understand the procedure, but but I just didn’t want to let her go. As long and bipolar disorder admitted to the hospi- as she’s competent, the choice, of living a tal for dialysis consideration. Her renal fail- she called “closure.” I felt absolutely help- end for up to 4 or 5 days a week or simply going to die if she was not put on dialysis telling herself that she’s lived a full life and through a chronic, not fatal, disease and unsure of whether I was going to deal more yet she’s refusing to choose life. I just ments, was hers. I realized that as physi- and let them make informed decisions. The was very close to her because she lived with ultimate will and choice to live rests with the patient and the patient only. What we lunch tray. She greeted me pleasantly, and could not walk or see very well. My brother want for the patient is irrelevant, no matter I introduced myself as a medical student.
her family, and her most recent hobbies.
Mrs. _____, choosing not to receive dialy- later attended her mother’s funeral. She sis, was going to die right in front of my called frequently during that time, lament- tures were remarkably similar to those of my grandmother when she was still alive. I ance from us. We all tried our best to be this discussion, and out of nowhere, tears strong for her, to say words of comfort and ally very close to Mrs. _____. Her bipolar disorder turned out to be a non-issue.
don’t think I ever appropriately grieved over my grandmother’s death. Mrs. _____’s decided to bring up the issue of dialysis replied, “So I guess I’m like your second inevitable death probably provided the first with her. I explained to her that in end- outlet for my bereavement since my grand- stage renal failure, dialysis acts as a “filter” that I was not willing to let her go. She metabolites from her blood. She looked at told me, “You’re still young, B_____, you’ll versations we shared. I did not tell any of get used to situations like this.” But I did my colleagues. I thought that it would be dialysis is.” So I asked her when she would locked up in a special place inside me for- like to start and if her family would be will- ever, but I share it today with all of you.
ing to help her out. She replied, “I’m not “hardened.” Not because I won’t care any- getting dialysis.” I was confused for a This article was submitted by a medical
student at Boston University School of
Medicine, Class of 2004.
IMPORTANT UPDATES FROM
REACH 1,200 PEDIATRICIANS
VIA THE FORUM
Send your e-mail address to email@example.com for instant notification of issues important to the MCAAP membership. The Forum 15
THE PRESIDENT WANTS YOU
♦ Feeling too busy to dive into MCAAP activities but NEWSLETTER OF
♦ Join your colleagues to further the goals of your THE MASSACHUSETTS CHAPTER
AMERICAN ACADEMY OF PEDIATRICS
♦ Build your professional network and extend the care you offer your patients beyond the examination room.
♦ Please let us know your areas of interest, and we will Name:_____________________________________________ Address: ___________________________________________ E-mail: ____________________________________________ Interests: __________________________________________ or e-mail Cathleen Haggerty at firstname.lastname@example.org.
President’s Message . . . . . . . . . . . . . . . . . 1
MCAAP Committee Updates . . . . . . . . . . . 1
What Is the MCAAP
Doing for You? . . . . . . . . . . . . . . . . . . . . . 2
Varicella Reporting . . . . . . . . . . . . . . . . . . 3
New MCAAP Officers . . . . . . . . . . . . . . . . 3
PCV7 Shortage Over . . . . . . . . . . . . . . . . . 4
Minors’ Access Cards . . . . . . . . . . . . . . . . 4
MCAAP Formulary Guide: Tiers . . . . . . . . 5
MCAAP Formulary Guide: Doses . . . . . . . 9
Air Quality Forecasting . . . . . . . . . . . . . . 12
Reactions to DTaP . . . . . . . . . . . . . . . . . . 13
PROS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Critical Incident . . . . . . . . . . . . . . . . . . . 15
– VOLUME 4 NO. 3 –
Published by the Massachusetts Chapter of the American Academy of Pediatrics, designed and printed by the Massachusetts Medical Society.
Chapter 12 RIOT CONTROL AGENTS INTRODUCTION CS ( o -CHLOROBENZYLIDENE MALONONITRILE) Physical Characteristics Clinical Effects CN (1-CHLOROACETOPHENONE) Physical Characteristics Clinical Effects SEVERE MEDICAL COMPLICATIONS FROM THE USE OF CS AND CN OTHER RIOT CONTROL COMPOUNDS DM (Diphenylaminearsine) CR (Dibenz (b,f) -1:4-oxazepine) CA (Bromobenzylcyanide)