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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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John P. Lichtenberger III, MD
Moderate availability Low availability a Germination of such grains or fermentation heart attack 25 10mg norvasc with visa. For information on diets arrhythmia list discount 5mg norvasc, see Table 54 b Assumed bio-availability of dietary zinc 50 percent hypertension quizlet norvasc 10mg overnight delivery. Upper limits of zinc intake Only a few occurrences of acute zinc poisoning have been reported blood pressure numbers what do they mean norvasc 5mg free shipping. The toxicity signs are nausea blood pressure medication recall 2015 generic norvasc 2.5 mg amex, vomiting blood pressure chart age 65 order norvasc 10mg amex, diarrhoea, fever, and lethargy and have been observed after ingestion of 4-8 g (60-120 mmol) zinc. Long-term zinc intakes higher than the requirements could, however, interact with the metabolism of other trace elements. Low copper and ceruloplasmin levels and anaemia have been observed after higher zinc intakes 450-660 mg/day (6. Changes in serum lipid pattern and in immune response have also been observed in zinc supplementation studies (41, 42). Because copper also has a central role in immune defence, these observations call for caution before large-scale zinc supplementation programmes are undertaken. Except for excessive intakes of some types of seafood, such intakes are unlikely to be attained with most diets. Adventitious zinc in water from contaminated wells and from galvanized cooking utensils could also lead to high zinc intakes. Unless otherwise specified, the intra-individual variation of zinc requirements is assumed to be 25 percent. Zinc absorption from diets in Malawi, Kenya, Mexico, and Guatemala was estimated to be 15 percent based on the high phytate-zinc molar ratio (37-42) in these diets, whereas an absorption of 30 percent was assumed for diets in Ghana, Guatemala, Egypt, and Papua New Guinea. Fermented maize and cassava products (kenkey, banku, and gari) in Ghana, yeast leavened wheat-based bread in Egypt, and the use of sago with a low phytate content as the staple in the New Guinean diets were assumed to result in a lower phytate-zinc molar ratio and a better availability. Most of the zinc supplementation studies have not provided dietary intake data, which could be used to identify the zinc intake critical for growth effects. In a recent study in Chile, positive effects on height gain in boys after 14 months of zinc supplementation was noted (44). Because only 15 percent of the zinc intake of the Chilean children was derived from flesh foods, availability was assumed to be relatively low. Krebs et al (45) observed no effect of zinc supplementation on human-milk zinc content or on maternal status of a group of lactating women and judged their intake sufficient to maintain adequate zinc status through 7 months or more of lactation. Reductions in urinary and faecal losses maintained normal plasma zinc concentrations over 5 weeks in 11 men with intakes of 2. A significant reduction of plasma zinc concentrations and changes in cellular immune response were observed. Sub-optimal zinc status has also been documented in pregnant women consuming diets with high phytate-zinc ratios (>17) (47). Frequent reproductive cycling and high malaria prevalence seemed to contribute to the impairment of zinc status. This knowledge is especially needed for understanding the role of zinc deficiency in the aetiology of stunting and impaired immunocompetence. For a better understanding of the relationship between diet and zinc supply, there is a need for further research to carefully evaluate the availability of zinc from diets typical of developing countries. The research should include an assessment of the effect of availability of adopting realistic and culturally accepted food preparation practises such as fermentation, germination, soaking, and inclusion of inexpensive and available animal protein sources in plant-food-based diets. Tissue zinc levels and zinc excretion during experimental zinc depletion in young men. Effect of dietary zinc on whole body surface loss of zinc: impact on estimation of zinc retention by balance method. Homeostatic control of zinc metabolism in men: zinc excretion and balance in men fed diets low in zinc. Changes in cytokine production and T cell subpopulations in experimentally induced zinc-deficient Humans. Methods for studying mineral and trace element absorption in Humans using stable isotopes. Kinetic analysis of zinc metabolism in Humans and simultaneous administration of 65Zn and 70Zn. Size of the zinc pools that exchange rapidly with plasma zinc in Humans: Alternative techniques for measuring and relation to dietary zinc intake. Zinc absorption and intestinal losses of endogenous zinc in young Chinese women with marginal zinc intakes. Zinc absorption estimated by fecal monitoring of zinc stable isotopes validated by comparison with whole-body retention of zinc radioisotopes in Humans. Zinc absorption, mineral balance, and blood lipids in women consuming controlled lactoovovegetarian and omnivorous diets for 8 wk. High- versus low-meat diets: effects on zinc absorption, iron status, and calcium, copper, iron, magnesium, manganese, nitrogen, phosphorus, and zinc balance in postmenopausal women. Reduction of the phytate content of bran by leavening in bread and its effect on absorption of zinc in man. Potential contribution of maternal zinc supplementation during pregnancy to maternal and child survival. Homeostatic regulation of zinc absorption and endogenous losses in zinc-deprived men. Complementary feeding of young children in developing countries: a review of current scientific knowledge. Iron, copper, and zinc status: response to supplementation with zinc or zinc and iron in adult females. A 14-mo zinc-supplementation trial in apparently healthy Chilean preschool children. Zinc supplementation during lactation: effects on maternal status and milk zinc concentrations. Erythrocytes, erythrocyte membranes, neutrophils and platelets as biopsy materials for the assessment of zinc status in Humans. Suboptimal zinc status in pregnant Malawian women: its association with low intakes of poorly available zinc, frequent reproductive cycling, and malaria. If it is possible to quantify such claims, antioxidant properties should be considered in decisions concerning the daily requirements of these nutrients. In addition, prooxidant metabolism and the importance of iron are also considered. Members of the Food and Nutrition Board of the National Research Council in the United States, recently defined a dietary antioxidant as a substance in foods which significantly decreases the adverse effects of reactive oxygen species, reactive nitrogen species, or both on normal physiologic function in humans (1). It is recognised that this definition is somewhat narrow because maintenance of membrane stability is also a feature of antioxidant function (2) and an important antioxidant function of both vitamin A (3) and zinc (4). However, it was decided to restrict consideration of antioxidant function in this document to nutrients which were likely to interact more directly with reactive species. Superoxide in particular is produced by leakage from the electron transport chains within the mitochondria and microsomal P450 systems (8) or formed more deliberately, for example, by activated phagocytes as part of the primary immune defence in response to foreign substances or to combat infection by micro-organisms (9). Nitric oxide is produced from L-arginine by nitric oxide synthases, and these enzymes are found in virtually every tissue of the mammalian body, albeit at widely different levels (7). Nitric oxide is a free radical but is believed to be essentially a beneficial metabolite and indeed it may react with lipid peroxides and function as an antioxidant (10). Nitric oxide also serves as a mediator whereby macrophages express cytotoxic activity against micro-organisms and neoplastic cells (11). If nitric oxide is at a sufficiently high concentration, it can react rapidly with superoxide in the absence of a catalyst to form peroxynitrite. Peroxynitrite is a potentially damaging nitrogen species which can react through several different mechanisms, including the formation of an intermediate with the reactivity of the hydroxyl radical (12). The degree of damage resulting from the temporary imbalance depends on the ability of the antioxidant systems to respond to the oxidant or prooxidant load. Fruits and vegetables are good sources of many antioxidants, and it is reported that diets rich in these foods are associated with a lower risk of the chronic diseases of cancer (15) and heart disease (16). Hence, it is believed that a healthful diet maintains the exogenous antioxidants at or near optimal levels thus reducing the risk of tissue damage. The most prominent representatives of dietary antioxidants are vitamin C, tocopherols, carotenoids, and flavonoids (17-19). Requirements for flavonoids are not being considered at this time and work on this subject is still very much in its infancy. In contrast, several intervention studies have been carried out to determine whether supplements of the other nutrients can provide additional benefits against such diseases. The components in biologic tissues make an ideal mixture of substrates for oxidation. Transition metals, particularly iron, are bound to both transport and storage proteins; abundant binding sites on such proteins prevent overloading the protein molecule with metal ions. Tissue structures, however, break down during inflammation and disease, and free iron and other transition metals have been detected (20, 21). In particular the highly reactive hydroxyl radical can be formed by the Fenton (reaction 1) and Haber-Weiss reactions (reaction 2; with an iron-salt catalyst) (22). Pathologic conditions greatly increase the concentrations of both superoxide and nitric oxide, and the formation of peroxynitrite has been demonstrated in macrophages, neutrophils, and cultured endothelium (reaction 3) (12, 23). Peroxynitrite can react through several different mechanisms, including the formation of an intermediate with the reactivity of the hydroxyl radical (12). The body alters the transport and distribution of iron by blocking iron mobilisation and absorption and stimulating iron uptake from plasma by liver, spleen, and macrophages (3, 24, 25). Nitric oxide has been shown to play a role in the coordination of iron traffic by mimicking the consequences of iron starvation and leading to the cellular uptake of iron (26). The changes accompanying disease are generally termed the acute-phase response and are, generally, protective (27). Some of the changes in plasma acute-phase reactants which affect iron at the onset of disease or trauma are shown in Table 57. Table 57 Systems altered in disease which reduce risk of autoxidation System Mobilisation and metabolism of iron Changes in plasma Decrease in transferrin Increase in ferritin Increase in lactoferrin Increase in haptoglobin Decrease in iron absorption Movement of plasma iron from blood to storage sites. Increase in antiproteinases Increase in fibrinogen Variable increase in white blood cells of which 70% are granulocytes. Physiologic objectives Reduce levels of circulating and tissue iron to reduce risk of free radical production and pro-oxidant damage. Positive acute phase proteins White blood cells Vitamin C metabolism Uptake of vitamin C from plasma by stimulated granulocytes. Reduction of plasma vitamin C in acute and chronic illness or stress-associated conditions. The long half-life means that these intermediates remain stable for long enough to interact in a controlled fashion with intermediates which prevent autoxidation, and the excess energy of the surplus electron is dissipated without damage to the tissues. The ability to recycle these dietary antioxidants may be an indication of their physiologic essentiality to function as antioxidants. Carotenoids are also biologic antioxidants but their antioxidant properties very much depend on oxygen tension and concentration (33, 34). At low oxygen tension -carotene acts as a chain-breaking antioxidant whereas at high oxygen tension it readily autoxidizes and exhibits pro-oxidant behaviour (33). Palozza (34) reviewed much of the evidence and suggests that -carotene has antioxidant activity between 2 and 20 mmHg of oxygen tension, but at the oxygen tension in air or above (>150 mmHg) it is much less effective as an antioxidant and can show pro-oxidant activity as the oxygen tension increases. Palozza (34) also suggests that autoxidation reactions of -carotene may be controlled by the presence of other antioxidants. There is some evidence that large supplements of fat-soluble nutrients such as -carotene and other carotenoids may compete with each other during absorption and lower plasma concentrations of other nutrients derived from the diet. However, a lack of other antioxidants is unlikely to explain the increased incidence of lung cancer in the -tocopherol -carotene intervention study, because there was no difference in cancer incidence between the group which received both -carotene and -tocopherol and the groups which received one treatment only (35). The free radical formed from a dietary antioxidant is potentially a pro-oxidant as is any other free radical. In biologic conditions which might deviate from the norm, there is always the potential for an antioxidant free radical to become a pro-oxidant if a suitable receptor molecule is present to accept the electron and promote the autoxidation (36). For example, vitamin C will interact with both copper and iron to generate cuprous or ferrous ions, respectively, both of which are potent pro-oxidants (29, 37). Fortunately, mineral ions are tightly bound to proteins and are usually unable to react with tissue components unless there is a breakdown in tissue integrity. Such circumstances can occur in association with disease and excessive phagocyte activation, but even under these circumstances there is rapid metabolic accommodation in the form of the acute-phase response to minimise the potentially damaging effects of an increase in free mineral ions in extra-cellular fluids (Table 57). Nutrients associated with endogenous antioxidant mechanisms Both zinc and selenium are intimately involved in protecting the body against oxidant stress. In addition, a selenium-dependent thyrodoxin reductase was recently characterised in human thyrocytes. It is suggested that in combination with iodine deficiency, the inability to remove high concentrations of hydrogen peroxide may cause atrophy in the thyroid gland, resulting in myxedematous cretinism (39). Nevertheless, one selenium intervention study reported remarkably lower risks of several cancers after 4.
Syndromes
Interventions with family caregivers of cancer patients: Meta-analysis of randomized trials arteria ileocolica buy generic norvasc 5 mg on-line. A national demonstration program on dementia day centers and respite services: An interim report blood pressure medication making blood pressure too low generic 10mg norvasc otc. Implementing an evidencebased caregiver intervention within an integrated healthcare system hypertension leads to buy norvasc 10mg. Dementia case management and risk of long-term care placement: A systematic review and meta-analysis hypertension hypotension buy norvasc 2.5mg low cost. Psychosocial telephone intervention for dementia caregivers: A randomized arteria lacrimalis generic norvasc 2.5mg on line, controlled trial blood pressure cuff and stethoscope generic norvasc 10 mg without prescription. The effect of a disease management intervention on quality and outcomes of dementia care: A randomized, controlled trial. Exploring the benefits of respite services to family caregivers: Mmethodological issues and current findings. Numerous barriers impede systematic recognition and partnership with family caregivers, including payment rules that discourage providers from spending time to communicate with caregivers, misinterpretations of privacy regulations, and a health insurance model oriented to individual coverage. The chapter describes the opportunities for advancing high-quality care, focusing in four priority areas: (1) identification, assessment, and support of family caregivers in the delivery of care; (2) inclusion of family caregiver experiences in quality measurement; (3) supporting family caregivers through health information technology; and (4) preparing care professionals to provide person- and family-centered care. Chapter 5 described the types of caregiver services and supports that have been tested and shown to be effective at improving caregiver outcomes. The experiences of caregivers in advocating for older adults mirror the difficulties that many Americans face in obtaining high-quality, high-value health care services. There is a lack of shared understanding and expectations among older adults, family care1 this report uses the terms "family caregiver" and "caregiver" interchangeably to refer specifically to family caregivers of older adults. One national survey found that only one in three family caregivers (32 percent) reported that a doctor, nurse, or social worker had ever asked them about what was needed to care for their relative. As a result, little is known about what might be achieved by better integration and support of family caregivers. For example, physicians, nurses, social workers, therapists, and other providers routinely initiate an encounter with a new patient by asking about their health history, the medications they are on, past diagnoses, previous treatments and surgeries, adverse reactions to any drugs, and so on. As a result, they may unintentionally make medication mistakes, or they may not be able to detect medication errors or side effects. Reducing Health Care Utilization the availability of a family caregiver is associated with fewer and shorter hospital stays for older adults (McClaran et al. Longitudinal descriptive studies have found that the availability of caregivers reduces home health care use and delays nursing home entry (Van Houtven and Norton, 2004). More recent findings from the Washington State Family Caregiver Support Program further suggest that providing screening and support for caregivers lowers overall use of Medicaid long-term care services (Lavelle et al. Anecdotal reports suggest that agencies with limited resources have used the availability of caregivers to deny older adults services that they need and are eligible for. Decision Making Older adults and their families confront a wide range of decisions in care delivery and planning for future care needs. Such decisions range from whether to adjust, stop, or start a prescribed medication, the selection of Copyright National Academy of Sciences. A considerable research literature has focused on shared decision making in health care. Given that the vast majority of individuals prefer to participate in decisions about their health (Chewning et al. The gap in knowledge is significant given variability in individual preferences for participating in medical decision making (Brom et al. Moreover, older individuals who lack the capacity to make informed decisions are likely to prefer or rely on the help of family members (Stacey et al. Such decisions may occur during the course of care when older adults and their family members communicate face to face with providers or they may occur during routine conversations, such as at the dinner table or in discussions among family members that do not involve the older adult. Not all family members may share the same views or possess the same information to guide decision making, leading to disagreement or conflict Copyright National Academy of Sciences. The nuances and range of considerations in decision making vary widely by specific circumstances but the process and effects may be highly consequential. For example, the challenges of surrogate decision making have been widely documented and may include stress, anxiety, or emotional burdens that persist for years (Vig et al. If the person lacks the capacity to manage his or her affairs, a guardian may be appointed through judicial proceedings. The strategy also calls for using quality measures to help achieve person- and family-centered care. However, this vision is not reflected in current approaches to quality measurement or care delivery and financing reform efforts. As providers, payers, and society work toward higher value systems of care to support population health, the need has never been greater for delivery systems to more effectively partner with and support family caregivers of older adults with complex needs. The "care team" is defined as including individuals, families, and the health care and supportive services workers who interact with individuals. It notes the distinction between person-centered and person- and familycentered care and emphasizes that the family should not simply be viewed as a "resource" for a particular individual, but rather as individuals who themselves may need information, training, or support (Feinberg, 2012). A plan of care reflects the goals, values, and preferences of the person and his or her family. The plan of care is based on wants and needs that are meaningful to the person and the support needs of family members or friends to enable them to continue to provide support without being overstressed. Emphasis on coordination and collaboration across settings of care Collaborative care integrates families in the care team, engaging them as partners in care, and providing tools for family caregivers themselves. Likewise, accreditation activities related to the Patient-Centered Medical Home and Accountable Care Organizations involve documenting core elements of quality care processes, with commensurate measurement opportunities. Person- and family-centered care is a natural link between delivery innovations and the major priorities of the National Quality Strategy (National Priorities Partnership, 2011). Addressing these issues will require stakeholders to be catalysts for broadbased change. Identification, assessment, and support of family caregivers in the delivery of care 2. Identify, Assess, and Support Family Caregivers in the Delivery of Care to Older Adults A pivotal first step toward supporting family caregivers will be a sustained effort to assess and address caregiver needs. Systematic identification of caregivers is an essential part of delivering care to older adults in virtu- Copyright National Academy of Sciences. To make this happen, documenting when older adults need a family caregiver to enact their care plan should become routine. Fundamental to the improvement of caregiving will be the development and adoption of caregiver assessment tools that can be used in practice. Yet older adults who rely on a family caregiver by definition need help to successfully navigate the complex service delivery environment or manage daily care needs. Paying for Recognition, Involvement, and Support of Family Caregivers As the predominant payers of care for older adults, Medicare and Medicaid payment and regulatory policies are critical to motivating and changing provider practice. Some recent innovations in Medicare and Medicaid provide the potential, although quite limited, for family- and person-centeredness in coverage, payment, and delivery of Copyright National Academy of Sciences. A financial incentive for state Medicaid programs; provides an enhanced federal match to states spending less than 50 percent of long-term services and supports care expenditures on homeand community-based settings and that implement structural changes, including use of a core standardized assessment instrument. Family caregiver assessment is recommended, but not required in core standardized assessment. Several new billing codes can be used by specified fee-forservice providers to bill Medicare for services that may involve contact with family caregivers. States may elect to establish integrated care models that promote care coordination for dually eligible Medicare and Medicaid enrollees. Balancing incentive program Medicare billing codes Financial alignment initiative continued Copyright National Academy of Sciences. States must provide for independent assessments of care recipients that include the need for physical, cognitive, or behavioral services and supports; strengths and preferences; available services and housing options; and whether an unpaid caregiver will provide any elements of the person-centered service plan (if yes, a caregiver assessment is required). Skilled nursing care and medical social services provided by home health agencies to Medicare beneficiaries can include caregiver supportive services. The guidelines for hospitals emphasize the importance of engaging both the individual and family during hospital discharge planning. Financial incentives for providers; eligible providers and other entities can receive awards if they meet specified standards for high-quality and coordinated care for a particular population. Moreover, anecdotal reports suggest that some state Medicaid-managed care organizations often compel unpaid assistance from a family caregiver even though federal rules require that unpaid supports be provided voluntarily (Carlson, 2016). Needs assessment and service planning are critical processes used to safeguard participant health and welfare and to ensure that services and supports enable participants to meet individual community living goals. Federal Medicaid person-centered care planning Copyright National Academy of Sciences. Despite attention to policies and services that recognize, support, and compensate family caregivers, Medicaid policy still falls short of commitment to a systematic approach to person- and family-centered care that takes into account the needs of both the care recipient and the family caregiver-at either the state or federal level. A meaningful commitment to the identification and support of family caregivers would also involve oversight and review of assessment tools to assure their appropriateness and effectiveness in serving both beneficiaries and caregivers. The largest is the National Family Caregiver Support Program, which distributes about $150 million to states and territories to provide caregivers with information, help in accessing services, individual counseling, education, respite care, and other services. For example, in 2012, Washington state increased its funding for the Family Caregiver Support Program by $3. In light of available knowledge and existing infrastructure, making a commitment to systematically identify and explicitly support family caregivers will require purposeful attention in the reform of federal entitlement programs and state benefit programs, as well as significant investment to develop and broadly implement metrics, tools, and policies that facilitate systematic identification, assessment, and support of caregivers in payment and delivery of care. Although changes to organizational culture and provider workflows are not inconsequential, the financial outlays required to bring about these changes are likely to be relatively modest. Although subsequent sections of this chapter address these topics in greater detail, these activities collectively rest on the ability to identify family caregivers who are now largely invisible in systems of care. Establishing approaches to systematically identify and meaningfully support family caregivers will require resources and motivation to undertake changes in provider practice. Likewise, performance standards should hold providers accountable for supporting family caregivers when the plan of care rests on their involvement. For those with complex care needs or multiple chronic conditions, technical quality may not align with the care or outcomes that matter most based on individual values, priorities, and goals of care (Boyd et al. For many older adults, highquality care involves supporting their family caregivers-by respecting their values and preferences without imposing financial burden, physical strain, or undue anxiety regarding lack of experience or knowledge to perform tasks expected of them. A theme throughout this work is that it is both individuals and families who engage in the planning, delivery, and evaluation of care across all levels of performance Copyright National Academy of Sciences. A conceptual framework has been agreed on by a multistakeholder committee that includes Caregiver Support as 1 of 11 measurement domains. Although the inclusion of caregiver measures is increasingly supported in principle, the development, validation, and endorsement of such measures will require resources and prioritization. Moreover, consensus processes for measure identification, selection, and prioritization takes time-years in many instances. Specifically, the system integrates critical clinical and social data (individual support needs) to Copyright National Academy of Sciences. The role of family members and friends in the use of these systems has not been well defined. Implementation barriers to proxy portal registration are numerous and include lack of availability. Current technology allows people to select 2 Information about the My HealtheVet program is available at. For example, someone might authorize a paid caregiver to schedule appointments or refill prescribed medications but bar his or her access to personal health information. Finally, organizations and federal and state governmental agencies tasked with monitoring the implementation and use of consumer-facing health information technologies should provide equal weight and attention to individual and family adoption in tracking diffusion and use. A third category of technology-based systems that is potentially useful for family caregivers as well as health care providers is embedded inhome activity-monitoring systems with unobtrusive sensors that can track behaviors, such as movement patterns. These types of systems can alert caregivers Copyright National Academy of Sciences. This can enable caregivers to stage an early intervention and potentially avoid catastrophic health events or hospitalization. One set of issues relates to monitoring protocols-when monitoring should occur. Other issues relate to privacy concerns and data-sharing privileges; data coding and integration (how to make the information meaningful and user-friendly to end users); and potential problems with false alarms. Attention to usability issues and caregiver training in the use of these systems is also paramount. It is beyond the scope of this report to assess the curricula and licensing requirements of the relevant professions. Nevertheless, it is clear that preparing providers to deliver person- and family-centered care to older adults will require a broad-based effort-across the educational continuum and in an interdisciplinary manner-to address and ensure the competence of their respective professions to work with family caregivers of older adults. Many disciplines are likely to encounter family caregivers of older adults, including physicians; physician assistants; nurses (including advanced practice nurses); social workers; psychologists; physical, occupational, and speech therapists; pharmacists; and direct care workers. Primary care physicians, nurse practitioners, and social workers serve an especially important role as communicator with Copyright National Academy of Sciences. Some promising efforts to identify needed standards and facilitate their implementation are under way, especially in nursing and social work (Kelly et al. For example, a State of the Science Symposium on Professional Partners Supporting Family Caregivers identified a set of rec- Copyright National Academy of Sciences.
The plan heart attack movie review 2.5 mg norvasc for sale, (also known as a plan of care or plan of treatment) must be established before treatment is begun arrhythmia recognition posters cheap 2.5 mg norvasc free shipping. The evaluation and treatment may occur and are both billable either on the same day or at subsequent visits blood pressure vitals buy norvasc 5 mg mastercard. Therapy may be initiated by qualified professionals or qualified personnel based on a dictated plan blood pressure for infants order norvasc 10 mg line. Treatment may begin before the plan is committed to writing only if the treatment is performed or supervised by the same clinician who establishes the plan heart attack manhattan clique remix 10mg norvasc visa. The treatment notes continue to require timed code treatment minutes and total treatment time and need not be separated by plan blood pressure of normal man norvasc 10 mg low price. Progress reports should be combined if it is possible to make clear that the goals for each plan are addressed. The plan of care shall be consistent with the related evaluation, which may be attached and is considered incorporated into the plan. The plan should strive to provide treatment in the most efficient and effective manner, balancing the best achievable outcome with the appropriate resources. Long term treatment goals should be developed for the entire episode of care in the current setting. When the episode is anticipated to be long enough to require more than one certification, the long term goals may be specific to the part of the episode that is being certified. Therapists typically also establish short term goals, such as goals for a week or month of therapy, to help track progress toward the goal for the episode of care. If the expected episode of care is short, for example therapy is expected to be completed in 4 to 6 treatment days, the long term and short term goals may be the same. In other instances measurable goals may not be achievable, such as when treatment in a particular setting is unexpectedly cut short (such as when care is transferred to another therapy provider) or when the beneficiary suffers an exacerbation of his/her existing condition terminating the current episode; documentation should state the clinical reasons progress cannot be shown. The functional impairments identified and expressed in the long term treatment goals must be consistent with those used in the claims-based functional reporting, using nonpayable G-codes and severity modifiers, for services furnished on or after January 1, 2013. Functional reporting and its associated documentation requirements are no longer applicable for claims or medical records for dates of service on and after January 1, 2019. When more than one discipline is treating a patient, each must establish a diagnosis, goals, etc. However, the form of the plan and the number of plans incorporated into one document are not limited as long as the required information is present and related to each discipline separately. For example, a physical therapist may not provide services under an occupational therapist plan of care. However, both may be treating the patient for the same condition at different times in the same day for goals consistent with their own scope of practice. The amount of treatment refers to the number of times in a day the type of treatment will be provided. The frequency refers to the number of times in a week the type of treatment is provided. If the episode of care is anticipated to extend beyond the 90 calendar day limit for certification of a plan, it is desirable, although not required, that the clinician also estimate the duration of the entire episode of care in this setting. It may be appropriate for therapists to taper the frequency of visits as the patient progresses toward an independent or caregiver assisted self-management program with the intent of improving outcomes and limiting treatment time. For example, treatment may be provided 3 times a week for 2 weeks, then 2 times a week for the next 2 weeks, then once a week for the last 2 weeks. When tapered frequency is planned, the exact number of treatments per frequency level is not required to be projected in the plan, because the changes should be made based on assessment of daily progress. For example, amount, frequency and duration may be documented as "once daily, 3 times a week tapered to once a week over 6 weeks". The clinician should consider any comorbidities, tissue healing, the ability of the patient and/or caregiver to do more independent self-management as treatment progresses, and any other factors related to frequency and duration of treatment. It is anticipated that clinicians may choose to make their plans more specific, in accordance with good practice. For example, they may include these optional elements: short term goals, goals and duration for the current episode of care, specific treatment interventions, procedures, modalities or techniques and the amount of each. Also, notations in the medical record of beginning date for the plan are recommended but not required to assist Medicare contractors in determining the dates of services for which the plan was effective. A change in long-term goals, (for example if a new condition was to be treated) would be a significant change. Method and Disposition of Certifications Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care. Since delayed certification is allowed, the date the certification is signed is important only to determine if it is timely or delayed. The format of all certifications and recertifications and the method by which they are obtained is determined by the individual facility and/or practitioner. For example, if during the course of treatment under a certified plan of care a physician sends an order for continued treatment for 2 more weeks, contractors shall accept the order as certification of continued treatment for 2 weeks under the same plan of care. If the new certification is for less treatment than previously planned and certified, this new certification takes the place of any previous certification. At the end of the 2 weeks of treatment (which might extend more than 2 calendar weeks from the date the order/certification was signed) another certification would be required if further treatment was documented as medically necessary. The certification should be retained in the clinical record and available if requested by the contractor. Since payment may be denied if a physician does not certify the plan, the therapist should forward the plan to the physician as soon as it is established. Evidence of diligence in providing the plan to the physician may be considered by the Medicare contractor during review in the event of a delayed certification. If the order to certify is verbal, it must be followed within 14 days by a signature to be timely. Recertification is not required if the duration of the initially certified plan of care is more than the duration (length) of the entire episode of treatment. Certifications signed on or after January 1, 2008, follow the rules in this section. Certifications signed on or prior to December 31, 2007, follow the rule in effect at that time, which required recertification every 30 calendar days. Payment and coverage conditions require that the plan must be reviewed, as often as necessary but at least whenever it is certified or recertified to complete the certification requirements. Recertifications that document the need for continued or modified therapy should be signed whenever the need for a significant modification of the plan becomes evident, or at least every 90 days after initiation of treatment under that plan, unless they are delayed. It is possible that patients will be discharged by the therapist before the end of the estimated treatment duration because some will improve faster than estimated and/or some were successfully progressed to an independent home program. After that date, services will not be considered reasonable and necessary due to lack of a certified plan. Certifications and recertifications by doctors of podiatric medicine must be consistent with the scope of the professional services provided by a doctor of podiatric medicine as authorized by applicable state law. Certifications are timely when the initial certification (or certification of a significantly modified plan of care) is dated within 30 calendar days of the initial treatment under that plan. Recertification is timely when dated during the duration of the initial plan of care or within 90 calendar days of the initial treatment under that plan, whichever is less. Certifications are acceptable without justification for 30 days after they are due. Delayed certification should include one or more certifications or recertifications on a single signed and dated document. Delayed certifications should include any evidence the provider or supplier considers necessary to justify the delay. For example, a certification may be delayed because the physician did not sign it, or the original was lost. In the case of a long delayed certification (over 6 months), the provider or supplier may choose to submit with the delayed certification some other documentation. Such documentation may be requested by the contractor for delayed certifications if it is required for review. It is not intended that needed therapy be stopped or denied when certification is delayed. If a certified plan of care ends March 30th and a new plan of care for continued treatment after March 30th is developed or signed by a therapist on April 15th and that plan is subsequently certified, that certification may be considered delayed and acceptable effective from the first treatment date after March 30th for the frequency and duration as described in the plan. Of course, documentation should continue to indicate that therapy during the delay is medically necessary, as it would for any treatment. Denials Due to Certification Denial for payment that is based on absence of certification is a technical denial, which means a statutory requirement has not been met. If an appropriate certification is later produced, the denial shall be overturned. For that reason, it is recommended that the patient be made aware of the need for certification and the consequences of its absence. A technical denial decision may be reopened by the contractor or reversed on appeal as appropriate, if delayed certification is later produced. However, since the inpatients of one institution may be considered the outpatients of another institution, all providers of therapy services may furnish such services to inpatients of another health facility. A certified distinct part of an institution is considered to be a separate institution from a nonparticipating part of the institution. Consequently, the certified distinct part may render covered therapy services to the inpatients of the noncertified part of the institution or to outpatients. Therapy services are payable when furnished in the home at the same physician fee schedule payment rates as in other outpatient settings. Additional expenses incurred by providers of outpatient therapy due to travel to the beneficiary are not covered. Under the Medicare law, there is no authority to require a provider to furnish a type of service. However, if the provider chooses to furnish a particular service, it may not charge any individual or other person for items or services for which the individual is entitled to have payment made under the program because it is bound by its agreement with Medicare. General To be covered, services must be skilled therapy services as described in this chapter and be rendered under the conditions specified. Services provided by professionals or personnel who do not meet the qualification standards, and services by qualified people that are not appropriate to the setting or conditions are unskilled services. A service is not considered a skilled therapy service merely because it is furnished by a therapist or by a therapist/therapy assistant under the direct or general supervision, as applicable, of a therapist. If a service can be self-administered or safely and effectively furnished by an unskilled person, without the direct or general supervision, as applicable, of a therapist, the service cannot be regarded as a skilled therapy service even though a therapist actually furnishes the service. Similarly, the unavailability of a competent person to provide a non-skilled service, notwithstanding the importance of the service to the patient, does not make it a skilled service when a therapist furnishes the service. Services that do not meet the requirements for covered therapy services in Medicare manuals are not payable using codes and descriptions as therapy services. For example, services related to activities for the general good and welfare of patients. Also, services not provided under a therapy plan of care, or provided by staff who are not qualified or appropriately supervised, are not payable therapy services. Examples of coverage policies that apply to all outpatient therapy claims are in this chapter, in Pub. Further details on documenting reasonable and necessary services are found in section 220. Reasonable and Necessary To be considered reasonable and necessary, each of the following conditions must be met. Services that do not require the performance or supervision of a therapist are not skilled and are not considered reasonable or necessary therapy services, even if they are performed or supervised by a qualified professional. However, this presumption is rebuttable and, if in the course of processing a claim, the contractor finds that services were not furnished under proper supervision, it shall deny the claim and bring this matter to the attention of the Division of Survey and Certification of the Regional Office. The key issue is whether the skills of a therapist are needed to treat the illness or injury, or whether the services can be carried out by nonskilled personnel. See items C and D for descriptions of covered skilled services; and the amount, frequency, and duration of the services must be reasonable under accepted standards of practice. The contractor shall consult local professionals or the state or national therapy associations in the development of any utilization guidelines. Rehabilitative Therapy Rehabilitative therapy includes services designed to address recovery or improvement in function and, when possible, restoration to a previous level of health and well-being. Therefore, evaluation, re-evaluation and assessment documented in the Progress Report should describe objective measurements which, when compared, show improvements in function, decrease in severity or rationalization for an optimistic outlook to justify continued treatment. For example, a terminally ill patient may begin to exhibit self-care, mobility, and/or safety dependence requiring skilled therapy services. Rehabilitative therapy is not required to effect improvement or restoration of function when a patient suffers a transient and easily reversible loss or reduction of function. If at any point in the treatment of an illness it is determined that the treatment is not rehabilitative, the services will no longer be considered reasonable and necessary under this section. Maintenance Programs Skilled therapy services that do not meet the criteria for rehabilitative therapy may be covered in certain circumstances as maintenance therapy under a maintenance program. The goals of a maintenance program would be, for example, to maintain functional status or to prevent or slow further deterioration in function.
All of these findings suggest that glucose level is an important risk factor for morbidity and mortality after stroke pulse pressure 46 cheap norvasc 10mg without a prescription. However blood pressure chart in europe buy norvasc 2.5mg with mastercard, it is not clear whether hyperglycemia itself affects stroke outcome or reflects blood pressure chart neonates order norvasc 2.5 mg free shipping, as a marker understanding prehypertension purchase 10 mg norvasc amex, the severity of the event due to the activation of stress hormones such as cortisol or norepinephrine arrhythmia consultants greenville sc discount norvasc 10mg without a prescription. Glucose level is an important risk factor for morbidity and mortality after stroke blood pressure medication names starting with m cheap norvasc 5 mg without a prescription, but it is unclear whether hyperglycemia itself affects stroke outcomes or reflects the severity of the event as a marker. The previous data raise the question how, and especially to what extent, should post-acute-stroke hyperglycemia be treated. The study was conducted among 933 hyperglycemic acute stroke patients who received glucosepotassium-insulin infusion versus placebo. In the treatment group significantly lowered glucose and blood pressure values were documented; however, no clinical benefit was found among the treated patients. There are a variety of methods of insulin administration, including continuous intravenous. The aggressive-treatment group was associated with somewhat better clinical outcomes, which were not statistically significant. According to the American guidelines [21], even lower serum glucose levels, possibly between 140 and 185 mg/dl, should trigger administration of insulin. Despite the current recommendation, a more aggressive approach is advised, especially in pre-thrombolysis patients. Many questions surrounding the role of glucose lowering therapy remain unanswered [32]. Hyperthermia Several animal studies [35, 36] demonstrated the correlation of elevated temperature and poor outcome in ischemic stroke models. In the Copenhagen stroke study [37] stroke severity was correlated with hyperthermia higher than 37. Other studies limited the correlation between stroke severity and hyperthermia to only the first 24 hours following stroke onset. In a prospective study temperature was recorded every 2 hours for 72 hours in 260 patients with a hemispheric ischemic stroke. Hyperthermia initiated only within the first 24 hours from stroke onset, but not afterward, was associated with larger infarct volume and worse outcome [38]. These animal studies and human observations raised the question regarding the role of hypothermia as a treatment for acute stroke. Hypothermia was introduced more than 50 years ago as a protective measure for the brain [39]. Mild induced hypothermia was found to improve neurological outcomes and reduce mortality following cardiac arrest due to ventricular fibrillation [40]; on the other hand, treatment with hypothermia aiming at 33 C within the first 8 hours after brain injury was not found to be effective [41]. Other applications for which therapeutic hypothermia was suggested include acute encephalitis, neonatal hypoxia and near drowning [39]. The use of antipyretics, such as acetaminophen, in high doses ranging between 3900 and 6000 mg daily [42,43], caused only very mild reduction in body temperature, ranging from 0. Similar results, of decreasing acute post-ischemic Chapter 17: Management of acute ischemic stroke and its complications cerebral edema, were found in a small pilot study of endovascular induced hypothermia [45]. The use of an endovascular cooling device which was inserted into the inferior vena cave was evaluated among patients with moderate to severe anterior circulation territory ischemic stroke in a randomized trial. Although no difference was found in the clinical outcome between the treatment group and the group randomized to standard medical management, the results suggest that this approach is feasible and that moderate hypothermia can be induced in patients with ischemic stroke quickly and effectively and is generally safe and well tolerated in most patients [46]. However, the current data do not support the use of induced hypothermia for treatment of patients with acute stroke. In conclusion, despite its therapeutic potential, hypothermia as a treatment for acute stroke has been investigated in only a few very small studies. Therapeutic hypothermia is feasible in acute stroke but owing to side-effects such as hypotension, cardiac arrhythmia, and pneumonia it is still thought of as experimental, and evidence of efficacy from clinical trials is needed [47]. The American Heart and Stroke Association [21] recommend that antipyretic agents should be administered in post-stroke febrile patients but the effectiveness of treating either febrile or non-febrile patients with antipyretics is not proven. Hyperthermia within the first 24 hours from stroke onset was associated with larger infarct volume and worse outcome, but the current data do not support the use of induced hypothermia aiming at a body temperature of 33 C for treatment of patients with acute stroke. Summary Optimal management of hypertension following stroke has not been yet established. A U-shaped relationship between baseline systolic blood pressure and both early death and late death or dependency has been demonstrated in clinical trials: early death increased by 17. Stroke patients with impaired consciousness showed higher mortality rates with increasing blood pressure. The benefit of blood pressure reduction as a secondary prevention of stroke is well established, but only a few trials have been performed in the acute stage. However, these few trials demonstrate a beneficial effect of lowering blood pressure. According to the American guidelines, indication to treat blood pressure starts with a systolic blood pressure of 220 mmHg, and lowering of blood pressure should not exceed 15% during the first 24 hours after the onset of stroke (Table 17. Increased mortality was found in both diabetic and stress-induced hyperglycemia groups, independent of age, stroke type and stroke size. According to the American guidelines even lower serum glucose levels, possibly between 140 and 185 mg/dl, should trigger administration of insulin. Hyperthermia within the first 24 hours from stroke onset was associated with larger infarct volume and worse outcome. Mild induced hypothermia was found to improve neurological outcome and reduce mortality following cardiac arrest due to ventricular fibrillation, but the current data (few very small studies) do not support the use of induced hypothermia for treatment of patients with acute In summary, hypertension, hyperglycemia and hyperthermia are common conditions following acute stroke. Occasionally, the benefit of this impact is no less than that of more "heroic" strategies such as intravenous and intraarterial thrombolysis. Despite the lack of consensus on the data and optimal management, one should carefully monitor these three "hyper links" and treat them appropriately. General stroke treatment recommendations according to current European Guidelines of the European Stroke Organisation [20]. Because of side-effects such as hypotension, cardiac arrhythmia and pneumonia, therapeutic hypothermia aiming at a body temperature of 33 C is feasible in acute stroke, but is still thought of as experimental. Management of post-stroke complications Stroke is a major cause of long-term physical, cognitive, emotional and social disability. In addition to the neurological impairment appearing in the acute phase, there are infrequently late complications which are often neglected. These complications have a great impact on the quality of life, outcome and chances of rehabilitation and may include post-stroke epilepsy, dementia, depression and fatigue. Other complications, such as infections, are dealt with in the 248 Chapter 17: Management of acute ischemic stroke and its complications following chapter. Prevention and management of complications according to current European Guidelines of the European Stroke Organisation [20]. Recommendations Post-stroke seizures Epilepsy is one of the most common serious neurological disorders and is associated with numerous social and psychological consequences. Stroke is the most commonly identified etiology of secondary epilepsy and accounts for 30% of newly diagnosed seizures in patients older than 60 years [48]. Although recognized as a major cause of epilepsy in the elderly, many questions still arise regarding the epidemiology, treatment and outcome of post-stroke seizures. The common definition of epilepsy includes at least two seizures with a time interval of at least 24 hours between the episodes. The current clinical classification of post-stroke seizures is made according to the period between the stroke and the first epileptic episode. A post-stroke seizure is defined as early if it occurs in the first 2 weeks after the stroke. The wide range is due to the different methodologies, terminologies and sizes of the populations in the different studies. In that study 14% of the patients with ischemic stroke and 20% of patients with hemorrhagic stroke had seizures during the first year; a second episode, required to establish epilepsy, was found in 2. Most of the patients with post-stroke epilepsy have simple partial seizures, while complex partial seizures are relatively rare. There is no evidence to prefer one antiepileptic drug over the others, but it is advised to avoid phenytoin because of interactions with anticoagulants and salicylates. Patients in this population should be advised to avoid factors increasing the risk of seizures, such as certain drugs [60]. The pathophysiology of early seizures is thought to be due to the increased excitatory activity mediated by the release of glutamate from the hypoxic tissue [62]. Late seizures are due to the development of tissue gliosis and neuronal damage in the infarct area [63]. An interesting question is whether post-stroke seizures worsen the outcome of patients after stroke. A cortical cerebral infarction disability was found to be greater in patients with seizures; on the other hand, in patients with cortical hemorrhage disability was found to be less [49]. The attending physician is required to deal with two important questions, the first being whether to start treatment after the first episode and the second being which anti-epileptic drug to prefer. According to the common clinical approach, treatment should be initiated only after the second episode. Observational studies suggest that isolated early seizures after stroke do not require treatment [52, 53]. Beginning treatment after early-onset seizures has not been associated with reduction of recurrent seizures after discontinuing the medication [64]. At this stage there are no evidence-based studies to recommend one drug over the others. It is best to avoid the old drugs, especially phenytoin, because of their pharmacokinetic profile and interactions with anticoagulants and salicylates [65]. Once again, the large variation in frequencies is due to methodological differences, including the point in time at which patients were assessed relative to the stroke onset and the different instruments and criteria for diagnosing depression that were used in the different studies. Differences in the measurement of depression, study design, and presentations of results may also have contributed to the heterogeneity of the findings. Some studies have found aphasia as a risk factor, while others have not obtained similar results [74]. The frequency of post-stroke depression is 33% and it resolves spontaneously within several months of onset in most patients. Antidepressant drugs can improve mood after stroke, but there is less evidence that these agents can be effective in a major depressive episode or prevention. Post-stroke dementia Stroke is an important risk factor for dementia and cognitive decline. The deficits should not occur exclusively during the course of an episode of delirium. One study, done among a population of elderly demented patients, demonstrated that the frequency of dementia was found to depend upon the diagnostic criteria used [79]. Despite some encouraging data regarding the prophylactic use of antidepressants in post-stroke patients there is still insufficient randomized evidence to support this approach in routine post-stroke management [68]. A single recent double-blind placebocontrolled study evaluated the administration of escitalopram in a population of non-depressed patients following stroke [76]. Patients who received placebo were significantly more likely to develop depression than ones who received escitalopram after 12 months follow-up. There is no good evidence to recommend psychotherapy for treatment or prevention of post-stroke depression, although such therapy can elevate mood. It is unclear whether these differences are due to genetic or environmental factors since, as in the previous trials mentioned, there were methodological differences between the studies. Despite the conflicting data the overall estimated frequency of dementia in post-stroke patients is about 28% and the fact that stroke is a major risk factor for dementia is well established [81]. Other mechanisms include hypoperfusion, hypoxic-ischemic disorders and shared pathogenic pathways with degenerative dementia, especially Alzheimer type. The borders between dementia of the neurodegenerative type and vascular dementia are nowadays less visible and both types of dementia include many similar risk factors and clinical and pathological characteristics. In a meta-analysis of randomized controlled trials cholinesterase inhibitors, which are administered for the treatment of degenerative-type dementia, were found to produce only small benefits in cognition of uncertain clinical significance in patients with mild to moderate vascular dementia. Post-stroke fatigue Another common and disabling late sequel of stroke is general fatigue [90, 91]. It is important to distinguish between "normal" fatigue, which is a state of general tiredness that is a result of overexertion and can be ameliorated by rest, and "pathological" fatigue, which is a more chronic condition, not related to previous exertion and not ameliorated by rest. It is important to emphasize that post-stroke fatigue is not always a part of post-stroke depression and can occur in the absence of depressive features [90, 96]. It is estimated that about 70% of post-stroke patients experience "pathological" fatigue. Fatigue was also rated by 40% of stroke patients as either their worst symptom or among their worst symptoms. Fatigue was found to be an independent predictor of functional disability and mortality [97]. The caring physician should be alert to identify possible predisposing factors and to diagnose "pathological" fatigue. The initial treatment should focus on optimizing the management of potential factors, exercise, sleep hygiene, stress reduction and cognitive behavior therapy. The pharmacological therapy includes the stimulant agents amantadine and modafinil. It is estimated that about 70% of post-stroke patients experience fatigue and 40% of patients rate it among their worst symptoms. Pharmacological treatment includes the stimulating agents amantadine and modafinil. Appropriate diagnosis and treatment of the late complications of stroke, which are often underdiagnosed and undertreated, are a crucial component in the management of stroke and should always be taken into consideration when dealing with stroke patients.
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