text:
Arizona House of Representatives
House Majority Research
Kristine Stoddard~
Assistant Legislative Research Analyst
(602) 926-5299
To: JOINT LEGISLATIVE AUDIT COMMITTEE
1700 W. Washington
Phoenix, AZ 85007-2848
cc: Representative Rick Murphy, Chair
Senator Jim Waring, Vice-Chair
Re: Sunset Review of the Medical Radiologic Technology Board of Examiners
Date: December 2, 2005
Attached is the final report ofthe sunset review ofthe Medical Radiologic Technology Board of
Examiners, which was conducted by the Senate Health and House ofRepresentatives Health
Committee ofReference.
This report has been distributed to the following individuals and agencies:
Governor ofthe State ofArizona
The Honorable Janet Napolitano
President ofthe Senate
Senator Ken Bennett
Senate Members
Senator Jim Waring, Vice-Chair
Senator Carolyn Allen
Senator Marsha Arzberger
Senator Robert Cannell
Senator Barbara Leff
Speaker ofthe House ofRepresentatives
Representative Jim Weiers
House Members
Representative Rick Murphy, Chair
Representative David Bradley
Representative Laura Knaperek
Representative Linda Lopez
Representative Doug Quelland
Medical Radiologic Technology Board of Examiners
Department of Library, Archives & Public Records
Auditor General
Senate Republican Staff
Senate Research Staff
Senate Democratic Staff
House Majority Staff
House Research Staff
House Democratic Staff
Senate Health and House ofRepresentatives Health
Committee ofReference Report
Medical Radiologic Technology Board ofExaminers
Date: December 2,2005
To: Joint Legislative Audit Committee
Representative Rick Murphy, Chair
Senator Jim Waring, Vice-Chair
Pursuant to Arizona Revised Statutes (ARS) §41-2953, the Joint Legislative Audit
Committee (JLAC) assigned the sunset review of the Medical Radiologic Technology
Board of Examiners (Board) to the Senate Health and House of Representatives Health
Committee of Reference.
The Board was established by Laws 1977, Chapter 145, §1, as a division of the Radiation
Regulatory Agency. The Board is charged with protecting citizens of the state from the
harmful effects of excessive and improper exposure to ionizing radiation. This requires
that the Board issue certificates to and collect fees from those who meet the minimum
standards. The Board requires persons operating ionizing equipment to practice under
the direction of a licensed practitioner. The Board is responsible for disciplining or
revoking the certificates of those who violate the statutory standards of conduct.
Additionally, the Board establishes standards of education, training and experience and
requires the examination and certification of operators of x-ray equipment. This includes
conducting inspections to assure that only certified individuals apply ionizing radiation to
humans and assuring that certified individuals are not practicing beyond the scope of
their certificate.
Committee ofReference Sunset Review Procedures
The Committee of Reference held one public meeting on November 8, 2005 to review the
Board's responses to the sunset factors as required by ARS §41-2954, subsections D and
F, and to hear public testimony.
Committee ofReference Recommendations
The Committee of Reference recommends continuing the Medical Board of Radiologic
Technology Board of Examiners for 10 years.
1. Sunset report requirements pursuant to ARS §4l-2954, subsections D and F.
2. Meeting Notice.
3. Minutes of the Committee of Reference meeting.
Arizona House of Representatives
House Majority Research
Kristine Stoddard ~
Assistant Legislative Research Analyst
(602) 926-5299
1700 W. Washington
phoenix, AZ 85007-2848
To: Members of the House and Senate Health Committees of Reference
Re: Sunset Review of the Medical Radiologic Technology Board of Examiners
Date: October 26, 2005
The Medical Radiologic Technology Board of Examiners (Board) is scheduled to sunset July 1,
2006. The following is a brief description of the history and duties of the Board, as well as the
Board's response to the sunset questionnaire. A public meeting is scheduled for November 8,
2005 to allow you to ask questions of the Board, take public testimony, and make a [mal
recommendation on the Board's continuation. If you have any questions or need further
assistance, please feel free to contact me.
BOARD mSTORY AND MISSION
The Board was established by Laws 1977, Chapter 145, §1, as a division of the Radiation
Regulatory Agency. The Board is charged with protecting citizens of the state from the harmful
effects of excessive and improper exposure to ionizing radiation. This requires that the Board
issue certificates to and collect fees from those who meet the minimum standards. The Board
requires persons operating ionizing equipment to practice under the direction of a licensed
practitioner. The Board is responsible for disciplining or revoking the certificates of those who
violate the statutory standards of conduct. Additionally, the Board establishes standards of
education, training and experience and requires the examination and certification of operators of
x-ray equipment. This includes conducting inspections to assure that only certified individuals
apply ionizing radiation to humans and assuring that certified individuals are not practicing
beyond the scope of their certificate.
October 26, 2005
The Board is a ten member board composed of four members who are practicing radiologic
technologists, who have at least five years' experience and who hold radiologic technology
certificates, two members who are licensed practitioners, one of whom is a radiologist; one
member who is a practical technologist in radiology and two public members. All members
serve three year terms that begin and end on the third Monday of January in the appropriate year.
The Board is statutorily required to meet at least once every six months. The Board is required
to hold examinations for applicants for certificates at least once every six months. Currently, the
Board certifies 7,702 technologists.
Pursuant to ARS §32-2823, the Board must deposit all monies for purposes oflicensure received
by the Board into the State Radiologic Technologist Certification Fund. In FY 2005, the State
Radiologic Technologist Certification Fund contained $247,700. The Board currently has three
full-time employees and two vacant administrative positions.
The Board does not require any statutory changes.
Staff contacted individuals and agencies in order to discuss their working relationships with the
Dick Gwilt from Indian Health Services stated that the COR must make a recommendation to
continue the Board because the Board serves over 5,000 radiographers and radiologic
technologists throughout Arizona. Mr. Gwilt also stated that the Board members have served
Arizona in the highest regard for years.
Janet Napolitano
Aubrey V. Godwin
4814 South 40th Street
August 29, 2005
Phoenix, Arizona 85040-2940 (602) 255-4845
Fax (602) 437-0705
Rick Murphy
State Representative
Chair, Health Committee of Reference
1700 West Washington, Suite H
Phoenix, AZ 85007-2844
Dear Chairman Murphy;
It is with pleasure I respond to your letter of June 30, 2005 regarding the sunset review ofthe Medical
Radiologic Technology Board of Examiners. Attached are the responses to the twelve factors listed in
your letter and in A.R.S. § 41-2954. In addition, also attached is the 2005 Annual Report of the Agency.
I look forward to responding to the questions the Committee of Reference may have regarding the
Again thank you for the time you and the Committee spend reviewing and improving this Agency.
/"I,_. A' t f7 ~ ~
/--t:~ /~ ~ l-r~
Aubrey y(Godwin, M.S., C.H.P.
1. The objective and purpose in establishing the agency.
Response. The Legislature created the Medical Radiologic Technology Board of
Examiners (Board) in 1977 to protect the public's health and safety against the harmful
effects of excessive radiation. Laws 1977, Chapter 145 § 1 state that protection "can in
some measure be accomplished by requiring adequate training and experience of persons
operating x-ray equipment."
The Board is statutorily empowered to determine minimum competency standards for
people who apply ionizing radiation to humans. The Board is charged with issuing
certificates to and collecting fees from those who meet these minimum standards. The
Board is also responsible for disciplining or revoking the certificates of those who violate
the statutory standards of conduct. The Board is authorize to conduct inspections to
assure that only certified individuals or those exempt from certification requirements
apply ionizing radiation to humans, and to assure that certified individual are not
practicing beyond the scope of their certificate.
2. The effectiveness with which the agency has met its objective and purpose and the
efficiency with which it has operated.
Response. The Board meets the requirements of the statute in that persons who have
demonstrated competence are certified to practice in Arizona. The Board either
administers a test or accepts those who have passed a national test of competence. In
addition, the Board investigates complaints regarding the competence of the certified
The current renewal process has all regular certificates issued to an individual expiring in
their birth month. This is the result of the amendment to the act, Laws 2001, Chapter 321
§ 5. This helps the certificate holders to remember their renewal date. Even so most of
the discipline cases are for a failure to renew the certificate. In addition, Laws 2002,
Chapter 233 § 2, added the practice on nuclear medicine technology and bone
densitometry technology to the list of certificates issued by the Board.
3. The extent to which the agency has operated within the public interest.
Response. The Board's authority to issue certificates to people who apply ionizing
radiation to humans serves the public interest by ensuring that those who hold such
certificates meet minimum competence standards. Such competence standards may
protect the public from unnecessary exposure to such radiation, and from misdiagnosis
due to inaccurate results from diagnostic tests. Since a violation of the statute is a petty
offence, when certified practice is detected and immediately stopped, they are not
referred to the county attorneys.
4. The extent to which rules adopted by the agency are consistent with the legislative
Response. The statute requires the Board to adopt rules setting minimum standards of
training and experience for persons to be certified. Since 1996, three rulemaking have
been completed. All were publicly announced and public comments received. The
Board has initiated further rulemakings to clarify current rules and define continuing
education requirements for renewals.
5. The extent to which the agency has encouraged input from the public before
adopting its rules and the extent to which it has informed the public as tom its
actions and their expected impact on the public.
Response. As noted in the previous response, all rulemakings have been appropriately
announced and we have received public input.
6. The extent to which the agency has been able to investigate and resolve complaints
that are within its jurisdiction.
Response. The Board received 246 complaints for the last three FYs. The Board was
able to resolve 192 of them during this time. In resolving these complaints the Board
initiated 242 investigations. Most of the complaints involved technologists working out
side of the scope of their certificate or failing to timely renew their expired certificate. At
least one case involved an individual who provided false training information on his
application. Several individuals were investigated who had criminal records.
7. The extent to which the Attorney General or any other applicable agency of state
government has the authority to prosecute actions under the enabling legislation.
Response. The Attorney General or county attorney has authority to prosecute actions
under the Board's enabling legislation. These would be prosecuted as a Class 2
misdemeanor, with a maximum fine of $750.00 and/or a sentence of not more than 4
months in jail.
8. The extent to which the agency has addressed deficiencies in its enabling statutes
that prevent it from fulfilling its statutory mandate.
Response. As noted above in 4., several changes to the statute have facilitated the ability
of the Board to conduct activities. These changes authorized the changes of the renewals
to the birth month of the certificate holder, clearly added nuclear medicine technologists
and authorized the bone density technologists as a practice group.
9. The extent to which changes are necessary in the laws of the agency to adequately
comply with these factors.
Response. It appears that the present statutory requirements are adequate. Recent
changes to the Statutes has certainly have aided the Board in accomplishing its mandates.
10. The extent to which the termination of the agency would significantly harm the
public health, safety or welfare.
Response. The termination of the Board would result in the gradual replacement of
trained personnel with untrained or barely trained operators. In time the radiation
exposure to patient will rise. Within perhaps 5 - 8 years many of the x-rays performed in
this state will expose areas of patients that should not have been exposed or use too much
x-ray to make the exposures. In both cases patients are receiving unnecessary radiation.
One could easily conclude that the situation would eventually be as it was when the
statute took effect in 1978, i.e. 67% of the x-ray equipment operators outside of the
hospitals and radiology clinics had no formal training in the use of x-ray equipment.
In addition, The State of Arizona would no longer comply with the Consumer-Patient
Radiation Health and Safety Act of 1981, P.L. 97-35.
11. The extent to which the level of regulation exercised by the agency is appropriate
and whether less or more stringent levels of regulation would be appropriate.
Response. In the Board's opinion, the present requirements for training and experience
of certificate holders are the minimum needed to properly use ionizing radiation on
12. The extent to which the agency has uses private contractors in the performance of
its duties and how effective use of private contractors could be accomplished.
Response. The Board uses test from the American Registry of Radiologic Technologists
to furnish the exams to those applying for the practical technologist certificate.
Additional issues to be addressed.
1. An identification of the problem or needs that the agency is intended to address.
Response. The Board is to assure the public of well trained users of x-ray equipment
when the x-rays are not applied by a licensed practitioner.
2. A statement, to the extent practicable, in quantitative and qualitative terms, of the
objectives of such agency and its anticipated accomplishments.
Response. The MRTBE certifies all users of human usage of radiation (except Dental)
by technologists. Of the 7,702 certified technologists, less than 10 are discovered or
reported as practicing without certification and training per year. In addition all
applications were processed within the time limits ofthe Agency.
3. An identification of any other agencies having similar, conflicting or duplicate
objectives, and an explanation of the manner in which the agency avoids duplication
or conflict with other such agencies.
Response. We are unaware of any current conflicts or duplication.
4. An assessment of the consequences of eliminating the agency or of consolidating it
with another agency.
Response. The termination of the Board would result in the gradual replacement of
trained personnel with untrained or barely trained operators. In time the radiation
exposure to patient will rise. Within perhaps 5 - 8 years many of the x-rays performed"in
this state will expose areas of patients that should not have been exposed or use too much
x-ray to make the exposures. In both cases patients are receiving unnecessary radiation.
One could easily conclude that the situation would eventually be as it was when the
statute took effect in 1978, i.e. 67% of the x-ray equipment operators outside of the
hospitals and radiology clinics had no formal training in the use of x-ray equipment.
In addition, The State of Arizona would no longer comply with the Consumer-Patient
Radiation Health and Safety Act of 1981, P.L. 97-35.
The consolidation of the Agency effects would be hard to estimate. The final results is
dependent on exactly how the law is amended in the combination of the Agencies.
X-ray Compliance Program
Radiation Monitoring Laboratory
Radioactive MateriallNon-Ionizing Program
Emergency Response
Medical Radiologic Technology Board of Examiners
During calendar year 2004, shippers reported that 13,700,000 Curies of radioactive materials in
the form of either Large Quantity Radioactive Material shipments or Highway Route Controlled
Quantity shipments which were shipped across Arizona. All but 15,000 Curies were transported
on 1-40. The appropriate legislative committees and Governor's Office were notified about the
general information of each shipment. In addition, law enforcement agencies were notified of
the details of each shipment. The carriers of such shipments were required to periodically notify
the Arizona Terrorism Intelligence Center while the shipments were in state. Please note these
statistics do not include any data for shipments smaller than the Large Quantity Radioactive
Material or Highway Route Controlled Quantity shipments. Virtually all of the shipments were
Cobalt 60 to be utilized in the irradiation of products.
The Agency conducted several training classes for first responders. In case of an accident
involving radioactive materials or a weapon of mass destruction, the first responders need to
have access to information regarding the presence and quantity of radiation. These classes
provide the necessary training for these individuals and the confidence to utilize the
instrumentation provided. The Agency is purchasing equipment for use in the event of a weapon
of mass destruction involving radioactive material. These devices are usually referred to as a
radioactive material dispersion device or RDD. The Agency has also participated in exercises
with the Phoenix Bomb Squad of the Phoenix Police Department.
In the event of a weapon of mass destruction attack in Arizona utilizing a radioactive material
dispersion device the Agency is prepared to advise the Governor and other elected officials of
the projected consequences. We estimate that if only one event occurs within the United States,
we will have federal support within 4 to 8 hours. If multiple events occur within the Unites
States, then federal support may be delayed by 12 to 48 hours arriving. Until federal support
arrives all radiological technical assessment will be made by the Agency.
In August of 2004, the Agency responded to a reported leakage of a U.S. Department of Energy
shipment. The shipment originated at the U.S. Department of Energy facility in Paducah, KY
and consisted of waste material bound for the Nevada Test Site for disposal. On arriving on the
scene, our representative determined, that while material was leaking out of the shipping
container, none of the leaked material was radioactive. Several questions did arise regarding the
adequacy of the shipping containers. We were informed that 3 of 5 containers were leaking in
this series of shipments. As a result of inquiries by the Governor, the U.S. Department of Energy
suspended the remaining shipments pending an investigation. The investigation was completed
in June and the shipments were expected to resume in July with improved containers and
packaging protocols.
As a result of concerns expressed by citizens in Mohave County regarding the fallout from the
Nuclear Weapons testing in the 1950s and 1960s, the Agency Director conducted a public
hearing. The Director's report of the hearing indicates that while some 50 persons testified as to
their personal suffering they were unable to specifically state the any given case was in fact
caused by the radiation exposure. Equally clear is, the Federal Government is paying
compensation to persons in other areas of the state which were exposed even less than the
cItlzens in Mohave County. The Director recommended to Governor Napolitano and the
National Academy of Science Committee that as a matter of simple equity, all of Mohave
County should be receiving such payments. The citizens were also quite concerned that the
United States may begin testing again, perhaps even secretly. At one time the Agency
conducted monitoring through out the State which would detect any unreported leaks of
significance, but the program had to be suspended due to budgetary constraints in 2002.
Fiscal Year 2005
The X-ray Program is responsible for the registration and inspection of machine produced
radiation sources. Personnel are also available to interact with registrants and the public on issues
of radiation safety.
Activity in the Program continues to increase. The number of facilities grew from 4501
Registrants in FY 2004 to the FY 2005 total of 4677 Registrants, a 3.9% increase. Concurrently,
the number of machines increased from 11028 to 11673, a 5.8% increase and the number of
tubes increased from 11683 to 12281, a 5.1% increase.
624 Facility Inspections were completed representing 13.3% of all registered facilities. These
inspections resulted in 101 violations occurring in 75 facilities. We inspected 1480 x-ray tubes
during FY 2005. We ended FY 2005 with 39.3 % of the facilities overdue for inspection
compared to 22.49 % overdue at the end of FY 2004. The overdue inspections can be directly
attributed to a reduction in the number of available, funded inspector positions.
X-ray Program Rules require that those personnel applying radiation to humans be either
licensed by the Medical Radiologic Technology Board of Examiners (MRTBE) or exempt from
the rules. There were 6 registrant MRTBE violations during FY 2005, which was less than the 17
violations in FY 2004. These violations do not include those issued by MRTBE. The decrease in
violations can be attributed to an increase in the MRTBE Investigator activity and a reduction in
the number of hospital and medical facilities inspected.
Numerous registration actions occurred during the year as facilities were bought, sold, traded,
merged and incorporated. These changes included replacement, modifications, additions and
deletions to radiation equipment inventories. There were 1801 documented record changes to our
database this fiscal year compared to 2212 changes in FY 2004.
Again, higher than usual personnel turnover was experienced during the year, which resulted in
filling 2 positions. At the end of the fiscal year, there were two unfunded positions. A budgetary
crisis during FY 2003 subsequently resulted in our loss of funding for two inspector positions.
In 1994 the Agency entered into an agreement with the Food and Drug Administration (FDA) to
administer the MQSA Program for the State of Arizona. This Program requires an annual
inspection of all state mammography facilities. Such an inspection consists of a comprehensive
review of the facilities' mammographic diagnostic capabilities inCluding the qualifications of
physicians, technologists and medical physicists; proper machine operation, development of
film, reporting of results, and medical audit of positive results.
The Agency has developed and implemented rules for state mammography facilities that either
coincide with the interim MQSA Law or provide for more specific rules applicable to the needs
of Arizona. As a result, a state inspection is also performed at the time of the MQSA inspection.
Substantial changes in state mammography regulations to comply with the final MQSA
Regulations of April 29, 1999, were made during the 5 year rule review and have been submitted
to the Governor's Regulatory Review Board.
During FY 2005, 140 facilities were inspected for the FDA and the state. Several facilities were
inspected more than once since their scheduled annual inspection rotation occurred twice during
the fiscal year. In retrospect, the State Inspection Program has improved the quality of
Mammography in Arizona as demonstrated by a gradual reduction in the number of violations as
the program has progressed. Specifically, the MQSA facility non-compliance rate has dropped
from 42% initially, to a rate of 15.9% at the end ofFY 1999. MQSA violations increased to 40 %
during fiscal 2000 due to new facility startups and final FDAlMQSA Regulation requirements.
State inspections during FY 2005 resulted in a noncompliance rate of 2.9%, a decrease in the rate
of 3.1% in FY 2004.
At present, the Agency has two State Health Physicist assigned to mammography inspection
duties. Future plans include training of an additional inspector to provide coverage for expanded
activities and personnel backup.
The FDA continues to encourage voluntary compliance as the primary goal of the MQSA
Program. The standards can be met with the continuous and diligent application of quality
control procedures. Improved diagnostic images and accurate mammographic film interpretation
will result in earlier detection of breast cancer prompting appropriate, life-saving, medical
During FY 2002 new rules were adopted which require those facilities with medical CT X-ray
Units to have their machine checked annually by a "qualified expert." The testing, as outlined in
the rules, involves checking CT machines for patient dose levels, table alignment, image
resolution and establishing quality control standard procedures. There are 177 CT facilities in
Arizona, an increase of 41.6 % over the 2004 total of 125. The CT facilities have demonstrated
compliance with the new rules for annual health physicist equipment review, providing the
patients with an additional measure of radiation safety.
We continued to be challenged by facilities that wished to do "walk-in" patients or what we call
screening. Rules allow a screening radiographic procedure only for mammography facilities. The
CT facilities are required to perform their studies, as are other medical facilities, based upon an
order from an Arizona licensed physician.
The regulatory and medical communities continue to debate the efficacy of "screening type CT
studies." While this discussion continues, the public is encouraged through advertisements to
seek out the CT Procedures that they think are appropriate for their personal health care.
The medical community introduced the new Pet/CT Combination Unit for diagnosing various
active disease processes, now referred to as Fusion Imaging. This temporarily created an issue of
technologist operator certification for us since nuclear medicine and x-ray were being used
Revisions in rules affected the radiographer community in Arizona by requiring a certification of
the radiation safety officer through testing. The American Society for Nondestructive Testing
was selected as the administrator for the examination. The Agency has proctored the examination
for radiographers several times during FY 2003. We are satisfied that this certification process
will improve the industrial radiography safety practices in Arizona.
Plans for FY 2006 are to maintain the overall number of inspections performed at a high level
consistent with efficient output. Newly hired State Health Physicists will continue their training
either at special off-site sessions or through in-service education within the Agency. We plan to
request additional clerical help to more efficiently respond to inquiries, to improve record
keeping and to shorten correspondence and registration application turn around time.
Fy2005 Annual Report
Category of Registrant Tubes Registered (%) Tubes Inspected (%) Facilities Non-Comp. (%)
Chiropractic 792 (6.45) 87 (10.98) 10 (11.49)
Dental 7,189 (58.54) 921 (12.81) 29(11.11)
Educational 154 (1.25) 2 (1.30) 0(0.00)
Hospital 1,252 (10.19) 39 (3.12) 3 (75.00)
Industrial 446 (3.63) 25 (5.61) 4 (33.33)
Medical 1,510 (12.30) 106 (7.02) 13 (20.63)
Mammography 265 (2.16) 214 (80.75) 4 (3.10)
Podiatry 133 (1.08) 12 (9.02) 3 (25.00)
Veterinary 540 (4.40) 62 (11.48) 9 (19.15)
Totals 12,281 1,468 (11.95) 75 (12.18)
Radiation Measurements Laboratory (RML) activities during Fiscal Year 2005 included the
following: Palo Verde Nuclear Generating Station (PVNGS) off-site radiological monitoring;
participation in emergency response drills at PVNGS requiring analytical analyses; limited
statewide environmental radiation monitoring; the Arizona Radon Project; and drinking water
analysis support to the Arizona Department of Environmental Quality (ADEQ).
The RML has continued to perform radiological monitoring in accordance with the Palo Verde
Nuclear Generating Station (PVNGS) Off-site Emergency Response Plan. This includes
sampling and analysis of air, water, soil, milk, vegetation, and fruit as well as the use of
thermoluminescent dosimeters (TLDs) to measure low-level ambient radiation. Resources
include a mobile laboratory for field sample analyses. Laboratory analysis results reveal no
increase in environmental background radiation levels in the vicinity ofPVNGS.
Due to budgetary constraints, the RML had to suspend monitoring other locations within the
state. The RML has contracted with the ADEQ to perform radioactive analyses for special
drinking water and aquifer studies in the state. Laboratory analyses results reveal some waters to
contain high levels of the naturally occurring radionuclides such as uranium and radium as
established by the Safe Drinking Water Act. Continued monitoring is necessary in assuring
future safe levels of radiation in Arizona's drinking water and represents one of the essential
components ofthe Agency's operations.
Annual Report FY 2005
The Radioactive Materials (RAM) Program is still struggling to adjust and adapt to the changing
needs of the Federal Government and the State of Arizona. The RAM Program, at this time, still
retains four FTE's and when filled, fulfills the varying duties plus their normal inspection and
compliance duties. One of the RAM positions spends most of their time drafting and publishing
new and amended rules that govern the way that the Agency conducts its licensing, registration
and inspection duties for the users of radioactive material and devices within the state.
Additionally, this person is also responsible for conducting administrative duties with regard to
RAM licensing, amendments and terminations. One of the RAM positions is tasked with the
duty of keeping up with the posting and entering of Sealed Source and Device (SS&D) changes
which are published by the United States Nuclear Regulatory Commission (USNRC).
Additionally, one person is responsible for maintaining a log of the Therapeutic and Diagnostic
Misadministration list. And finally, the fourth RAM member is responsible for the maintenance
of the out-of-state licensee's which use RAM within the state while performing work in Arizona
under Reciprocity.
Personnel shortage problems continue to plague the RAM program. The newly acquired RAM
inspector, hired in November 2003, sent to the USNRC five week course in September 2004 and
trained by the existing RAM inspectors, was lost to ASU in March of 2005. Fortunately, an XRay
inspector trained at the same USNRC five week course in September, 2004, was recruited to
fill the position. However, this person had to attend NEXT training on CT scanning X-Ray
devices and has to perform a number of inspections within the state on these devices.
Additionally, the individual has to be trained to perform RAM inspections. This Program has
been continually tasked with the need to train new personnel in the performance of their duties
which has caused the Program to fall further behind in the performance ofRAM inspections.
This is further complicated by the fact that a vacant RAM position can not be filled due to budget
constraints. This continues to have a deleterious effect on the ability ofRAM to keep up with its
schedule of required RAM inspections.
The continued non-availability of funding by the USNRC and the State of Arizona for the
training and maintenance of inspector expertise has impacted greatly in the ability of ARRA
inspection personnel to maintain currency with the fast changing regulatory requirements.
Arizona's regulatory authority to control sources of non-ionizing radiation stems from the Title
30, Chapter 4 sections authorizing other aspects of the program. The regulations controlling
sources of non-ionizing radiation are found at Title 12, Chapter 1, Article 14 of the Arizona
Administrative Code. The sources specifically covered by regulation include laser sources, radio
frequency (RF) sources, and sources of ultraviolet radiation produced by electronic devices. The
statutory authority and the regulatory framework appropriately cover these sources and will help
to assure Arizona residents of protection from unnecessary and hazardous exposures.
The number of nonionizing radiation registrants continues to increase annually. We have a
current total of seven hundred thirty six registrants as of July 1, 2005. The total number of
current registrants represents an overall increase of ninety-six new registrants. With the largest
number being medical laser users. Approximately 17 percent of the registrants were inspected
during the year.
The nonionizing radiation protection program has one FTE authorized. The program growth
requires that efforts be placed on significant issues and projects. Maintenance of a satisfactory
non-ionizing radiation program will require additional staffing. Additional time has been
utilized in support of the Radioactive Materials Program due to staffing shortages within the
NRC mandated program. Laser use in the human arena evolves daily with new procedures and
laser/light source equipment being developed. Significant increases in cosmetics/aesthetics for
hair removal and skin rejuvenation are being observed.
Title 12, Chapter 1, Article 14 of the Arizona Administrative Code has finally been approved and
is now in effect. The rule changes appear to have been accepted, with much activity in bringing
the registrants into compliance. An inordinate amount of time has been devoted to the
Cosmetic/Hair Removal issues during the year. This area of laser use is evolving faster that any
other aspect of non-ionizing radiation use and has the potential for significant impact on the
general public.
Licensing Statistics
Radioactive Materials Licensing and Inspection Program
Licenses (Total Number)
Medical (Types A, B, C, Broad and Tele)
General Medical
Industrial (Types A, B, C, Limited, Portable, and Fixed Gauges)
Industrial Radiography (Fixed and Mobile)
Academic (Broad and Limited)
Miscellaneous Licenses
Number of Particle Accelerator's
Number of High Dose Rate Brachytherapy's (Included in the Licensed Facility)
New Licenses and Renewals
New Particle Accelerator Registration and Renewals
Inspections Performed
Licensing Actions (Amendments and Terminations)
*** Reciprocity (Inspections)
As of January 1996, the RAM Program assumed the responsibility for the inspection and registration of
Particle Accelerators (PA's). Management ofthese radiation users was transferred to RAM from the XRAY
Not included in the overall Licensee total.
Reciprocity is Arizona's recognition of an out-of-state licensee's Specific License for the use of radioactive
materials within the State of Arizona. A General License is issued for this purpose.
Registration Type
Tanning Facilities
Medical Laser Facilities
Industrial Laser Facilities
NON-Ionizing Radiation Statistics
# Inspected
# Registrations
Laser Light Shows 9 51
Radio Frequency Facilities .'")I 24
Power Line Surveys 00
Other, include Radioactive Material 31
Total inspections 122 Total Registrations 736
New Registrants
Registrant Tenninations
Total Registrant Actions
The Emergency Response Program (ER) is involved in and responds to radioactive materials
(RAM) incidents. This includes preparation for and participation in offsite response to any
incident occurring at the Palo Verde Nuclear Generating Station (PVNGS); the transportation of
transuranics to the Waste Isolation Pilot Plant (WIPP), and on-scene response to hazardous
materials incidents statewide in which RAM is involved. Training is also provided to
organizations that respond initially to hazardous materials incidents around the state: police, fire,
medical and emergency service personneL The ER Program also tracks, and provides assistance
in inspections of special radioactive materials shipments that travel across Arizona Interstate
As part of the radiation emergency response planning effort, the program requested and was
granted U.S. Department ofHome Land Security funds. The funds have allowed the program to
acquire critical radiation monitoring equipment that will be essential to the response effort
should a radiological incident occur in the state. The program will continue to strive for
improvement in our planning efforts to meeting our state and national priorities of preventing
and responding to any radiological emergency.
Training this fiscal year involved conducting two four-day training sessions in response to the
Palo Verde Nuclear Generating Station (PVNGS). Several monitor pool refresher classes and
participation in a full-scale Plume Exposure DrilL The Program conducted a large number of
training sessions for hazardous materials first responders covering both "standard" response and
if necessary, response to a "Dirty Bomb" -Explosives with Radioactive Materials used by
terrorists. It is the Program's goal to continue to train, assist and respond to any and all
radiological incidents within our State.
The Waste Isolation Pilot Plant (WIPP) in southern New Mexico has been open for several years
and has been receiving transuranic waste. The first shipment of transuranics to the WIPP
occurred along Arizona 1-40 in January 2004. However, the waste scheduled to transit Arizona
will be from the Nevada Test Site and Lawrence Livermore National Laboratory and is
characterized as contact handled, meaning that radiation dose rate outside the containers is very
low. The Program's Emergency Response Coordinator for radioactive waste activities has been
extremely active in reviewing and streamlining WIPP-related training programs primarily for
first responders, but also for medical personnel and hospitals. Coordination and outreach
activities with affected state agencies, e.g., Emergency Management, Transportation and Public
Safety, and with the five counties through which 1-40 passes - Mohave, Yavapai, Coconino,
Navajo, and Apache - for medical and first responder training have been major functions of this
position during the past several years. Principal activities for first responders included
equipment issue, e.g., survey instrument kits to units not receiving them in FY 2004 including
instrument training; binoculars, instrument exchange for calibration; and personal protective
equipment. W1PP briefings were also conducted and several meetings involving the affected
states were held to assure continued safety.
During this fiscal year, ER and the Agency responded to 13 incidents involving radioactive
materials. Several incidents involved moisture/density gauges that were stolen or involved in
accidents; others involved radioactive scrap that were detected at the entrance of their facility
and reported to the agency. The most noted incident/response was a Department of Energy
shipment of Uranium Tetrafluoride (UF4) that appeared to be leaking material en route to the
uranium disposal site in Nevada. The incident response and investigation concluded no
radioactive material had leaked from the shipment package. Governor Napolitano was deeply
concerned about the incident and sent a letter to DOE requesting an appropriate investigation of
the shipping program for this campaign. The Governor also was concerned as to what steps are
being taken to improve the integrity of radioactive shipment across the State of Arizona.
The Agency has continued the program of placing civil defense monitoring instruments with
response organizations that want them. This year, ER calibrated 45 survey instruments, 200
dosimeters, and exchanged/distributed 45 civil defense instrument sets to HAZMAT
RADIOACTIVE SffiPMENTS THROUGH ARIZONA
Fifty three highway route controlled quantity (HRCQ) shipments totaling 10.7 million curies of
radioactive material crossed Arizona highways this fiscal year. Notifications were sent to DPS
officers to alert them of these shipments in the case of they are involved in an accident or
Communication is one of the most important aspects of emergency response planning as well as
of the actual response. During this reporting period, there were 55 Nuclear Alert Net (NAN)
drills and four telecommunications tests. The latter tests are those in which the entire
communications system is checked.
Emergency Response Program is committed to providing the best possible response capability to
the citizens of Arizona. The program will continue to work with our partners in the first
responder community and provide highest quality of assistance to any radiological accident or
incident in the state of Arizona.
Arizona Medical Radiologic Technology Board of Examiners
2004-2005 Annual Report
The Medical Radiologic Technology Board of Examiners (MRTBE) was established in 1977
after extensive study and review of documented statistics revealed that: (1) the major portion of
the populations man-made radiation exposure in the United States is from the use of medical and
dental x-ray producing equipment; and (2) of that portion, a significant amount is unnecessary
because ofthe sub-optimal use of equipment by the operator. The preamble of the MRTBE law
"It is declared to be the policy ofthis State that the health and safety of the people of the state
must be protected against the harmful effects of excessive and improper exposure to ionizing
radiation. Such protection can, in some major measure, be accomplished by requiring adequate
training and experience of persons operating ionizing radiation equipment under the direction of
licensed practitioners. It is the purpose of this act to establish standards of education, training
and experience and to require the examination and certification of operators of x-ray equipment."
Arizona Revised Statutes §32-2801 et. sec., provide for a Board of Examiners consisting often
members appointed by the Governor, and a statutory chairman who is the Director of the Arizona
Radiation Regulatory Agency. The responsibilities of the Board include:
Assuring that applicants have met minimum standards of education and training.
Setting standards for, and granting approval to schools of radiologic technology.
Administering certification exams for technologists, special permit applicants and refresher
exams for technologists who have not practiced for three years.
Conducting investigations to assure compliance with MRTBE statutes and rules.
Pursuing statutory remedies to resolve problems involving uncertified, non-exempt ionizing
machine operators.
Interacting with national and state professional and certifying organizations for technologists.
Assuring optimum testing standards by contracting when necessary with national professional
registries to administer certifying exams to qualified applicants.
Radiologic Technologist
Therapy Radiologic Technologist
Nuclear Medicine Technologist
Mammography Radiologic Technologist
Practical Radiologic Technologist
Practical Radiologic Technologist Unlimited
Practical Radiologic Technologist Podiatry
Special Permit
Number of Active Certificates
Aubrey V. Godwin, MS, Chairman
Tammy Allgood, Public Member
Carol A. Conti, Radiologic Technologist
Dean L. Gain, M.D., Licensed Practitioner
Marco Lara, Radiologic Technologist
Michael J. Locke, Practical Radiologic Technologist
Jonathan Sanders, Radiologic Technologist
Martin G. Schotten, Radiologic Technologist
Burton N.Shapiro, D.C., Licensed Practitioner
Shirley Wagner, Nuclear Medicine Technologist
Vacant, Public Member
John M.Gray, RT
Executive Director
Sarah Penttinen
Special Investigator
Stephanie Erra
Administrative Secretary
Administrative Secretary (2)
Correspondence should be to:
Mr. John Gray, RT; MRTBE; 4814 S. 40th Street; Phoenix, AZ 85040-2940. Phone (602) 2554845
Interim agendas can be obtained via the Internet at http://www.azleg.state.az.usllnterimCommittees.asp
Tuesday, November 8,2005
9:00 a.m.
House Hearing Room 1
1. Call to Order - Opening Remarks
2. Health Facilities Authority
• Presentation by the Health Facilities Authority
• Public Testimony
• Discussion and Recommendations by Committee of Reference
3. Medical Radiologic Technology Board of Examiners
• Presentation by the Medical Radiologic Technology Board of Examiners
• Public Testimony
• Discussion and Recommendations by Committee of Reference
4. Nursing Care Institution Administration and Assisted Living Facility Managers Board
• Presentation by the Nursing Care Institution Administration and Assisted Living
Facility Managers Board
• Public Testimony
• Discussion and Recommendations by Committee of Reference
5. Board of Homeopathic Medical Examiners
• Presentation by the Board of Homeopathic Medical Examiners
• Public Testimony
• Discussion and Recommendations by Committee of Reference
6. Arizona Alliance of Surgical Specialists
• Presentation by the Arizona Alliance of Surgical Specialists
• Public Testimony
• Discussion and Recommendations by Committee of Reference
7. Arizona Association for Home Care
• Presentation by the Arizona Association for Home Care
• Public Testimony
• Discussion and Recommendations by Committee of Reference
8. Arizona Midwifery Institute
• Presentation by the Arizona Midwifery Institute
• Public Testimony
• Discussion and Recommendations by Committee of Reference
9. Adjourn
Senator Jim Waring, Co-Chair
Senator Carolyn AI/en
Senator Marsha Arzberger
Senator Robert Cannell
Senator Barbara Leff
Representative Rick Murphy, Co-Chair
Representative David Bradley
Representative Laura Knaperek
Representative Linda Lopez
Representative Doug Quelland
People with disabilities may request reasonable accommodations such as interpreters,
alternative formats, or assistance with physical accessibility. If you require accommodations,
please contact the Chief Clerk's Office at (602) 926-3032, TOO (602) 926-3241.
Minutes of the Meeting
Tuesday, November 8, 2005
9:00 a.m., House Hearing Room 1
Members Present:
Senator Jim Waring, Co-Chair
Senator Carolyn Allen
Senator Marsha Arzberger
Senator Robert Cannell
Senator Barbara Left
Members Absent:
Representative David Bradley
Beth Kohler, Senate Health Research Analyst
Elizabeth Baskett, House Health Research Analyst
Representative Rick Murphy, Co-Chair
Representative Laura Knaperek
Representative Linda Lopez
Representative Doug Quelland
Co-chairman Murphy called the meeting to order at 9:12 a.m. and attendance was
noted. .
Presentation by the Health Facilities Authority
Blaine Bandi, Executive Director, Health Facilities Authority (HFA), stated that his
organization was established in 1977 to issue bonds exempt from income tax on the
Authorities interest which enables them to get lower interest rates. He explained that the
Authority would then loan their proceeds to health care facilities at lower rates than the
healthcare facilities would receive from banks. Mr. Sandi remarked that the Authority
provided low cost loans for rural and underserved healthcare facilities.
He stated that rural communities that have benefited from the program included:
• Flagstaff
• Kingman
• Prescott
• Wickenburg
• Douglas
• Springerville
• Page
• Bisbee
• Camp Verde
• Fort Mojave
• Peach Springs
• Sacaton
• Elfrida
• Morenci
• Ajo
• St. Michaels
. Bandi remarked that the Heaith Facilities Authority was not a reg!.llatory agency and
that it existed solely to improve the health care for the residents of Arizona through the
financing of critical health care projects. He remarked that failure to continue the
Authority would deprive the State's health care providers of a needed source of tax
exempt financing. He respectfully requested the Committee of Reference recommend
the Arizona Health Facilities Authority be continued for ten years.
In response to Senator Cannell's question about the possibility of a hospital not paying
their loan back, Mr. Sandi told the Committee that since the inception of the HFA in
1977, this had only occurred once. He remarked that payments by that hospital were
still being made to HFA. Mr. Sandi added that the residents of the State have no legal
obligation to back up those bonds because they were issued solely on the credit of the
Representative Knaperek asked Mr. Sandi to list the seven directors for HFA and he did
so as follows:
1. Bruce Gulledge, health care underwriter who does financing for health
care institutions across the country.
2. Donald Shropshire, former hospital administrator; Tucson Medical
3. Jennifer Ryan, community health center director from Southern Arizona.
4. Rufus Glasper, Chancellor of the Maricopa County Community College
Tuesday, November 8, 2005
Page 2
5. William Emerson, City Attorney for the City of Peoria.
6. Susan Straussner, Community Health Nurse from Parnell County.
7. Steven Russo, Sond Attorney based in Tucson.
In response to Representative Knaperek's question about funding, Mr. Sandi told the
Committee that the HFA's annual budget was approximately $300,000 per year and that
revenues to the Authority were generated through bond financing activities. He stated
that when the HFA approved bonds, applicants are paying one basis point, which is .01
of one percent of total financing. He remarked that additionally applicants paid 7.5 basis
points which was equal to .075 percent. Mr. Sandi told the Committee that the HFA
brought in between $300,000 to one million dollars per year, a five year cycle with one
million dollars every fifth year. He added that the extra money was used for loans to
other healthcare facilities in underserved parts of the State. Mr. Sandi told the
Committee that the credit rate was predicated on a number of things, the most
prominent being the credit worthiness of the applicant and also on the term and purpose
of~ loan. He remarked that he had seen the interest rates in the range of about four
petrent up to about seven percent.
Representative Knaperek asked the amount of savings in interest rates there was for
people who used the HFA services. Mr. Sandi responded that historically, the industry
used a figure of 15 percent savings going to tax exempt financing versus taxable
financing. He stated that today, when interest rates are lower, that 15 percent figure
would be closer to 10 or 11 percent.
In response to Representative Quelland, Mr. Sandi stated that the title holder on any
property in which the HFA loaned money is going to be that non-profit corporation. He
remarked that the HFA had liens on record for every loan they do. Mr. Sandi explained
that the bond financing has specific gUidelines and rules the HFA must follow in the
event of a default.
In response to Senator Leff, Mr. Sandi told the Committee that HFA hired a lobbyist
solely from lack of experience with legislative scenarios and to help the organization
navigate through the process.
Representative Quelland moved that the Senate Health and House
Health Committee of Reference recommend to continue the Health
Facilities Authority Board for ten years. By voice vote, the motion
Presentation by the Medical Radiologic Technology Board of Examiners
Aubrey Godwin, Director, Radiation Regulatory Agency, told the Committee that the
Medical Radiologic Technology Board of Examiners (MRTBE) was created in 1977 by
Tuesday, November 8, 2005
Page 3
legislation due to the large number of unqualified technicians in the State. He stated that
the role of MRTBE was to make sure that technicians or people applying ionizing
radiation to a human being had been properly trained. He remarked that the type of
technologist observed by MRTBE were X-ray, therapy. nuclear medicine and
mammography technologists. Mr. Godwin pointed out that nuclear medicine technology
had been added recently to MRTBE's certification program. He stated that MRTBE
presently had approximately 9,000 certificate holders, some of whom hold dual
certification. Mr. Godwin pointed out that most of the MRTBE cases dealing with
disciplinary matters were related to failure to pay dues or questionable certifications
since their last sunset review.
In response to Senator Allen, Mr. Godwin explained that drug treatment was made
available through MRTBE for certified technicians who may need it and failure to
successfully complete these proceedings would result in termination of certification.
In response to Senator Cannell, Mr. Godwin said that most of the drug related issues
with technicians took place in larger institutions such as hospitals as opposed to private
physician offices. He stated that if the institution where a troubled technician worked
had a drug treatment program, MRTBE would direct the technician to utilize that
program and if not, the technician would attend. an independent drug program paid for
by the technician.
In response to Senator Arzberger, Mr. Godwin remarked that due to the different State
requirements for technician certification, out of town applicants must be certified in
Arizona before working in this State.
In response to Representative Knaperek, Mr. Godwin told the Committee that there
were both nationally certified and non-nationally certified radiological technician schools
in Arizona. He stated that the vacancy on MRTBE had been available for less than one
In response to Representative Murphy, Mr. Godwin told the Committee that he looked
forward to finding a citizen to fill the vacancy on the MRTBE.
In response to Representative Knaperek, Mr. Godwin remarked that due to the shortage
of technicians in the State, Arizona has experienced an influx of out of State
In response to Senator Allen, John Gray, Program Manager, MRTBE, informed the
Committee that a high school graduate could enter into the field of radiological
technology either through community college or privately funded programs. He added
that private school training took two years or less.
In response to Senator Leff, Mr. Godwin stated that there was a continuing education
requirement in place for the field of radiological technology due to changing technology.
Tuesday, November 8, 2005
Page 4
Public Testimony
Jerry High, Arizona State Society of Radiologic Technologists, told the Committee
that out of concern for public safety, he was glad that certification was required before
becoming a technician.
In response to Senator Leff, Mr. Hyde said that passing the "Registry," a test sponsored
by the American Association of Radiologic Technology (AART) was very difficult, yet
allowed him to be nationally certified.
In response to Senator Leff, Mr. Godwin told the Committee that radiologic
technologists were certified professionals, not licensed professionals.
Stephen Sapareto, Director of Medical Physics, Banner Good Samaritan Hospital,
stated that he was the boss of the technologists at his facility and expressed the
importance of technologists to be certified. He pointed out that another group certified
by MRTBE were radiologic therapists, who administered ongoing care such as
chemotherapy, and that it was especially important for these therapists to be certified.
In ~Pbnse to Senator Leff, Mr. Safereto explained that radiologic technologists and
therapists had a chief technologist or therapist supervising them, followed by a chain of
command that ultimately led to a physician at his facility.
Jeff Siupik, Director of Radiation Services, MRTBE told the Committee that being a
director of technologists, he is concerned about the shortage of technologists in the
State due to strict standards by the MRTBE on non-local technologist operating
machinery in a crisis situation.
Senator Leff opined that two weeks, the time it takes for MRTBE to certify a non-local
technician, was not a long period of time.
Representative Quelland moved that the Senate Health and House
Health Committee of Reference recommend to continue the Medical
Radiologic Technology Board of Examiners for ten years. The motion
CARRIED by voice vote.
Presentation by the Board of Examiners of Nursing Care Institution
Administrators and Assisted Living Facility Managers
Allen Imig, Executive Director, Board of Examiners of Nursing Care Institution
Administrators and Assisted Living Facility Managers (BENCIAIALFM), informed
the Committee that the Board was created in 1975 to protect the public's health and
welfare by regulating and licensing nursing care institution administrators. He stated that
in 1990, the board statutes were amended to add the responsibility of certifying and
regulating adult home care managers and renamed in 1998 to Assisted Living Facility
Managers. The mission of the Board was to protect the health, welfare and safety of its
Tuesday, November 8,2005
Page 5
citizens, to seek and institute the use of services of nursing care institution
administrators and assisted living facility managers. Mr. Imig said that the Board's
procedures helped ensure quality and competency standards were met by
administrators and managers. In addition, the Board approves continuing education
courses to make sure quality and useful education is being taught. He explained that
since June of 2005, the Board had undergone an "extreme makeover" with virtually all
new members being appointed. This reduced the back log of uninvestigated complaints
significantly. Mr. Imig told the Committee that the Board had reduced their staff from five
to three, leaving an executive director, investigator and a licensing coordinator. He
encouraged the Committee to continue the BENCIAIALFM.
In response to Senator Allen, Mr. Imig said that the Board consisted of five managers,
two public members and the remaining members were administrators.
Senator Allen opined that home care nursing staff deserved better pay.
In response to Senator Waring, Mr. Imig stated that the changes made to the Board has
helped, but not solved its financial problems.
In response to Senator Arzberger, Mr. Imig said that his Board investigated complaints
from citizens regarding private care nurses and administrators as well as complaints
filed by the Department of Health Services.
In response to Senator Waring, Mr. Imig told the Committee that the Board's website
contained information regarding decisions on disciplinary action.
In response to Senator Allen, Mr. Imig explained that out of the last renewal period for
managers, 2,000 of 2,500-2,600 renewal notices sent were renewed, causing 578
expired notices to be sent by the Board.
In response to Senator Leff, Mr. Imig opined that his Board received between 60 and 70
complaints a year, mainly not health care related but administrative related.
In response to Senator Waring, Mr. Imig stated that with the current staff, the Board
should catch up on its back log of complaints by January 2006.
In response to Representative Quelland, Mr. Imig remarked that the Board was actively
seeking replacements for the three vacancies on the Board.
Senator Left suggested that the Committee send a letter to the Governor encouraging
her to appoint the three positions.
In response to Representative Quelland, Mr. Imig opined that he would like to see a five
year continuation be given to the Board.
Tuesday, November 8,2005
Page 6
Representative Knaperek remarked that time elected to the Board would reflect
concerns with term limits and not reflect faith in Mr. Imig.
Public Testimony
Robert Frechettee, President, Arizona Health Care Association (AHCA), told the
Committee that on behalf of his Board, he would like to offer support in the continuation
of the BENCIAIALFM. He opined that the efforts implemented by the new staff showed
that the Board was very serious about suggestions and concerns brought forth by the
In response to Senator Waring, Mr. Bruschette stated that the AHCA was seen as the
organization that represented the for profit facilities, containing some non-profit facilities
and representing assisted living communities and independent full service communities.
He said that Assisted Living Federation represents assisted living centers in homes and
the Arizona Association of Homes for the Aging represents a number of facilities seen
as non-profit businesses.
In response to Senator Cannell, Mr. Bruschette opined that if fee increases were
n~!sary to fund the continuation of the Board, that it would be supported by AHCA.
Senator Leff stated that if the Committee made a five year recommendation at this
meeting and the audit comes out in December and is changed, the legislation coming
out in January does not have to be the same as the recommendation.
Representative Knaperek told.the Committee that Mr. Imig had a good work history as a
Director in other fields.
In response to Representative Knaperek, Beth Kohler, Senate Health Research Analyst,
stated that the first audit of the Board would take place approximately six months after
nomination adding an 18· month follow up audit, only if the requirements and
recommendations made by the report were not met.
Representative Quelland moved that the Senate Health and House
Health Committee of Reference recommend that the Board of
Examiners of Nursing Care Institution Administrators and Assisted
Living Facility Managers be continued for two years. The motion
Representative Quelland moved that the Senate Health and House
Health Committee of Reference recommend that the Board of
Examiners Nursing Care Institution Administrators and Assisted
Living Facility Managers be continued for five years pending the
findings of the Auditor General's report due in December of 2005.
The motion CARRIED.
Tuesday, November 8,2005
Page 7
Presentation by the Board of Homeopathic Medical Examiners
Chris Springer, Executive Director, Homeopathic Board, told the Committee that
she had worked for the Board of Homeopathic Medical Examiners (BHME) since 1999.
She complimented appointments made to the Board by all of the Governors on both the
Democrat and Republican side. She opined that the laws governing the licensing of
homeopathic physicians set forth by the State had been upheld. Ms. Springer stated
that a potential audit could be helpful in improving procedures and welcomed the
process of an impartial audit. She said that the Board currently has 117 licensed
homeopathic physicians.
Senator Leff opined that it was nice to hear Ms. Springer suggest an audit of the Board
and noted that BHME had gone approximately 20 years without an audit.
Senator Allen opined that she would like to see an audit of the BHME as well. She
added that in no way did legislation intend to do away with the homeopathic form of
In response to Representative Lopez, Ms. Springer stated that a licensed homeopathic
physician could only continue to practice in one state after receiving disciplinary action
in another state for less than one year, due to the Board's annual. renewal application
required of all homeopathic physicians, which would discover the violation in the other
~~e. .
In response to Representative Murphy, Ms. Springer said that there was the possibility
of a physician being dishonest about any past disciplinary action, however, there is a
standard penalty in place for such an event.
In response to Senator Waring, Ms. Springer told the Committee that there was not an
easily accessible data base of criminal background checks for physicians and added
that the fee to search names on the federal data base was $3.75 per name.
Senator Leff opined that being dishonest on an application should have strong
consequences for any physician when dealing with the subject matter of past
disciplinary action.
Dr. Charles Schwengel, President of the Homeopathic Medical Licensing Board,
told the Committee that being dishonest on an application was the most egregious of
unprofessional conduct that could happen.
In response to Representative Knaperek, Ms. Springer stated that a physician lying on
the application was discovered once and a letter of concern was issued.
Representative Knaperek opined that there should be a certain amount of consideration
afforded to the applicant on whether the incident was an issue of forgetfulness or
deliberate intent.
Tuesday, November 8, 2005
Page 8
In response to Senator Cannell, Ms. Springer stated that setting aside funds to check
each individual physician's background would be a step in the right direction.
Senator Allen remarked that the concerns stated today could be addressed in the
forthcoming audit.
In response to Representative Quelland, Ms. Springer told the Committee that some
traditional doctors became homeopathic physicians, and then dropped their traditional
medical license.
In response to Representative Quelland's comments on a medical doctor dropping their
license to pursue homeopathy due to decreased chances of medical malpractice
occuring, Dr. Schwengel remarked that he could not comment on the personal reasons
a physician might do this.
In response to Representative Murphy, Ms. Springer stated that the percentage of
homeopathic physicians who were previously licensed as medical doctors was very low.
Rep~!entative Murphy told the Committee that some physicians may choose to not
carry medical malpractice insurance to avoid becoming a target for medical malpractice.
Senator Cannell opined that there was a fear with physicians of becoming a target for
medical malpractice by carrying medical malpractice insurance.
In response to Senator Waring, Ms. Springer stated that BHME kept records indefinitely
of reported complaints against homeopathic physicians. She told the Committee that in
her opinion, the BHME should only keep records for up to five years similar to other
medical boards.
In response to Senator Waring, Ms. Springer remarked that she felt it necessary to keep
records of complaints for longer than five years, only if they were substantiated.
In response to Senator Allen suggesting that more public members should be on the
BHME, Ms. Springer said that additional public members on the Board would be a good
Public Testimony
Dr. Kathleen Fry, dually licensed by the Arizona Medical Board and Arizona
Homeopathic Medical Board, told the Committee that she had gathered a large
amount of important information pertaining to the BHME that she would like to share
with the Legislature and the Office of the Auditor General. She stated that she had been
committed to the practice of homeopathic and alternative medicine for twenty years in
Scottsdale, Arizona. She remarked that it was not her intent to keep patients from
receiving homeopathic care. Dr. Fry opined that the BHME had been grossly negligent
Tuesday, November 8, 2005
Page 9
in its spiritual, moral and judicial responsibilities to protect the public from unscrupulous
physicians by licensing felons, failing to adequately discipline physicians who had
harmed patients, failing to adequately file complaints against other board members and
by giving licenses to physicians who could not pass a basic oral examination of
homeopathy. She stated that when she was recruited to the BHME in 1994, she was
informed by the Board that her dues were necessary to keep the Board in existence and
to allow her to continue to practice homeopathic medicine. Dr. Fry remarked that the
dues for the Association were $1000 per year in addition to the $500 per year licensing
fee and the $150 dispensing fee. She explained that if a homeopathic physician in
Arizona lost their M.D. license in another state, they could still practice homeopathy
here in Arizona which gives that physician the power to write prescriptions for all
classes of drugs, conduct minor surgery in their office, perform acupuncture and various
other medical techniques. In conclusion, Dr. Fry told the Committee that the
homeopathic license gives the physician a much broader range of modalities that they
can use with much less scrutiny and training.
In response to Senator Waring, Dr. Fry stated that in theory, physicians who had marks
on their records in other states should be rehabilitated in that state before being allowed
a license in Arizona, but that had not always been the case.
In response to Representative Knaperek, Dr. Fry remarked that transcripts from board
meetings that she had obtained from Ms. Springer, were public record.
In response to Senator Leff, Dr. Fry explained that a device called a sputnik originated
in Russia and is swallowed by a patient and designed to kill parasites by radiation. She
told the committee that a physician sold the device to a patient in Florida over the
phone, and that upon taking this device orally, the patient developed a bowel
obstruction resulting in the removal of several feet of her intestine. She added that the
said physician, being one of the originators of the BHME, only received a letter of
concern and an apology by the Board for placing that letter in the physicians file.
In response to Senator Waring, Dr. Springer told the Committee that she disagreed with
Ms. Fry's perception of the Board.
Dr. Todd Rowe, Homeopathic and Integrative Medical Physician, Desert Institute
of Classical Homeopathy, dually licensed, told the Committee that he had been
practicing homeopathic medicine for over twenty years. He urged the Committee to
continue the BHME. He remarked that after attending several meetings over the years
of the BHME, he had found most of what Dr. Fry said to be untrue.
In response to Senator Cannell, Dr. Rowe stated that the number of out-of-state
homeopathic physicians licensed in Arizona was very small. He explained that Arizona
was one of only three states who had homeopathy boards and that this was another
reason for an increase in out-of-state applicants in this State.
Tuesday, November 8,2005
Page 10
In response to Senator Left, Dr. Rowe said that his homeopathy school had a 1,000
hour program for homeopathy, with plans on expanding that program to 4,000 hours
within the next few years.
In response to Senator Left, Dr. Rowe stated that the qualifications for a license for
homeopathy consisted of either 40 hours of class of homeopathy, in addition to 300
hours of alternative medicine, or 90 hours of class for homeopathy. He opined that this
met the minimum requirements to become a homeopathic physician and commented on
the fact that some applicants were already licensed medical doctors.
Lee Bakunin, practicing attorney in Arizona for 36 years, representing self, told the
committee that he had spent the last eleven years of his life studying homeopathy. He
explained that after the required 90 hours, there was no continuing education required
to continue practicing homeopathy. Mr. Bakunin said that the Auditor General may
come across the problem of incomplete records of past BHME meetings.
In response to Representative Quelland, Mr. Bakunin said that he currently had studied
about2,000 hours of homeopathy.
Glady~ Conroy, patient of homeopathy, representing self stated that homeopathy
had saved her life. She told the Committee that standard medication caused her great
Clifford Heinrich, practicing family physician for alternative medicines, opined that
no alternative medical board should be able to have jurisdiction over the spiritual
practice of homeopathy. He added that he had obtained over 1,200 hours of
homeopathy. Dr. Heinrich told the Committee that he had a petition with 200 signatures
recognizing homeopathy as a spiritual practice. He stated that he had an additional
petition to request the Legislature audit the BHME for "reasons previously addressed in
the meeting."
In response to Senator Allen, Dr. Heinrich opined that· homeopathy was being
misrepresented by the BHME from its original spiritual foundation, causing the public to
believe they were receiving homeopathic care when in fact, they were not.
In response to Representative Knaperek question about the spiritual aspect of
homeopathy, Dr. Heinrich explained that a nonmaterial substance was one that had
been diluted to a point where the original property is no longer there, leaving only the
essence of that object.
In response to Representative Murphy, Dr. Heinrich told the Committee that he wanted
the separation between homeopathy and alternative medicines distinguished by the
Amanya Jacobs, Director of Evolution of Self/Soul School Homeopathy, remarked
that she was deeply committed to making homeopathy available to all citizens in the
Tuesday, November 8, 2005
Page 11
State. She said that the Board regulated activities that it deemed homeopathy which
were totally unrelated to that area of medicine. Ms. Jacobs stated that she was in favor
of an audit of the BHME.
Linda Heming, Arizona Homeopathic and Integrative Medical Association, told the
committee that western medicine could not help her and homeopathy saved her life.
Senator Leff remarked that the open meeting law stated that recordings and minutes
must be kept by the open body and must be accurate and open for inspection three
days after the meeting, with no language about whether or not they could be destroyed
at any time period.
Russell Olinsky, patient of homeopathy, spoke in favor of the BHME.
Cynthia MacLuskie, patient of homeopathy, told the Committee that all homeopathy
medicines were not available at health food stores and that prescriptions were the only
way to obtain some of these medicines.
Lisa Platt, Arizona Homeopathic and Integrative Medical Association, speaking on
b;~ha!f of the BHME, remarked that BHME was not recruiting felons. She stated that a
number of patients had told her how homeopathy had saved their lives.
Senator Allen moved that the Senate Health and House Health
Committee of Reference recommend that the Board of Homeopathic
Medical Examiners continue for two years, adding the request for an
audit addressing the concerns covered in today's committee.
Representative Quelland explained his vote. He said that although he did not have an
educational background in homeopathy, the homeopathic physicians had a certain
amount of disagreement and confusion among themselves. He reminded the
Committee that this was just a recommendation and that someone was going to create
a bill and that bill would be voted on, making today's vote not a guarantee that the
Board will continue, and he voted "aye."
Senator Cannell explained his vote. He said that although he advocated homeopathy
and the continuation of the Board, that the BHME had suffered a "major black eye"
today. He opined that the director and the president of the boards had not changed their
attitudes and that they should consider their Board a precious commodity by not diluting
their group of good physicians with out of state applicants with questionable credentials
and he voted "aye."
Senator Leff explained her vote. She requested the Auditor General to do both a
financial and performance audit. She remarked that the people who came forward today
against the Board should feel free to do so without retaliation and she voted "aye."
Tuesday, November 8, 2005
Page 12
Senator Waring explained his vote. He said that he was very frustrated with the Board,
and that he would be the first to vote "no" on a bill in the following session if changes
weren't made, but since today's vote was merely a recommendation, he would vote
Representative Murphy explained his vote. He said that he shared many of the
concerns voiced by the Committee members today and looked forward to hearing what
the Auditor General had to say and he voted "aye."
The motion CARRIED by a roll call vote of 9-0-1 (Attachment 1).
Representative Murphy RECESSED the meeting at 1:35 p.m. to the sound of the gavel.
Representative Murphy RECONVENED the meeting at 2:30 p.m.
Presentation by the Arizona Midwifery Institute
Marinah Valenzuela Farrell, President of the Arizona Midwifery Institute (AMI),
sUQ"mitted handouts (Attachment A) and (Attachment B) to the Committee. She told the
Committee that as midwives, their main concern was for safe outcomes of mothers and.;.~
babies. She remarked that midwives chose home birth because they believe that birth is
a natural and safe event in the life of a woman. Ms. Farrell explained that in the 1970's,
midwifery became licensed in the State, yet because of medical liability issues,
midwives had experienced difficulty in consults with physicians and access to items to
assist in home birth. .
In response to Senator Allen, Ms. Farrell stated that midwife licensing exams were very
tough and that she had received specialized intravenous training in New Mexico through
the local hospital.
In response to Senator Cannell, Ms. Farrell told the Committee that licensing of
midwives was dependent upon number of hours of experience in child birth delivery with
that applicant. She stated that there were also schools available to midwives that
involved intense clinical training. Ms. Farrell said that a surveyor in the Department of
Special Licensure administered a national exam to applicants in which upon passing,
the applicant must then go through an oral board and upon passing this, must complete
a practical exam which is overseen by the surveyor and· other midwives. She told the
Committee that midwives were trained in resuscitating babies.
In response to Senator Leff, Ms. Farrell stated that the midwives were requesting that a
physician not be required to sign off on supplies.
Representative Lopez opined that her own personal experience of giving birth to her last
two children at home from midwives was a wonderful experience.
Tuesday, November 8, 2005
Page 13
Representative Quelland informed the Committee that Arizona had 53 licensed
midwives with 22 of them located in Maricopa County and that there were 343 midwife
births in the home in 2004 in the State.
In response to Representative Quelland, Ms. Farrell remarked that none of the 343
reported midwife births reported in 2004 resulted in any problems. She stated that
although medical malpractice and liability insurance was available to midwives, the
majority refused it due to its cost in proportion to their pay. She told the Committee that
the Arizona Health Care Cost Containment System (AHCCCS) discontinued the
payment for midwife delivery two years ago due to midwives not carrying medical
malpractice and liability insurance which could possibly put AHCCCS at risk for such
Senator Left stated that midwives dealt mostly with low-risk births and that she would
like to see the issue of AHCCCS discontinuing payment for midwife births examined.
Senator Cannell opined that the Committee should hear from AHCCCS because they
obviously found midwifery funds a financial risk for some legitimate reason.
Ms. Farrell told the Committee that mothers who chose home births mainly did so, not
for financial reasons, but because of belief that the hospital environment was just one
intervention leading to another.
Public Testimony
Rory Hays, Arizona Nurses Association, said that the items asked for by the AMI
were appropriate, if accompanied by more training. She stated that she opposed
expanding prescription privileges for anything requiring a Drug Enforcement Agency
In response to Representative Quelland, Ms. Hays said that certification would be
appropriate for midwives.
Ms. Farrell stated that the only thing midwives were requesting was the power to obtain
items already in their reach through a physician, without that physician's pre-approval
and that the laws were already in place on limitations for uses with these items.
Representative Quelland moved that the Senate Health and House
Health Committee of Reference recommend that the Legislature
expand the scope of practice for Arizona's licensed midwives by
allowing procurement, possession, and administration of various
medical devices and medications which will be named in the bill. The
motion was CARRIED by voice vote.
Tuesday, November 8,2005
Page 14
Senator Allen opined that midwifery was a choice to be made by the citizen and she
hoped that fatalities did not occur due to the choice of using such a method.
Presentation by the Arizona Association for Home Care
Suzanne Gilstrap, representing the patients for the Arizona Association for Home
Care (AAHC), stated that AAHC was founded in 1983 with a mission to advance quality
home care as an integral component of the health care delivery system. She told the
Committee that she believed in continuing education for home care providers. She
remarked that AAHC had discussed having a joint workshop with the Physical Therapy
Association (PTA) but never actually initiated these workshops. Ms. Gilstrap requested
that the Committee grant an expansion to allow physical therapy assistants to work
under general supervision of a physical therapist as opposed to direct supervision. She
told the Committee that the AAHC respectfully requested the joint Committee
recommend that physical therapy assistants be allowed to practice in the home health
care setting and only in that setting under the following conditions:
• The supervising physical therapist shall be solely responsible for
evaluating the patient and determining a plan of care.
• The supervising physical therapist shall be available at all times via
telecommunication while the physical therapist assistant is providing
treatment interventions.
• The supervising physical therapist supervises no more than two physical
therapy assistants. .
• The supervising physical therapist shall see the patient and revise the plan
of care no less than every 21 days.
• The supervising physical therapist not assign responsibilities to the
physical therapy assistants that in any way allow them to provide
evaluation services for procedures.
• Continuing education requirements should be added to the statute as well.
• The physical therapist would be the one responsible for final evaluation
and discharge of the patient.
In response to Senator Arzberger, Ms. Gilstrap said that proposing a mileage limit would
be a good idea in reference to a physical therapist along with the constant
telecommunication contact. She stated that it was not unusual to recommend that the
practice of home care be extended to other areas outside of the home such as
Tuesday, November 8, 2005
Page 15
In response to Senator Left, Ms. Gilstrap remarked that the AAHC was not intending to
mandate what physical therapists do, but to enable legislation that would allow them to
In response to Representative Murphy, Ms. Gilstrap stated that home care therapist
assistants were well schooled for their job no matter what setting, with the exception of
no clinical experience required of the physical therapist.
In response to Senator Waring, Ms. Gilstrap remarked that in all fields of medicine,
health care providers were experiencing an inability to serve patients.
Representative Lopez opined that an outside organization should not be directing
physical therapists on how to conduct their practice.
In response to Senator Allen, Ms. Gilstrap told the Committee that currently more than
45 states allow general supervision in the home health care setting and that the only
two states that do not allow it are Pennsylvania and Arizona.
Public Testimony
Karen Jeselun, President of the Arizona Association for Home Care, stated that
even if there were no home care physical therapist available at the time, a patient could.
still be released from the hospital even though they required home care to continue
recovery. Ms. Jeselun compared the relationship between a physical therapist and a
physical therapist assistant to that of a registered nurse and a licensed practical nurse.
She told the Committee that all of their home care providers go through an interview
process, a mandatory criminal background check and participate in orientation often
with preceptors.
In response to Representative Knaperek, Ms. Jeselun stated that Medicare currently
paid home health agencies on an episode basis, meaning for every 60 days of time that
patient is in the care of a home health provider, the home care provider gets a lump
sum. She opined that she was hoping to serve more patients with no increase in cost.
Susie Stevens, representing the Arizona Physical Therapy Association (AZPTA),
informed the Committee that the definitions of general supervision and direct
supervision needed to be reviewed. She stated that she was there in opposition to the
sunrise request.
Heidi Herbst Paakkonen, Executive Director of the Arizona Board of Physical
Therapy (ABPT), told the Committee that the ABPT regulates about 3,200 physical
therapists and 434 physical therapist assistants. She said that due to lack of detailed
information at this time, she would encourage the Board to oppose the Sunrise
Application of the AAHC.
Tuesday, November 8,2005
Page 16
In response to Representative Knaperek, Ms. Paakkonen remarked that there were
exactly 3,268 licensed in the State but not all of them worked in Arizona. She told the
Committee that approximately 2,800 physical therapists listed Arizona addresses. She
stated that there were 434 physical therapy assistants and that approximately 396
reside in Arizona and that it was ABPT's estimate that 350 of them were currently
working in the field of physical therapy.
In response to Representative Quelland, Ms. Paakkonen stated that the ABPT was
required by statute to have three physical therapists and two public members, but no
physical therapist assistants.
In response to Senator Leff, Ms. Paakkonen told the Committee that the ABPT does
and has disciplined physical therapist assistants.
Bob Direnfeld, President of the Arizona Physical Therapy Association (AZPTA),
remarked that his organization was the only one in the State representing physical
therapists. He told the Committee that his association opposed the idea of general
supervision. Mr. Direnfeld said that patients were getting discharged from the hospital
too early in most cases compared to years ago, which cause a greater need for these
home care physicians. He remarked that a therapist was ultimately responsible for
anything the physical therapy assistant does which puts the physical therapist's license
on the line.
In response to Representative Murphy, Mr. Direnfeld opined that passing legislation
supporting general care could potentially decrease an even larger amount of physical
In response to Senator Cannell, Mr. Direnfeld stated that he was not sure that there was
a shortage in home health care providers. He also remarked that setting a parameter or
definition of a home care patient, would cut down on the patient load.
Representative Knaperek opined that physical therapist assistants should have more of
a vote on the Board.
Peter Zawicki, in favor of the sunrise recommendation, told the Committee that
physical therapists and physical therapist assistants were trained at community colleges
and technical schools across the country. He opined that it was critical that there be
communication between the physical therapist and the physical therapist assistant in all
patient care.
In response to Senator Cannell, Mr. Zawicki stated that physical therapist assistants
were under direct supervision during the education process.
In response to Representative Murphy, Mr. Zawicki remarked that to be able to perform
in public health care, it would be helpful if a physical therapist assistant had a certain
amount or certain tvJIoe of trainina_ .
Tuesday, November 8, 2005
Page 17
Senator Leff opined that home health patients are the most vulnerable patients and she
felt uncomfortable "experimenting" with the care of those patients.
Kerry Halcomb, Physical Therapy on Wheels, representing AAHC, opined that he
did not believe that a physical therapist could adequately supervise a physical therapist
Gayle Haas, physical therapist, representing AAHC, remarked that a physical
therapist and a physical therapist assistant can work together for years and develop a
relationship which allowed for better understanding and communication skills with one
Deborah Bornmann, physical therapist, stated that she did not feel represented by
her own board. She opined that it was great for an outside organization to try to help
physical therapists.
Representative Quelland moved that the Senate Health and House
Health Committee of Reference recommend that the Legislature
expand the scope of practice for licensed physical therapist
assistants by allowing home health visits under the general
. supervision of licensed physical therapists. The motion was
CARRIED by voice vote.
Senator Waring stated that although he was unhappy with what he had heard
today, he hoped discussions were started to improve the situation.
Representative Knaperek remarked that she hoped they could work out their
differences for the benefit of the State.
Senator Arzberger opined that changes do need to be made and issues need to
be addressed.
Representative Murphy stated that hopefully, this would get people back into
There being no further business, the meeting was adjourned at 5:12 p.m.
RespectfUlly submitted,
Jeff Turner
Committee Secretary
(Tapes and attachments on file in the Secretary of the Senate's Office/Resource Center, Room 115.)
Tuesday, November 8,2005
Page 18
Senate Health and House of Representatives Health Committee
of Reference
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Rep. Bradley
Rep. KnaR~rek
Rep. Lopez
Rep. Quelland
Senator Allen
Senator Arzberger
Senator Cannell
Senator Left
Senator Waring, CoChair
Rep. Murphy, CoChair
Committee Secretary J~; =tJ fSNbl2-.
November 8, 2005
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Click tabs to swap between content that is broken into logical sections.


text: Well went to the bow shop and they had a last years Nemesis for 499. I said I'll give you 450 and they said 479 ok and I said and one of those Trophy Ridge Punisher 5 sights. So an Alien has landed at my house just 15 minutes ago with a new sight. I'll post a pic as soon as I get a chance.

subset: commoncrawl


text:
- Base0"
- Season0"
- 0Open Runs
- 0Groomed Runs
- 0Running Lifts
With diverse terrain for beginner ease to challenging expert runs, Snowbasin also offers three progressive terrain parks and 26km of groomed Nordic trails. With 3,000 skiable acres and 3,000 vertical feet, Snowbasin is best known for wide-open bowls, gladed runs, manicured groomers, powder stashes days after a storm, and rarely a lift line. Snowbasin has world-class snowmaking and one of the most advanced lift systems in the West.
Enjoy award-winning cuisine including mountaintop dining with spectacular views and magnificent day lodges. Make the most of day on the mountain with more than 100 certified instructors, adaptive programs, state-licensed day care and children's programs. And for more family fun, don't miss the four-lane lift assisted tubing hill.
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Snowbasin is just 35 miles north of Salt Lake City with easy access to the Park City Area. Après ski in Downtown Ogden, just 17 miles away. Find out why Snowbasin is consistently recognized as one of the best of the best!


text:
Juvenile rheumatoid arthritis (JRA) is a disease of the joints in children. It can effect a child over a long period of time. JRA often starts before the child is 16 years old.
In JRA, the joint to become red and swollen. It will make the joint painful and difficult to move. JRA can also lead to long term damage to the joint. For some, JRA can interfere with the child's growth and development.
There are five major types of JRA:
- Pauciarticular JRA—four or less joints are affected in the first 6 months of illness
- Polyarticular JRA—five or more joints are affected in the first 6 months of illness
- Systemic onset JRA (also called Still's disease)—affects the entire body, least common type of JRA
- Enthesitis associated arthritis—there is also swelling of the tendon at the bone
- Psoriatic arthritis—associated with a skin disease called psoriasis
JRA can be a serious condition. Your child will need care from a doctor. The sooner JRA is treated, the better the outcome.
JRA is caused by a problem of the immune system. The normal job of the immune system is to find and destroy items that should not be in the body, like viruses. With JRA, the immune system attacks the healthy tissue in the joint. It is not clear why this happens. The immune system problems may be caused by genetics and/or factors in the environment.
Risk Factors
There are no clear risk factors for JRA. Factors that may be associated with some types of JRA include:
- Girls are more likely to get JRA than boys
Family history of:
- Anterior uveitis with eye pain
- Inflammatory back arthritis (ankylosing spondylitis)
- Inflammatory bowel disease
- Arthritis and a family history of psoriasis in a first-degree relative (for psoriatic arthritis)
JRA symptoms may be mild or severe. If your child has any of these, do not assume it is due to JRA. These symptoms may be caused by other, less serious conditions. See your doctor if your child has any of these symptoms:
- Joint stiffness, especially in the morning or after periods of rest
- Pain, swelling, tenderness, or weakness in the joints
- Fever
- Weight loss
- Fatigue or irritability
- Swelling in the eye—especially associated with eye pain, redness, or sensitivity to light
- Swollen lymph nodes
Growth problems, such as:
- Growth that is too fast or too slow in one joint (may cause one leg or arm to be longer than the other)
- Joints grow unevenly, off to one side
- Overall growth may be slowed
Some symptoms are specific to each type of JRA. For example:
Symptoms common with
pauciarticular JRA include:
- Problems most often found in large joints. These joints include knees, ankles, wrists, and elbows.
- If left-side joint is affected the right-side similar joint will not be affected. For example, if right knee is affected the left knee will be healthy.
- May also have swelling and pain at on the tendons and ligaments attached to the bone.
Symptoms common with
polyarticular JRA include:
- Problems found most often in small joints of the fingers and hands. May also affect weight-bearing joints like the knees, hips, ankles, and feet.
- Joints on both sides of the body are affected. For example if left hand is affected the right hand will also be affected
- May also have a blood disorder called anemia . This is an abnormally low number of red blood cells.
One type of polyarticular JRA may occur with:
- A low-grade fever
- Nodules—bumps on parts of body that receive a lot of pressure such as elbows
Symptoms common with systemic onset JRA include:
- Some of the first signs may be a high fever, chills, and a rash on the thighs and chest. May appear on and off for weeks or months.
- May have swelling in heart, lungs, and surrounding tissues.
- Lymph nodes, liver, and/or spleen may become enlarged.
- Children with enthesitis arthritis often have tenderness over joint where the pelvis and spine.
- Children with psoriatic arthritis often have finger or toe swelling. There may also be damage on fingernails.
Often, there are remissions and flare-ups. Remission is a time when the symptoms are better or disappear. Flare-ups are times when symptoms become worse.
More than one test may be needed to diagnose JRA. The tests will also help to eliminate the possibility of other diseases.
Your doctor will ask about your child's symptoms. You will also be asked about your family medical history. A physical exam will be done. Your child may be referred to a special doctor if JRA is suspected. The specialist is a doctor that focuses on diseases of the joints.
Tests that may be ordered include:
- Images of joints and bones such as x-rays
Laboratory tests on blood, urine, and/or joint fluid:
- May be used to eliminate other health conditions such as physical injury, infections, other autoimmune diseases, and some forms of cancer
- Can also help to determine specific type of JRA
- Eye examinations—to look for swelling in the eye
Talk with your doctor about the best plan for your child. The plan will work to control swelling, relieve pain, and control joint damage. The goal is to keep a high level of physical and social function. This will help keep a good quality of life. Treatment options include the following:
There are several types of medication that may be used:
- Nonsteroidal anti-inflammatory drugs (NSAIDs)—to help swelling and pain
- Disease-modifying antirheumatic drugs (DMARDs)—to slow the progression of the disease
- Tumor necrosis factor (TNF) blockers —to decrease swelling, pain, and joint stiffness
- Interleukin inhibitors—to reduces disease activity
- Corticosteroids through IV or by mouth—for swelling
- Steroid injections into the joint—may help relieve swelling and pain in some children
Polyarticular JRA may become inactive in children who begin medications within 2 years of onset.
Physical Therapy
Exercise is done to strengthen muscles and to help manage pain. Strong nearby muscles will support the joint. It also help to recover the range of motion of the joints. Normal daily activity are encouraged. Non-contact sports and recreational activities may be good options. Physical activities can also help boost a child's confidence in their physical abilities.
Physical therapy may be needed. This will help to make the muscles strong and keep the joints moving well.
Maintenance Devices
Splints and other devices may be recommended. They may be worn to keep bone and joint growth normal. Some joints may get stuck in a bent position. These devices can help prevent this.
Revision Information
- Reviewer: Kari Kassir, MD
- Review Date: 12/2013 -
- Update Date: 09/02/2014 -


text:
Petrossian - New York
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Room is downstairs with windows looking out on 58th Street. Furnished with oak floors, mirrors and a faux fireplace
Semi Private space that can hold up to 32 for seated dinner or 40 for cocktails
Can be screened off for semi privacy.
Buy - out for whole restaurant capacity 75 - minimum of $10,000.00


text:
Ends at midnight! Get 20% off everything with code LIKEFAMILY. Details.
Enter code LIKEFAMILY in your shopping bag to receive 20% off your order. Discount excludes Gift Certificates and items in our Art Collection. Not applicable to previous purchases. Only one promo code per purchase; not combinable with any other offers or your Designer Circle discount. Offer ends at 11:59 pm (PT) on 10/14/2014.
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