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By: Paul Reynolds, PharmD, BCPS
- Critical Care Pharmacy Specialist, University of Colorado Hospital
- Clinical Assistant Professor, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
http://www.ucdenver.edu/academics/colleges/pharmacy/Departments/ClinicalPharmacy/DOCPFaculty/Q-Z/Pages/Paul-Reynolds,-PharmD.aspx
It may be considered in un (unresponsive to muscle relaxant overdose treatment generic zanaflex 2mg free shipping noxious stimuli) or under general usual or rare circumstances muscle relaxant pictures purchase zanaflex 2 mg online, such as natural disasters anesthesia quercetin muscle relaxant cheap 2mg zanaflex overnight delivery. Alternate methods with fewer conditions and bon dioxide is acceptable with conditions for use in disadvantages are recommended whenever feasible spasms right flank buy zanaflex without a prescription. The disadvantages of electrocution outweigh stances, including but not limited to, natural disasters its advantages; therefore it is not recommended for and large-scale disease outbreaks. Alternate meth with fewer conditions and disadvantages are recom ods with fewer conditions and disadvantages should mended for companion animals where feasible. A method cause of the limited information available regarding acceptable with conditions, use of gunshot may be their effectiveness and high probability of pain asso appropriate in remote areas or emergency situations ciated with injection in awake animals. Doing so will assist in re trolled laboratory setting has been described as an ef lieving anxiety and pain for the animal, in addition to fective and humane method of euthanasia for rabbits reducing safety risks for personnel. Penetrating captive bolt is not recommended as a routine approach to the euthana sia of dogs, cats, or other small companion animals, S1. The resistance of altricial neonates (eg, sedation or even death of animals that consume the cats, dogs, mice, rats) to euthanasia methods whose body. For this reason safe handling and appropriate mechanisms rely on hypoxia suggests that the uterus disposal of the remains are critically important. Addi should not be opened for substantially longer periods tional information is available in Section I8, Disposal than for precocial neonates,24 perhaps 1 hour or lon of Animal Remains. When circulation is compro the S5, Avians; S6, Finfsh and Aquatic Invertebrates; mised by the animal’s condition and sedation or anes and S7, Zoologic and Free-Ranging Nondomestic Ani thesia may reduce the likelihood of successful injec mals sections of the Guidelines. Alter via an injection of a barbiturate or barbituric acid natively, general anesthesia may be induced, followed derivative (eg, sodium pentobarbital) as previously by administration of a euthanasia agent. Fetuses should be left undisturbed in the uterus for 15 to 20 minutes after the bitch or queen S1. This guidance is also gener Euthanasia protocols in large breeding facilities ally applicable to nonmammalian species, with eutha may differ from those utilized in a clinical practice set nasia of eggs per guidance provided in the S5, Avians; ting. Indications for euthanasia in breeding facilities S6, Finfsh and Aquatic Invertebrates; and S7 Zoologic include neonates with congenital defects, acquired and Free-Ranging Nondomestic Animals sections of abnormalities or diseases within any segment of the the Guidelines. Intraperitoneal injections of pento population, or other conditions that render animals barbital should be avoided whenever possible during unsuitable for breeding or sale. Euthanasia may be the later stages of pregnancy due to the likelihood of performed on an individual-animal basis, or in groups. Re od of euthanasia in preweanling dogs, cats, and small gardless of method and number of animals being eu mammals. Intraosseous injection may also be used, if thanized, procedures must be performed in a profes strategies are used to minimize discomfort from in sional, compassionate manner by trained individuals jection by using intraosseous catheters that may be under veterinary oversight. Appropriate techniques in place (see Section M2, Noninhaled Agents, of the for assuring death must be applied individually, re Guidelines), or if the animal is anesthetized prior to gardless of the number of animals being euthanized. When and tissue collection can also be a critical factor af euthanizing animals that are well socialized without fecting choice of euthanasia method. One indi (eg, bilateral thoracotomy, exsanguination, perfusion vidual restrains the animal and the other administers with fxatives, injection of potassium chloride). Animals used tious animals, a sedative or anesthetic should be ad in infectious disease studies may require special han ministered prior to attempting euthanasia. Be All activities related to the euthanasia of rodents cause of the diversity of animals received by shelters, deserve consideration equivalent to the euthanasia technicians performing euthanasia must have a good method itself, and may factor into the choice of meth understanding of animal behavior and restraint, the od. Activities that contribute to distress in rodents in proper use of equipment, and the variety of euthana 26 clude transport, handling (in animals not accustomed sia drugs available and their effects. Meth has mandatory veterinary input and considers animal ods of euthanasia likely to elicit distress vocalizations welfare, requirements for postmortem tissue speci or pheromones that other animals in the room could mens, and interference of euthanasia agents or meth hear or smell may be best performed in another loca ods with study results. Sim form strong emotional bonds with companion ani ilarly, wild-caught animals should be handled and eu mals in scientifc settings, so sensitivity to grief and compassion fatigue is necessary. Death should be confrmed by physical examination, ensured by adjunctive physical method, or obviated S2 Laboratory Animals 46 by validation of euthanasia chambers and process. Methods acceptable with conditions are equiva lent to acceptable methods when all criteria for ap S2. The euthanasia dose is typically 3 elsewhere in the Guidelines, and usually apply to times the anesthetic dose. Some other commonly used barbiturate for laboratory rodents commonly used laboratory animal species are ad because of its long shelf life and rapidity of action. Venous but the degree of pain and a suitable method for con access in these animals is typically diffcult, and in trolling pain have yet to be defned. Euthanasia meth Dissociative agent combinations—In conscious ods can lead to metabolic and histologic artifacts rodents, ketamine and similar dissociative agents that may affect research outcomes. When used as a sole euthanasia agent Ethanol—Intraperitoneal injections of 70% to delivered via vaporizer for anesthetic induction and 100% ethanol may be an appropriate method of eu overdose, animals may need to be exposed for pro thanasia for adult mice when physical methods are longed time periods to ensure death. Cervical dislocation re understanding that there is potential for increased quires neither special equipment nor transport of the distress due to dyspnea at lower fow rates or mucous animal and yields tissues uncontaminated by chemi membrane pain associated with fow rates at the high cal agents. If handled correctly, rats and mice tings and has been determined to be as aversive as do not show evidence of hypothalamic-pituitary-ad other inhalants,52,66 it is acceptable with conditions as renal axis activation from decapitation or from being present when other rats or mice are decapitated. Personnel should be trained on anesthetized Nitrous oxide—Although nitrous oxide may be or dead animals to demonstrate profciency. There are no data to support the use sia of laboratory animals as they are not rapidly act of hypothermia as a single method, and it should be ing, require high doses, and are not true anesthetic followed with a secondary method following loss of agents. As cold surfaces can cause tissue damage Urethane—Urethane is a human carcinogen and presumably pain, the animals should not come used as a laboratory rodent anesthetic under certain in direct contact with ice or precooled surfaces. It has a slow onset of action but a long pothermia for anesthesia is not recommended after duration of anesthesia. Rat and mouse pups are born cervical region is acceptable with conditions for fetal neurologically immature when compared with hu and neonatal mice and rats. Precocial young should the research goals will often infuence the choice be treated as adults. Appropriate restraint for the species cy to breath-hold when confronted with unpleasant must always be applied. In a controlled cation with sedatives may reduce potential aversion setting such as a biomedical research facility where responses. In large commercial production operations for ceptable with conditions for rabbits when performed biomedical research or meat, or to safely euthanize by individuals with a demonstrated high degree of injured wild rabbits, the method selected will de technical profciency. The need for technical compe tency is great in heavy or mature rabbits in which pend on the availability of resources and the skill and the large muscle mass in the cervical region makes training of the operator. Mechani should be handled and euthanized in the manner cal devices designed to frmly hold the rabbit’s head least distressful to them. Death should always be veri and facilitate the operator’s applying downward force fed. Lack of breathing and palpable heartbeat as well to the hips and back legs reduce the strength needed as a fxed dilated pupil are some of the easiest recog by the operator to euthanize rabbits. The captive bolt must be main vices are available, venous access may be obtained via tained in clean working order, positioned correctly the ear. In the case of fractious rabbits, sedation may (by placing the captive bolt slightly paramedian on be necessary to gain venous access for administration 106 the frontal bone as close to the ears as possible), of an injectable barbiturate or injectable barbiturate and operated safely by trained personnel. Barbiturates may also be administered tial to stabilize the head to prevent misses. The concurrent use of local anesthetics and an should be restrained on nonslip fooring, preferably ticonvulsants may aid in prevention of pain,47 but it in an open-top container allowing the rear of the should be considered that these compounds may also rabbit to be pressed against the container wall. These approaches are ing the nondominant hand, the operator should re acceptable for companion rabbits as well. These devices are of CondItIons methods ten aesthetically displeasing and often result in envi S2. Operators must be trained, preferably on ting, such as a biomedical research facility or vet cadavers. Using the nondominant hand, the able for zebrafsh (Danio rerio) to be euthanized by operator should restrain the rabbit by pressing on the rapid chilling (2° to 4°C) until loss of orientation and shoulder blades, and the thumb and forefnger should cessation of operculur movements. The tional exposure of the fsh to chilled water for times device must be maintained in clean working order, specifc to fsh size and age108,110,111 should be used to positioned correctly (center of the forehead, with ensure death. Rapid chilling of adult zebrafsh result the barrel placed in front of the ears and behind the ed in cessation of vital signs (10.
The transducer is apposed perpendicular to spasms on left side of body buy discount zanaflex line Its use has been shown to muscle relaxant gas buy zanaflex once a day significantly change the the long axis of the ribs in order to muscle relaxant used during surgery generic zanaflex 2 mg fast delivery obtain an image diagnosis and treatment of the hypoxic patient in the of two ribs cut in a transverse fashion (Fig muscle relaxant vecuronium buy cheap zanaflex 2 mg on line. The parietal and visceral necessary in order to perform thoracic and lung pleura creating this interface move in a synchronous ultrasound accurately and safely. This movement, called ‘lung sliding’, described originally in veterinary medicine, is one of probe, but a linear high-frequency probe can also be the most important findings during any ultrasound && used [12 ]. Lung ultrasound can be done in a sitting or the lung parenchyma located under the pleural supine patient. All zones planes that are used: the sagittal and the coronal on each hemithorax must be scanned in order to plane (Fig. Both abdominal rooms are in a supine position, this approach will lateral upper quadrants can also be examined in be discussed here. Different imaging modalities are used ciples in the identification of specific disorders are depending on expected disorder. The linear array (a), the phased array (note the simple pleural effusion) (b), the convex (c) and the transesophageal echocardiography transducer (note the complex pleural effusion) (d). It is often quoted that lung ultra Ultrasounds are sound waves with a frequency sound makes facts out of artefacts. After lung sliding, higher than what can be perceived by the human the most common artefacts in lung ultrasound are ear. The A line energy absorbed as well as the time between the artefact is the single or multiple horizontal reflec emission and reception of the ultrasound wave by tions of the pleural interface. The emitted ultra the transducer, the software is able to generate sound wave is reflected multiple times by the an image depicting the underlying structures. This back and forth phenomenon Ultrasounds are completely reflected by air, so it is gives a false impression to the imaging software that impossible in theory to see the air-filled lung paren the pleural interface is deeper. In both normal and abnormal conditions, ated by a distance equivalent to the thickness of the the thoracic cavity and the lungs may contain some subcutaneous tissue between the ultrasound probe physiologic or pathologic fluid. A lines are present in a the relation between the ultrasound wave and the normal lung as well as in the presence of a pneumo air contained in the alveolar interstitial space of the thorax (Fig. This artefact is created by repetitive reflections of the ultrasound wave within the lung parenchyma because of a higher concentration of physiologic or pathologic fluid [13,17]. This artefact is a vertical white line, originating from the visceral pleura, and reaching the bottom of the screen (Fig. The presence of B lines is used in the diagnosis of alveolar interstitial syndrome. The presence of B lines will automatically exclude the presence of a pneumothorax. The use of color Doppler can of multiple horizontal lines that correspond to facilitate recognition of this artefact (Fig. This image ends on the presence of a lung pulse artefact excludes a pneumo pleural line. This motion will generate an artefact that originates from the pleural line and looks like sand on a beach. Although it does not constitute a normal ence of the following artefacts: lung sliding, A lines, lung sliding, it implies an intact pleural interface. Typical lung ultrasound image obtained with a these are white vertical white lines originating from the linear transducer at 6cm deep. Note the horizontal A lines pleural interface and reaching the bottom of the screen. They can be bilateral or limited to one part of the lung and associated with lobar pneumonia, pul monary contusion, or atelectasis. The same constel lation of artefacts will be seen for each of these disorders, but their distribution will vary depending on the spread of the disease. Typical lung ultrasound image obtained with a seen, having a similar aspect to liver parenchyma linear transducer at 6cm deep. Pneumothorax is the disorder that made lung ultrasound gain so much popularity in the recent decade. A recent case report describes the diagnosis separated by less than 3 mm are a sign of alveolar as of an intraoperative pneumothorax using lung opposed to interstitial lung disease [18,20]. This diagnosis interstitial disease can be diffuse as in cardiogenic had a significant impact on the intraoperative && course of these patients [10 ]. Ruling out a pneu mothorax in a hypoxic mechanically ventilated patient who underwent central venous access is critical. A complete bilateral lung ultrasound in search of pneumothorax can be done in less than 3min. Inthe presence of a pneumothorax, air will be present between the parietal and the visceral pleura. As air completely reflects ultrasound waves, the visceral pleura will not be seen, and there will be no lung sliding. At the border of the pneumothorax, the pleural interface should be intact, and normal lung sliding should be present. This transition point between the intermittent presence and absence of a lung sliding is called the ‘lung point’. This corresponds to lung pulse (white If there is a pneumothorax, the absence of lung arrows) (a). Adding color Doppler to the motion mode sliding will create a series of black and white hori image and the electrocardiogram facilitates lung pulse zontal lines, called the ‘stratospheric or barcode’ identification (white arrows) (b). Thoracic examination using a phased array transducer shows B lines on the chest wall (a). The same artefact is also present on the transesophageal echocardiographic examination at the aortic arch level (b). M-Mode as a transition between a seashore sign and specific for pneumothorax [21]. The lung point, seen on M keep in mind that lung ultrasound is more useful in Mode or conventional two dimensional, is 100% excluding than confirming a pneumothorax. The corresponding chest radiograph (c) and computed tomography of the chest are shown (d). The lung parenchyma has the same aspect as liver on ultrasound, hence the word lung hepatization used in pathology. Thoracic ultrasound on the anterior chest (zone 1 and 2) shows A lines with no sliding lung (a). A more lateral position (zone 3 and 4) reveals normal sliding lung with B lines (b). The patient had no right superior vena cava that explains the unsuccessful attempt in inserting the right internal jugular. Note on the chest radiograph (c) the position of the pulmonary artery catheter in the left superior vena cava and through the coronary sinus. Note also the transesophageal echocardiography probe used for postoperative monitoring. The barcode (or stratospheric) aspect of the motion mode followed by the normal seashore sign. Caution must be taken if a lung point is ident the lung point, alternative methods of diagnosis ified in the lower parts of the lungs. The excursion of are suggested in a nonlife-threatening situation, the diaphragm, for instance, above the liver can give remembering that supine chest radiograph is not a false impression of lung point. Caution line, the fourth intercostal space on anterior axillary must also be taken if a lung pulse is identified close line, the sixth intercostal space on the midaxillary to the sternum as pulsation of a mammary artery line, and the eighth intercostal space on the could lead to false exclusion of pneumothorax. However, the identi Thoracic ultrasound can rapidly identify simple or fication of a lung point is essential to confirm the complex pleural effusions. During expiration, the motion mode aspect of the liver is seen (lateral portion of the image outside the arrow). She was started on low molecular weight heparin, 3 days ago for lower extremity deep venous thrombophlebitis. Thoracic ultrasound revealed an isoechoic mobile mass corresponding to an hematoma (a) that was confirmed on chest radiograph (b) and computed tomography (c).
After one year spasms thumb joint purchase zanaflex online pills, the course was repeated over one month with the administration of isoniazid 600 mg/d and Maxaquin (lomefloxacin) 400 mg/d spasms hiatal hernia order zanaflex from india. Following two and a half months of complex anti-tuberculosis therapy gas spasms best zanaflex 4mg, positive dynamics appeared owing to infantile spasms 2 month old discount zanaflex 2 mg with visa the regression of the foci in the lungs (see Fig. The results of blood analyses found improvements in both the anaemia and infection. The epicentre of the local radiation injury was focused on the lower lobe of the left lung, which strongly indicated that this portion of lung tissue was subject to a maximum dose of 10 Gy. One year after exposure, a scar fibrosis formed in the lower lobe of the left lung, which was located in the epicentre of the area in which the maximal 86 dose was absorbed. The scar fibrosis formed while a metatuberculosis change in other parts of the lungs took place (see Figs 52 and 53). The dynamic changes in the lung–bronchial system corresponded quite well to the functional status of the lungs. Local radiation injury On 29 May 2002, an operation was performed which consisted of a necrectomy of the radial ulcers and the application of a split dermatome autograft that was taken from the front surface of the left hip. However, during the post-operative period, the skin grafts failed to acclimatize (see Fig. Single hearths of weak granulations were found in the muscles that had stitches positioned at angles in the upper and lower part of the wound. This caused the skin grafts to spontaneously detach and increased the amount of separated skin. Considering the sickliness of the wound and indications of drug dependency, it was decided to continue surgical wound cleansing under anaesthesia using vacuum bandages and antibiotics, which took into consideration the sensitivity of the Staphylococcus. By day 300 after exposure, vacuum bandages were applied more tightly in the upper medial and lateral edges of the wound, causing granulations to appear more flourishingly (see Fig. A second necrectomy of the wound and a skin transplantation of the granulated wound areas were performed on 6 September 2002 (see Fig. Practically 70% of the surface epithelized, except the central part and the lower medial edge of the wound (see Figs 59–61). On 2 December 2002, the necrectomy of the non-epithelized wound areas and plastic surgery of two split grafts were performed (see Fig. The grafts were taken from the right hip and were placed on the central part of the wound between the angle of the left shoulder blade and the lower edge of the wound. On 15 April 2003, two expanders (700 ml each) were attached to the right half of the back and a third expander was attached on the left side surface of the chest (see Fig. A major plastic surgical operation was performed for the simultaneous transfer of the right side of the shoulder blade skin sized 28–30 cm, and a section of the skin from the left side of the chest into the middle of the radial affection. An autodermoplastic operation of three skin sections taken from the side surfaces of both hips was performed on the area of the body where the skin was transplanted (see Fig. Following a histological examination, scars appeared on the incised tissue, along with fibrosis and an infection. The mobility of the sixth, seventh and eighth ribs was examined after the bandaging was removed 96 (see Figs 69–72). It was suspected that osteomyelitis had developed, and there were pathological fractures to the sixth, seventh and eighth ribs. New bandages were applied practically every day that had non-adhering nets and were made from bees’ wax with antibiotic additives that were sensitive to the flora microorganisms (see Fig. An operation was performed on 8 September 2003, which removed part of the fifth, sixth seventh and eighth ribs and also treated the infected area of the left shoulder blade. In addition, a simultaneous autoplastics procedure using a movable skin graft from the hip on the right side of the wound area was performed during the operation (see Fig. Following a histological examination, the soft tissue and bones showed fibrosis and a chronic infection, with a fibrotic necrotic component. This provides a compelling explanation of the ineffectiveness of the autotransplantation of the skin grafts, despite the use of movable, blood supplied grafts. The reason was that the pathological fracture had been complicated by the development of osteomyelitis, in addition to the radial osteoporosis that had already developed. In the acute infection periods of the injury, the sinus tachycardia measured up to 109 bpm and deterioration of the left ventricle myocardium status was observed. An echocardiography was performed which showed insignificant dilatation of the right auricle and global contraction of the left ventricle, without any peculiarities detected during the total observation period. In January 2003, indirect signs of transitory lung hypertension and insignificant degenerative changes of the aorta valve folds were detected. Analyses of the dynamic blood samples identified frequent relapses of iron deficiency anaemia, which was particularly noticeable after the operations had been performed. Normal levels of erythrocyte numbers in the blood were only sustainable by the constant provision of iron supplements. Preventive measures and the treatment of infections of the injury were performed throughout the duration of his treatment. Antibiotics were used in a controlled environment and so were flora sensitivity tests (including gentamicin, lincomycin, meropenem, Tienam, Maxaquin, rifampicin, nystatin and Nizoral). Following indications of significant intoxication and considering the complications owing to the infection of the injury. The status of the wound on 10 October 2003 (day 677 after exposure) is presented in Fig. On the surface of the open wound, there was a large amount of pus secretion, and a secondary necrosis of the muscles, ribs, shoulder bones and vertebrae increased in depth. Repeated samples taken from the wound identified poly-resistant microbes, the largest quantity of which was the blue pus bacillus. He exhibited a high fever, signs of respiratory insufficiency (with an inspiratory rate of 80 per min), an expressed intoxication and an arterial hypotension. X ray examinations were performed that revealed pneumonic locus near the right root of the lung. Despite a large amount of antibiotic therapy, multi-organ dysfunction (respiratory, kidney hepatic, cardiovascular and wound exhaustion) and intoxication ensued. In addition, his severe somatic pathology debilitated the multilayer graft operations with axial blood supply, which were performed to close the wound and to restore atrophy of the exposed tissue. Furthermore, infection was able to enter through the areas of the skin not completely covering the wound. The use of various collagen films or imitation leather that can mechanically close the skin completely could have been a solution in this case. It should be noted that he had tuberculosis and had previously suffered from narcotism. However, there was no sign of aplasia in the peripheral blood cells at the time of admission to the Percy Military Training Hospital. The location of the cutaneous radiological lesion covered the whole posterior side of the thorax from the waist up to the scapulae. The lesion was a wide, moist, epidermal denudation (approximately 30 cm 20 cm), which covered more than 8% of the total body surface of the body, but without any signs of deep necrosis. It was surrounded by a distinct contour, an inflamed halo (approximately 3 cm) and dyschromia of the skin (see Fig. After seven days of local treatment with sulfadiazine and removal of the yellow fibrin layer, the central lesion was non-haemorrhagic with a granulation bud that exhibited yellow hypovascularized areas (see Fig. A lack of accurate information on the exposure scenario causes difficulties in deriving a dose reconstruction for radiological overexposures by numerical methods. The absorbed dose can only be determined if both the position of the radioactive source and the exposure times are known. This increased the accuracy of the absorbed dose estimation and the estimation of the respective contributions in the dose distribution of the localized 108 and whole body irradiation. The whole body dose obtained from the second study is closer to the dose assessed by cytogenetic assay [6]. Material and methods Conventional biological dosimetry relies on the determination of the frequency of chromosomal aberrations such as dicentrics in the circulating lymphocytes. This approach is satisfactory and reliable when the dose is distributed uniformly over the whole body, but is limited in the case of localized irradiations, where only a small fraction of the circulating lymphocytes are irradiated. The skin is the first organ targeted in all instances of localized overexposure, and the victim suffers from more or less severe burns.
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Such therapy may involve: • the evaluation spasms poster purchase genuine zanaflex online, and reevaluation as required muscle relaxant for anxiety buy zanaflex 2mg with visa, of a patient’s level of function by administering diagnostic and prognostic tests; • the selection and teaching of task-oriented therapeutic activities designed to spasms right side under rib cage order zanaflex restore physical function; spasms under left breastbone zanaflex 2 mg with visa. Also, they qualify who on or before December 31, 1977, had 2 years of appropriate experience as an occupational therapist, and had achieved a satisfactory grade on a proficiency examination conducted, approved, or sponsored by the U. For example, they qualify if they were licensed or otherwise regulated by the state in which practicing on or before December 31, 2009. The phrase, “by the state in which practicing” includes any authorization to practice provided by the same state in which the service is provided, including temporary licensure, regardless of the location of the entity billing the services. They act at the direction and under the supervision of the treating occupational therapist and in accordance with state laws. The level and frequency of supervision differs by setting (and by state or local law). Separate coverage and billing provisions apply to items that meet the definition of brace in §130 of this manual. Services provided by aides, even if under the supervision of a therapist, are not therapy services in the outpatient setting and are not covered by Medicare. Although an aide may help the therapist by providing unskilled services, those services that are unskilled are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services. Application of Medicare Guidelines to Occupational Therapy Services Occupational therapy may be required for a patient with a specific diagnosed psychiatric illness. If such services are required, they are covered assuming the coverage criteria are met. However, where an individual’s motivational needs are not related to a specific diagnosed psychiatric illness, the meeting of such needs does not usually require an individualized therapeutic program. Such needs can be met through general activity programs or the efforts of other professional personnel involved in the care of the patient. Patient motivation is an appropriate and inherent function of all health disciplines, which is interwoven with other functions performed by such personnel for the patient. Accordingly, since the special skills of an occupational therapist are not required, an occupational therapy program for individuals who do not have a specific diagnosed psychiatric illness is not to be considered reasonable and necessary for the treatment of an illness or injury. Occupational therapy may include vocational and prevocational assessment and training. When services provided by an occupational therapist are related solely to specific employment opportunities, work skills, or work settings, they are not reasonable or necessary for the diagnosis or treatment of an illness or injury and are not covered. For example, an assessment of sitting and standing tolerance might be nonvocational for a mother of young children or a retired individual living alone, but could also be a vocational test for a sales clerk. Training an amputee in the use of prosthesis for telephoning is necessary for everyday activities as well as for employment purposes. Major changes in life style may be mandatory for an individual with a substantial disability. The techniques of adjustment cannot be considered exclusively vocational or nonvocational. General Speech-language pathology services are those services provided within the scope of practice of speech-language pathologists and necessary for the diagnosis and treatment of speech and language disorders, which result in communication disabilities and for the diagnosis and treatment of swallowing disorders (dysphagia), regardless of the presence of a communication disability. Qualified Speech-Language Pathologist Defined A qualified speech-language pathologist for program coverage purposes meets one of the following requirements: • the education and experience requirements for a Certificate of Clinical Competence in (speech-language pathology) granted by the American Speech Language Hearing Association; or • Meets the educational requirements for certification and is in the process of accumulating the supervised experience required for certification. Services of Speech-Language Pathology Support Personnel Services of speech-language pathology assistants are not recognized for Medicare coverage. Services provided by speech-language pathology assistants, even if they are licensed to provide services in their states, will be considered unskilled services and denied as not reasonable and necessary if they are billed as therapy services. Services provided by aides, even if under the supervision of a therapist, are not therapy services and are not covered by Medicare. Although an aide may help the therapist by providing unskilled services, those services are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services. Evaluation Services Speech-language pathology evaluation services are covered if they are reasonable and necessary and not excluded as routine screening by §1862(a)(7) of the Act. The speech language pathologist employs a variety of formal and informal speech, language, and dysphagia assessment tests to ascertain the type, causal factor(s), and severity of the speech and language or swallowing disorders. Reevaluation of patients for whom speech, language and swallowing were previously contraindicated is covered only if the patient exhibits a change in medical condition. Although hearing screening by the speech language pathologist may be part of an evaluation, it is not billable as a separate service. Therapeutic Services the following are examples of common medical disorders and resulting communication deficits, which may necessitate active rehabilitative therapy. This list is not all-inclusive: Cerebrovascular disease such as cerebral vascular accidents presenting with dysphagia, aphasia/dysphasia, apraxia, and dysarthria; Neurological disease such as Parkinsonism or Multiple Sclerosis with dysarthria, dysphagia, inadequate respiratory volume/control, or voice disorder; or Laryngeal carcinoma requiring laryngectomy resulting in aphonia. Impairments of the Auditory System the terms, aural rehabilitation, auditory rehabilitation, auditory processing, lipreading and speech reading are among the terms used to describe covered services related to perception and comprehension of sound through the auditory system. For example: ° Auditory processing evaluation and treatment may be covered and medically necessary. Examples include but are not limited to services for certain neurological impairments or the absence of natural auditory stimulation that results in impaired ability to process sound. Certain auditory processing disorders require diagnostic audiological tests in addition to speech-language pathology evaluation and treatment. Audiologists and speech-language pathologists both evaluate beneficiaries for disorders of the auditory system using different skills and techniques, but only speech-language pathologists may provide treatment. Assessment for the need for rehabilitation of the auditory system (but not the vestibular system) may be done by a speech language pathologist. Examples include but are not limited to: evaluation of comprehension and production of language in oral, signed or written modalities, speech and voice production, listening skills, speech reading, communications strategies, and the impact of the hearing loss on the patient/client and family. Examples of rehabilitation include but are not limited to treatment that focuses on comprehension, and production of language in oral, signed or written modalities; speech and voice production, auditory training, speech reading, multimodal. In determining the necessity for treatment, the beneficiary’s performance in both clinical and natural environment should be considered. Dysphagia Dysphagia, or difficulty in swallowing, can cause food to enter the airway, resulting in coughing, choking, pulmonary problems, aspiration or inadequate nutrition and hydration with resultant weight loss, failure to thrive, pneumonia and death. It is most often due to complex neurological and/or structural impairments including head and neck trauma, cerebrovascular accident, neuromuscular degenerative diseases, head and neck cancer, dementias, and encephalopathies. For these reasons, it is important that only qualified professionals with specific training and experience in this disorder provide evaluation and treatment. The speech-language pathologist performs clinical and instrumental assessments and analyzes and integrates the diagnostic information to determine candidacy for intervention as well as appropriate compensations and rehabilitative therapy techniques. The professional rendering care must have education, experience and demonstrated competencies. Competencies include but are not limited to: identifying abnormal upper aerodigestive tract structure and function; conducting an oral, pharyngeal, laryngeal and respiratory function examination as it relates to the functional assessment of swallowing; recommending methods of oral intake and risk precautions; and developing a treatment plan employing appropriate compensations and therapy techniques. Therapist refers only to a qualified physical therapist, occupational therapist or speech-language pathologist. For further details on issues concerning enrollment, see the provider enrollment Web site at Private practice also includes therapists who are practicing therapy as employees of another supplier, of a professional corporation or other incorporated therapy practice. Private practice does not include individuals when they are working as employees of an institutional provider. Services should be furnished in the therapist’s or group’s office or in the patient’s home. The office is defined as the location(s) where the practice is operated, in the state(s) where the therapist (and practice, if applicable) is legally authorized to furnish services, during the hours that the therapist engages in the practice at that location. If services are furnished in a private practice office space, that space shall be owned, leased, or rented by the practice and used for the exclusive purpose of operating the practice. For descriptions of aquatic therapy in a community center pool see section 220C of this chapter. Therapists in private practice must be approved as meeting certain requirements, but do not execute a formal provider agreement with the Secretary. Or, a therapist is employed by another supplier and furnishes services in facilities provided at the expense of that supplier. The therapist need not be in full-time private practice but must be engaged in private practice on a regular basis; i. If a therapist is not enrolled, the services of that therapist must be directly supervised by an enrolled therapist. Direct supervision requires that the supervising private practice therapist be present in the office suite at the time the service is performed.
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