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Virginia Fleming, PharmD, BCPS

• Clinical Assistant Professor, Clinical and Administrative Pharmacy
• University of Georgia College of Pharmacy, Athens, Georgia

https://rx.uga.edu/faculty-member/virginia-fleming-pharm-d/

However acne vulgaris description buy benzac paypal, according to more recent data skin care homemade cheap 20gr benzac visa, apply is created skin care arbonne buy generic benzac 20 gr, which can drive fuid from the intravascular space ing the Holliday-Segar method as well as fuid choice may not into the intracellular space because intracellular osmolal be appropriate in all clinical scenarios today skin care anti aging cheap benzac 20 gr without prescription. Isotonic Fluids into question the appropriateness of the traditional hypotonic Crystalloid fuids have historically been chosen on the basis fuids historically suggested by Holliday-Segar for use in hos of Holliday-Segar estimates acne jensen boots sale cheap generic benzac uk, which account for maintenance pitalized pediatric patients today acne 2 weeks pregnant order benzac 20gr fast delivery. When Holliday-Segar lining poor clinical outcomes associated with hyponatremia estimated pediatric electrolytes in the 1950s, requirements in hospitalized patients as well as studies comparing hypo were suggested to fall between what would be consumed tonic fuids with isotonic fuids have been published over from breast milk and adult requirements (McNab 2016). A post hoc exploratory analysis showed sig A 2014 Cochrane review evaluated 10 trials in which most nifcant differences in serum sodium change from baseline, patients (n=1106) were children (3 months to 18 years of age) with those in the hypotonic group having a decrease in serum (McNab 2014). The primary end point, risk of developing hypona From this review of available data on the subject, no clear tremia (serum sodium less than 135 mEq/L), was halved in consensus or generalization can be made for all hospitalized those receiving isotonic fuid compared with those receiv patients. The risk of critically ill children, at least during the frst 24 hours of hos hypernatremia was unclear from this investigation. Because pitalization, are more appropriate and possibly safer than adverse events associated with either fuid were rare, compar traditional hypotonic fuids with respect to serum sodium ative safety determinations are not possible from this study. Other outcomes such as hos Although limitations exist in the interpretation and clinical pital length of stay and mortality have not specifcally been application of data from this systematic review, isotonic fuids evaluated. For noncritically ill children, the evidence is less may be preferable to hypotonic fuids, at least during the frst clear, and therapy should be individualized according to clin 24 hours of hospitalization of surgical or critically ill patients. Specifc considerations may be required A similar systematic review of randomized trials of hospi because many factors may affect the risk of hyponatremia. Postmenarchal females are at a higher heart failure, renal dysfunction, and liver disease or those risk than males. Before puberty, all children are at a higher who required fuid resuscitation or replacement therapy were risk than adults of cerebral edema in the setting of hyponatre excluded from the analysis. Eleven studies evaluating 1095 mia because of the relative inability of the developing brain to medical and surgical patients 3 months to 18 years of age adapt to hyponatremia/excess free water and a higher brain were included in the analysis. Of studies that reported mean plasma sodium concentrations Fluid Considerations: Management (n=7), patients receiving hypotonic fuid had signifcantly of Dehydration/Correction of Deficits lower serum sodium concentrations as well as decreased Guiding Principles sodium concentrations from baseline. However, isotonic fu Fluid defcits are defned as losses of fuid above what is ids did not increase the risk of hypernatremia compared with expected through insensible and sensible losses. One hundred ten children with a median fusion is compromised, and negative clinical outcomes occur. Clinical Signs, Symptoms, and Correlates of Dehydrationa Clinical Signs Mild Dehydration Moderate Dehydration Severe Dehydration Pulse Full, normal rate Slightly increased Rapid, weak Systolic blood pressure Normal Normal-low Shock Urinary output Normal or decreased Markedly decreased Anuric. Liquids such as juice, sports beverages, and milk are not appropriate oral Of importance, signs and symptoms of dehydration must fuids for dehydration because of inappropriate glucose and continually be reevaluated because the previously men electrolyte composition; however, children who are breastfed tioned calculations are only estimates. Assessment of laboratory values, including acid over 4 hours is provided in small aliquots (Meyers 2009). For base status and serum electrolytes, must also be included moderate dehydration, 100 mL/kg is provided over 4 hours. This is espe For patients with more severe dehydration or those who cially important in children requiring intravenous fuid ther cannot be rehydrated enterally, intravenous fuids are used to apy to make up for fuid defcits. The general approach to restoring fuid balance can be broken into three phases: phase 1, acute Classification of Dehydration resuscitation. Isotonic be determined: isonatremic, hyponatremic, or hypernatre crystalloid fuids such as normal saline or lactated Ringer mic (Meyers 2009). Table 6 provides an overview of the three main types of acute resuscitation is warranted to correct for hemodynamic dehydration. Dehydration: isonatremic, hyponatremic and hypernatremic recognition and management. Boluses may be repeated two are used, with the choice of crystalloid fuid closely mimick or three times to adequately restore perfusion. In clinical practice, replace tion of tachycardia and hypotension and improved capillary ment fuid may be given on a milliliter/milliliter basis or as a refll). Although certain fuids contain electrolytes vided from the boluses given in phase 1) is administered over such as potassium, many institutions do not allow potassium 8 hours. During phase 3, two-thirds of maintenance fuid plus to be added to replacement fuids for safety reasons. For patients with hypernatremic the electrolytes (sodium, potassium, magnesium, calcium, or hyponatremic dehydration, serum sodium must not be cor phosphorus) are essential to maintain normal biochemical rected faster than 12 mEq/L/day because of the risks of cere reactions and homeostatic functioning (Table 8). Both serum Fluid Therapy electrolyte balance and normal balance are guided by renal Replacement fuid therapy accounts for ongoing losses such function (Meyers 2009). Under normal processes, the electro as vomiting, diarrhea, suctioning, chest tubes, and shunts lyte balance is maintained. For patients with ongoing losses, medications can cause electrolyte abnormalities. In assess the amount and type of fuid loss is evaluated, which then ing electrolytes, three basic steps guide therapy: determine guides the fuid choice. The most precise way of determining the cause, classify it as acute or chronic, and determine a the type of fuid for replacement fuids is a laboratory analy therapeutic plan to manage the electrolyte abnormality. However, this is costly and not the following discussion, each electrolyte will be reviewed, always clinically feasible. For practicality, reference tables with summaries of normal function, excess, and defcits. Potassium homeostasis is pri ness, fever, lack of intake, and medications such as diuretic marily maintained through renal elimination, which varies therapy and hypertonic saline. In severe hypernatremia, cerebral cellular dehy as hormones, acid-base status, and osmolality also play a dration can occur, which can progress to hemorrhage, neu role in potassium regulation (Rhoda 2011). Medications such rologic sequelae such as seizures, coma, and death (Powers as diuretics or nephrotoxic agents can affect potassium bal 2015; Rhoda 2011). For example, if hypernatremia is caused by the lack of oral Hyperkalemia intake of fuid resulting in dehydration, correcting the dehy Hyperkalemia is defned as a serum potassium concentra dration will correct the serum sodium. Because potassium is the primary intracellular cat will correct this electrolyte abnormality. If the serum sodium ion, pseudohyperkalemia should be ruled out before mak is greater than 160 mEq/L, correction should not occur faster ing an assessment. Hyponatremia is one of signs and symptoms of elevated potassium include muscle the most common electrolyte disturbances. Treatment of hyponatremia involves including dietary sources as well as medications. Pharmaco judicious administration of intravenous fuids to correct fuid logic management of hyperkalemia includes agents that shift and sodium balance. Her mother reports Laboratory tests show the following: that she has done her best to keep up with the fuid loss by giving the child small sips of oral rehydration fuid. The child has been 155 115 20 refusing enteral nutrition but has tolerated the sips of rehydra 73 tion fuid. Of note, a serum sodium of 145 mEq/L was chosen as the desired When assessing whether a fuid bolus is required, the level of dehy serum sodium in order to avoid over-correction of sodium. However, if loose To estimate fuid requirements, the percent dehydration and fuid stools continue, these should be estimated and added into the defcit must frst be calculated: calculations. When choosing the crystalloid fuid to use, sodium and potassium requirements should be included. To avoid complications, serum sodium should not be corrected faster than 12 mEq/L/day. Calcium, which stabilizes the cardiac myocytes, may be defnes hypermagnesemia (Schmidt 2010). Typically, mild hypermagnesemia is tolerated well, but when serum magnesium concentra Hypokalemia tions exceed 3 mg/dL, neurologic, neuromuscular, and car Hypokalemia (serum sodium of less than 3. Although symptoms should be administered to stabilize the cardiac muscle, and are nonspecifc, presentation may include constipation/ileus, in some cases, dialysis may be required. Most cases, how dysrhythmias, paralysis, muscle necrosis, and possibly, in ever, are mild and can be managed by decreasing magnesium severe cases, death. In the neonatal popu potassium either orally or intravenously, depending on sever lation, hypermagnesemia may result from the placental trans ity. Hypomagnesemia Because potassium supplementation is irritating to veins, Hypomagnesemia is defned as magnesium concentrations peripheral fuid concentration must not exceed 0. Finally, if hypomagnesemia mia occurs in patients with acute tubular necrosis, renal tubu is present, magnesium concentrations must be corrected lar acidosis, hyperaldosteronism, and Bartter syndrome and concomitantly. Hypomagnesemia is common in Magnesium hospitalized patients and is associated with apathy, depres Primary Physiologic Function and Normal sion, muscle weakness, ataxia, muscle cramps, and cardiac Homeostasis complications. During administration, hemodynamics, specifcally of bone (more than 50% of magnesium resides in the bone) as blood pressure, should be monitored. Magnesium is absorbed in the jeju num, with absorption inversely proportional to intake. Homeostasis If dietary intake is low, magnesium will be leached from the Calcium (typical range 6. When con mg/dL, depending on age), is critically important for main centrations are high, calcitonin is released from the thyroid, taining cellular function, bone and cell membrane composi which inhibits bone resorption and increases renal elimination. Homeostasis is maintained through ionized and is primarily located in the teeth and bone. Hypercalcemia Hypercalcemia defnitions depend on normal values for age Hyperphosphatemia as well as nutritional factors such as circulating albumin. Cor Serum values above age-expected normal concentrations rected calcium is calculated as follows: defne hyperphosphatemia (Schmidt 2010). Hyperphosphate mg mia can be caused by metastatic calcifcations, hypocalce Corrected calcium = easuredtotal calcium dL mia, or hypoxemia (Rhoda 2011). Most hyperphosphatemia is tolerated well, and many patients may be asymptomatic g + 0. However, symptoms, when present, often dL include anorexia, nausea and vomiting, dehydration, poor Although hypercalcemia may be the result of increased appetite, neuromuscular symptoms, and tachycardia (Rhoda dietary intake, increased vitamin A or D concentrations, renal 2011; Schmidt 2010). Patients with hypercalcemia low volume is suspected, volume repletion may be required. In mild to moderate cases of hyper Hypophosphatemia calcemia, fuid therapy is frst line and usually effective. For Hypophosphatemia is defned by serum concentrations less severe cases, intravenous fuid therapy, loop diuretics, and than 2. This dialysis therapy may be needed to prevent dysrhythmias, kid condition is common in critically ill children as well as in ney failure, and death. Hypocalcemia Hypophosphatemia may also be present in patients receiv Hypocalcemia is defned as a corrected calcium or ionized ing phosphate binders or those with alkalosis. Clinical signs calcium below age-appropriate normal values (Schmidt include, but are not limited to , neurologic and neuromuscular 2010). Although the equation above can be used to calculate symptoms and cardiac, respiratory, or hematologic dysfunc corrected calcium, when possible an ionized calcium level tion. If presentation and symptoms are mild, management should be obtained for greater accuracy. Therefore, intravenous temia, decreased parathyroid hormone activity, blood trans supplementation is required when moderate or severe hypo fusions, and rhabdomyolysis. In hypocalcemia, hypomagnesemia must also be the practicing pediatric pharmacist plays a key role in assessed for and corrected, if present. For neonates receiv assessing and managing fuids and electrolytes across the ing parenteral nutrition, hypocalcemia may result from an age spectrum. A solid foundation in understanding the com inability to provide adequate amounts of calcium because position of body fuids, fuid requirements, and regulations; of intravenous fuid compatibility issues. Depending on the assessing and managing dehydration, understanding the severity of hypocalcemia, treatment involves oral or intrave physiologic functions of electrolytes, and managing electro nous calcium supplementation. Comparison of iso Practice Points tonic and hypotonic intravenous maintenance fuids: a When approaching fuid and electrolyte therapy in the pediatric randomized clinical trial.

To limit the risk for loco-regional problems skin care shiseido purchase generic benzac on-line, aggressive oral hygiene should be initiated in all patients undergoing radia tion treatment acne kids order benzac 20 gr amex, including routine brushing and oral/ pharyngeal irrigation with a combination of salt water and baking soda solution acne 4 hour buy 20 gr benzac amex. This solution can be made by boiling one quart of water and adding one teaspoon of salt and one teaspoon of baking soda acne 9gag order benzac 20gr with visa. The irrigation should be performed at least every three to four hours on a daily basis during the waking hours acne 3 step system buy benzac 20gr mastercard. Third skin care regimen purchase discount benzac line, aggres sive observation of these patients for development of fungal infections should be maintained, and systemic antifungals initiated should evidence of infection be present. Delay or termination of therapy should be considered if signifcant and/or life-threatening side effects are becoming manifest. In addition to acute management, patients should be placed on long-term care specifcally with respect to dental management. Monitoring of dentition should be maintained, and prevention measures for caries initiated. Chemotherapy Similar to the use of radiation therapy, the use of chemotherapy should be used with caution. Aggressive monitoring for these side effects, especially bone marrow failure, must be considered routine. In addition, monitoring for cisplatin effects on sensorineural hearing should also be a routine in these patients. If hearing sequelae develop as a con sequence of the cisplatin treatment, cisplatin should be changed to carboplatin, which has similar effcacy but lower risk for ototoxicity. Until new therapeutic and preventative mea sures are available, strict abstinence from tobacco and alcohol, avoidance of second-hand smoke, maintenance of oral hygiene, and aggressive routine screening are the most immediate ways to reduce the development 262 Fanconi Anemia: Guidelines for Diagnosis and Management and morbidity of head and neck cancer in this patient population. Early and frequent head and neck examina tions, including careful oral cavity evaluations and fex ible fberoptic laryngoscopy are important surveillance measures. High incidence of head and neck squamous cell carcinoma in patients with Fan coni anemia. Human papillomavirus-associated head and neck squamous cell carcinoma: mounting evidence for an etio logic role for human papillomavirus in a subset of head and neck cancers. This group consists of individuals diagnosed and treated in child hood and those newly diagnosed as adults. The former group is growing as a result of increased recognition and testing, combined with better transplant results and improved supportive care options. However, to date, the adult population has not been studied as a group in prospective studies. However, we have commented where there is suffcient information and have referenced other chapters where appropriate. Issues will differ by degree of prior evaluation and treatment, current symptom complex, and the evolving clinical database pertinent to this patient group. For the adult patient, management of expecta tions, family dynamics and external drivers, such as workplace and social environment, are likely to be criti cal components of care. Experience in other disorders highlights that the need for a clear defnition of the rela tive roles and responsibilities of the care team and the patient is particularly relevant for individuals diagnosed in childhood and historically managed in the context of (surrogate) parental decision-making. Such informa tion will be a critical part of managing the issues listed below, as well as additional needs and problems to be defned. Although a few of these patients have not developed bone marrow failure or hemato logic malignancies, and some may not do so in their lifetimes, all require scheduled hematologic evalua tions (see Chapter 3). They may also be at risk for iron overload and need chelation or may be chronically chelated and require management of chelation side-effects (see Chapter 3). Importantly, the improving results of trans plantation, particularly from unrelated donors, suggest that transplantation will remain an option for many of these patients. The dialogue regarding a possible decision to proceed to transplant should be informed by the most current transplant results in adult patients and requires continuing education and counseling of affected individuals. Long-term use of medications and chronic graft-versus-host disease may affect hematopoietic functioning. In particular, squamous cell cancers of the head and neck, and cervi cal and vulvar cancers in women, occur at remarkably high rates and at younger than expected ages. Patients must be continually re-educated regarding this complication and be screened by an educated specialist. Behaviors increasing risk for these malignancies, such as smoking and alcohol consumption, should be dis cussed as part of a pre-emptive strategy. The beneft seems likely to be as great or greater than that of the general population, although the data regarding the ultimate cancer-preventing effcacy of these vaccines 268 Fanconi Anemia: Guidelines for Diagnosis and Management in any population remain to be determined. In addition, the incidence of other tumors, including gastrointesti nal and breast cancers in particular, may be excessive. The evolving data will need to be carefully evaluated to develop appropriate monitoring (and treatment) strate gies that respect the desire to minimize radiation expo sure and treatment-related toxicity. Advances in assisted reproduction techniques have led to new possibilities for the prevention and treatment of infertil ity. These issues may be particularly challenging to address with newly diagnosed patients. In addition, the effects of oral hypoglycemics developed for the gen eral population will need to be evaluated in this patient subgroup. However, the best practice for following and managing patients is unknown and will need to be established by collaboration between various expert providers. Further challenges in these areas will be provided by integrating the side-effects of prior and ongoing therapies with management of these, and other, results of normal aging. Transition of Care Transition of care from pediatric to adult medicine is an important issue in young adults with complex and chronic illnesses. European coun tries with comprehensive state-supported health care systems have often taken the lead in the development of these transition systems. In most centers, pediatric services defne their target population by age, and adults may not be treated by pediatric subspecialists or in pediatric in-patient facilities. Young adult patients must develop indepen dence and undertake personal responsibility for their health care. Timing of transition is important and must be seen as a process, not an abrupt transfer of services. Data show 270 Fanconi Anemia: Guidelines for Diagnosis and Management that the most successful transitions are initiated at a very early stage with prospective education of the fam ily and patient regarding future transition. In contrast, timing may be very situation-dependent, as it is likely to be inap propriate to transition a patient with quickly progress ing disease or at the end of life. As in all childhood diseases, surrogate decision-making imposes many demands on parents and guardians. There is a potential risk of parental over-protectiveness in the setting of requisite attention to safety, and the age-appropriate pursuit of adolescent independence may be particularly diffcult for parents. Recent follow-up of adult survivors of childhood acute lymphoblastic leukemia shows more adverse mental health functional impairment and activity limitations compared with their healthy siblings. Studies to date show that these latter issues of adulthood are also inadequately addressed in many pediatric healthcare settings, thus further exacer bating the stress on patients and families. Medical compliance may also be an issue, particularly during adolescence and during the transition period. For individuals newly diagnosed in adulthood, the ramifcations of established relationships (with spouses, partners, employers, etc. The knowledge base is as yet insuffcient for understanding best practices, and the provider pool within the community of physicians caring for adult patients is not yet well educated as to either the nature of the disorder or the needs of the patients. Hematologic abnormalities in Fanconi anemia: an International Fanconi Anemia Registry study. Improving transition from pediatric to adult cystic fbrosis care: lessons from a national survey of current practices. Strategies for improving transition to adult cystic fbrosis care, based on patient and parent views. Trends in transi tion from pediatric to adult health care services for young adults with chronic conditions. Transition pro grams in cystic fbrosis centers: perceptions of pediatric and adult program directors. Twenty-fve-year follow-up among survivors of childhood acute lymphoblastic leukemia: a report from the Childhood Cancer Survivor Study. Additionally, the consultation should include information about cur rent research opportunities and support groups, future reproductive options and their familial implications. This history can be help ful in determining the inheritance pattern as well as the genetic basis of the disease. Inheritance Fanconi anemia is predominantly inherited in an auto somal recessive fashion. Cancer Background the counselor should obtain a detailed investigation of family cancer history, with a special emphasis on breast, ovarian, and prostate cancer. Features of hereditary cancer syndromes include multiple close family members with cancer, an autosomal dominant pattern of cancer inheri tance, an early age of onset of cancer, bilateral breast cancer, more than one primary tumor, and male breast cancer. Rare autoso mal recessive diseases have an increased frequency of carriers who are consanguineous. For these reasons, genetic testing should not be delayed and should be completed in a step-wise progression. Alternative 278 Fanconi Anemia: Guidelines for Diagnosis and Management testing strategies include ethnicity-based genetic sub typing and comprehensive mutation screening. Retrovirus-mediated complementation group testing requires cells from patients that can be grown and are sensitive to cross linking agents. For some patients, complementation group testing will not be possible due to these sample limita tions. Furthermore, complementation group testing can currently classify patients into 8 of the 13 known com plementation groups. Groups that currently can be clas sifed by complementation group testing include (A, B, C, G, E, F, J, and L). Genes not currently identifable by complementation group testing include D1, D2, I, M, and N. Mutation analysis is necessary to classify indi viduals into one of these fve groups. In approximately 2-3% of the cases, a complementation group will not be identifed and a gene mutation will not be found in any of the known 13 genes (personal correspondence with Arleen Auerbach, PhD, the Rockefeller University). Mutation analysis is used to confrm the initial complementation group result, to perform other genetic tests such as carrier testing, prenatal testing, and preimplantation genetic diagnosis and, in some cases, to direct medical care and/or enroll in specifc research studies. Genetic testing results Genetic testing Genetic testing results can be used for carrier could show may be inconclusive or testing, prenatal testing, unknown family mutations may not be and preimplantation relationships identified. Genetic testing Family members information can be may not want helpful to family to know information members. Genetic testing results may be used for inclusion in certain research projects or clinical trials. Genetic testing can have many benefts, risks, and limitations and is a personal decision. A detailed conversation and informed consent of the patient and/or legal guardian must be completed prior to undertaking mutation analysis. Genotype-Phenotype Correlations In most cases it is not possible to predict the clinical course of this genetically and clinically heterogeneous disease. Lack of genotype-phenotype correlation is evidenced by siblings with the exact same gene muta tions with radically different phenotypic manifestations. Cancer Risks for Fanconi Anemia Carriers the current data collected through the International Fanconi Anemia Registry show that most carriers are not at increased risk of cancer, but several specifc genes and particular mutations do confer cancer risks. Due to the increase in these specifc cancers, Chapter 15: Genetic Counseling 283 recommendations for proper screening and surgical options have been created by the National Comprehen sive Cancer Network as described below. Discussion should include reproductive plans, menopausal symptoms, and degree of protection for breast and ovarian cancer. Clinical Breast Exam Seek medical advice for any breast mass, pain or change Mammogram Not typically advised in the absence of other risk factors such as gynecomastia 284 Fanconi Anemia: Guidelines for Diagnosis and Management In addition to screening for cancer, ways to attempt to reduce the risks of cancer include chemoprevention and surgery. Chemoprevention for breast cancer is most commonly achieved using the drug tamoxifen. The use of tamoxifen for fve years has been shown to reduce the incidence of breast cancer by 43% in women who have an increased risk. Carriers should be informed of this potential increased risk and be encouraged to discuss this fnding with their health care providers. Reproductive Issues Reproductive counseling is part of the genetic counsel ing process. There is always a chance that an error leading to misdiagnosis could occur in the testing or embryological process. It can be a very stressful experience physically, emotionally, and fnan cially for couples who undergo the procedure. Practice issues subcommittee of the National Society of Genetic CounselorsFamilial Cancer Risk Counseling Special Interest Group. Risk assessment and genetic counseling for hereditary breast and ovarian cancer: Recommenda tions of the National Society of Genetic Counselors.

This practice of topping off dispensers may lead to bacterial contamination of the soap skin care di jakarta order benzac once a day. For handwashing skin care clinic best 20gr benzac, use a bucket with a tap that can be turned off to lather hands and turned on again for rinsing skin care gadgets purchase benzac 20gr amex, and then turned off with a paper towel after rinsing acne fighting foods buy benzac 20gr with amex. Alternatively skin care jogja benzac 20gr sale, use a bucket and pitcher acne yeast infection buy benzac 20 gr overnight delivery, or just pour water over hands and have an extra bucket to collect used water. There is heightened awareness and hand hygiene is essential for preventing Ebola Virus Disease as well other infections. Improvement requires ongoing education, communication, perseverance, dedication, engagement, leadership support, creativity, and adaptability. Remember: A multimodal strategy offers the most reliable method for delivering long-term improvements in hand hygiene in health care facilities. Monitoring of hand hygiene practices and feedback: Monitor hand hygiene practices, infrastructure, perceptions, and knowledge, while providing results feedback to health care workers. Reminders in the workplace: Remind staff periodically about hand hygiene using approaches such as text messages, posters, and job aids. Prevention and Control of Ebola Virus Disease in Health Care Facilities with Limited Resources 4-7 Note the following: Glycerol has humectant, but other emollients may be used for skin care, provided they are inexpensive, widely available, and miscible in water and alcohol, and do not add to toxicity or promote allergy. Verify alcohol concentration with the alcoholmeter and make the necessary adjustments in volume in the preparation formulation to obtain the final recommended concentration. Often, the contaminated hands of a health care worker or contaminated equipment/environmental surfaces are involved. In caring for patients with Ebola, protection from patient, equipment, and environmental surfaces contaminated or potentially contaminated with blood or body fluids is recommended. Due to their size, particles remain airborne briefly and travel only about 3 feet to 6 feet (1 to 2 meters) or less. There is no evidence that Ebola is spread by coughing or sneezing and Ebola is not transmitted through the air. For patients with Ebola, these can be produced by aerosolized or nebulized medication administration, diagnostic sputum induction, endotracheal intubation, bronchoscopy or airway suctioning, and positive pressure ventilation via face mask. However, for patients with Ebola Virus Disease, droplet nuclei can be produced by aerosol-generating procedures (including aerosolized or nebulized medication administration, diagnostic sputum induction, endotracheal intubation, bronchoscopy or airway suctioning, and positive pressure ventilation via face mask). To prevent transmission of Ebola, it is recommended that health care workers wear an N-95 respirator when performing any aerosol generating procedures. N-95 mask seal check: A procedure conducted by the wearer of a particulate respirator each time it is worn to determine if the respirator is properly sealed to the face. It includes a positive pressure check (breathing out to check for leak on exhalation) and negative pressure check (breathing in to check for leak on inhalation). Personal protective barriers are a key method for protecting health care workers from exposure to blood and body fluids from patients infected with Ebola virus. That health care workers in West Prevention and Control of Ebola Virus Disease in Health Care Facilities with Limited Resources 5-1 Africa, Spain, and the U. Face 1 covers, protective footwear, head covers, and gowns or coveralls are also essential for protection. Therefore, it is essential that all health care workers use Standard Precautions consistently for all patients, regardless of their 1 World Health Organization. Personal Protective Equipment in the Context of Filovirus Disease Outbreak Response: Rapid Advice Guideline (October), at: apps. How to Conduct Safe and Dignified Burial of a Patient Who Has Died from Suspected or Confirmed Ebola Virus Disease, at: apps. While 6 the viral load is highest in blood, bleeding is seen in only a minority of patients. Other body fluids such as vomit, feces, sweat, saliva, urine, amniotic fluid, and semen may also contain virus (on 2 occasion, high levels of virus can be found) and be involved in transmission. Transmission can occur through direct contact with these body fluids, or through contact with fomites. Transmission through intact skin has not been documented, but infection can be transmitted 2 through non-intact skin and through penetrating injuries of the skin, such as needle-stick injuries. How to Take Off Examination Gloves (Correct technique is very important to prevent contamination. A poorly fitting glove can limit your ability to perform the task and may be damaged (torn or cut) more easily. Wear your normal size glove under the cuff of the gown/coverall and the same size or next size up over the cuff of the gown/coverall. It is recommended especially for tall people or those undertaking strenuous activities (such as carrying patients). Guideline on Hand Hygiene in Health Care in the Context of Filovirus Disease Outbreak Response: Rapid Advice Guideline (November), at: apps. Respirators form a tight seal against the skin and filter small airborne pathogens passing through the material or around the edges during inhalation as well as block large particle droplets, splashes, sprays, or splatter. To put on a particulate respirator: Cup the respirator in your hand, with the nosepiece at your fingertips, allowing the headbands to hang freely below your hand. Pull the top strap over your head, resting it high at the top of the back of your head. Pull the bottom strap over your head and position it around the neck below the ears. Fitting Instructors for Respirators Perform a seal check before each use: Cover the front of the respirator with both hands, being careful not to disturb the position of respirator. Leakage will result in loss of negative pressure in the respirator due to air entering through gaps in the seal. Step 3: Tie back hair; for eyeglasses, use anti-fog spray and have a band to hold glasses in place. Prevention and Control of Ebola Virus Disease in Health Care Facilities with Limited Resources 5-7 Steps 4: Use the bathroom. If rubber boots are not available, wear closed, puncture and fluid-resistant shoes with no laces or opening at the top of the foot. The trained assistant reads the following to the health care workers, step-by-step: Step 8: Perform hand hygiene with sanitizer or soap and water, ensuring that all surfaces of the hands are cleaned. Step 10: Put on first pair of gloves (if you have a short cuff pair, put them on now). Gown: Put on gown and ensure it fully covers torso from neck to knees, arms to end of wrists, and wraps around the back. Step 15: Medical mask: Put on, tie securely, and pinch the bridge of the nose to ensure that the mask is correctly positioned. N-95 respirator: Cup the respirator in the hand, with the nosepiece at fingertips. Step 16: Put on head cover, ensuring face, neck, and head to eyebrows are fully covered. Step 17: Spray face shield or goggles with anti-fog spray and wipe with clean cloth. Step 18: Put on face shield or goggles and tighten to fit head securely and hold head cover in place. Step 22: Enter the isolation room or patient care area after clearance from the trained assistant. Step 10: Remove apron by rolling contaminated front inward and place it in the waste bag. Step 15: Remove face shield: by tilting the head slightly forward, grabbing the rear strap, and pulling it over the head, gently allowing the face shield to fall forward. Place them in the waste bag or, if reprocessing, put them in the container with disinfectant. Step 17: Remove head cover by grasping it from the back and pulling it away from the head (not touching face or skin). Step 19: Remove gown: Grasp shoulders of gown and pull forward to break ties (or have trained assistant undo ties at back). Prevention and Control of Ebola Virus Disease in Health Care Facilities with Limited Resources 5-11 Avoid contact of scrubs with outer surface of gown or suit. Step 21: If wearing shoe covers, remove them using hands-free technique, if possible, and place them in waste bag, touching only the inside of the shoe covers. Step 28: Clean first boot/shoe by: Spraying: Trained assistant sprays front, back, and bottoms with 0. Step clean boot/shoe into low-risk area while other foot remains in isolation area. Step 29: Clean second boot/shoe by: Spraying: Trained assistant sprays front, back, and bottoms with 0. Symptoms of heat-related illness are a continuum of mild to moderate to severe and even life threatening. Prevention and Control of Ebola Virus Disease in Health Care Facilities with Limited Resources 5-13 Table 5-1 describes the severity of heat-related illnesses from heat cramps and heat exhaustion to a very serious complication, heat stroke. It includes body temperature, sweating rates, urine output, and gastrointestinal, cardiovascular, and central nervous systems, for example. Under each column under heat-related conditions, the effects on the body systems are described to aid clinical diagnosis and manage the condition accordingly. The outbreaks of Ebola Virus Disease in these countries have severely affected routine health care services including very crucial maternal and child health services, with expected further increases in maternal mortality ratios. In resource-limited settings, Ebola Virus Disease outbreaks can devastate already fragile health systems. During the 2014 outbreak, a large number of health care providers have succumbed to Ebola infection. In many facilities, the fear among health care providers has resulted in abandonment of patients, further limiting access to emergency obstetric care services. Full compliance with infection prevention and control recommendations in managing all pregnant women is critical to protect health care workers and other non-infected patients in the facility. The goal is to provide optimal comfort and care to the patients while protecting staff and other patients. Given the high risk of splashes of blood and body fluids, including amniotic fluid, in the care of pregnant women, it is recommended that health care workers wear face shields that cover the entire surface area of the face. These guidelines should be followed meticulously to avoid any exposure to blood and body fluids. Heavily soiled linen should be disposed of as contaminated waste if at all possible. Therefore, cleaning of patient care areas and surfaces as described in Chapter 7 is an important part of prevention. Given the high 3 concentrations of Ebola virus in blood and other body fluids, spills of blood and body fluids on environmental surfaces or equipment should be cleaned as soon as possible as described in Chapter 7. Prevention and Control of Ebola Virus Disease in Health Care Facilities with Limited Resources 6-3 Recommended obstetric practices for managing pregnant women infected with Ebola and their babies are summarized in the following box. The overall purpose is to maximize the safety of all staff who are working within high-risk areas. The guidance provided below is based on limited experience of several organizations currently involved in Ebola response in West Africa. Women who are suspected or confirmed to have Ebola Virus Disease and are pregnant, are in labor, are delivering, or are in the postpartum period should be managed in an isolation room/area (as described in Chapter 3). Communicate with the woman and her relatives the importance of taking the woman to the health care facility immediately if she develops a high fever of sudden onset with severe body aches. Provide compassionate care and morphine for pain management to allow death in a dignified manner. However, there is not enough information to provide guidance about the length of time after illness onset at which it is safe for infants to resume 5 breastfeeding. While the mechanism of transmission from mother to baby is not clear, the following key messages should be applied. Given the potential risk of transmission to an infant through breastfeeding, a woman who has been admitted as a suspected case may have already infected her breastfed infant. If the baby is breastfed from another woman, there is a theoretical risk of the woman getting infected from the baby. Use the following flowcharts (Figure 6-1 and Figure 6-2) to make decisions about advising infant feeding in different situations. Prevention and Control of Ebola Virus Disease in Health Care Facilities with Limited Resources 6-5 Figure 6-1. Note that terms used for cadres like social workers and social welfare department personnel need to be adapted to each setting. Breastfeeding Summary Ebola virus is secreted in breast milk and can be transmitted to infants via breast milk. In previous Ebola Virus Disease outbreaks, newborns of mothers infected with Ebola have not survived beyond 19 days. Following the guidance above will allow you to make an appropriate decision about advising a patient about breastfeeding. Cleaning is required before disinfection because dirt and debris reduce the effectiveness of chemical disinfectants. Disinfectants are classified as low-, intermediate-, or high-level depending on their ability to kill or inactivate some (low or intermediate-level) or all (high-level) microorganisms.

In return skin care regimen benzac 20gr online, the providers help keep the payer costs under control by limiting the amount of reimbursement they receive for each encounter acne nodules buy discount benzac 20gr on-line. By staying within the payer network acne bomber jacket discount benzac 20 gr with amex, the patient saves the insurance company or employer money while still receiving quality healthcare skin care korean brand buy benzac 20gr mastercard. Looking at standard contracts Many payers or networks have standardized contracts that they offer to healthcare providers acne 4 year old benzac 20 gr sale. If the payer is not compliant with either the contract or state laws skin care must haves buy cheap benzac line, penalties are usually applied in the form of interest that compounds daily. This may include such items as implants, screws, anchors, plates, rods, and so on. Make sure you read each contract carefully and familiarize your self with each set of payer circumstances. Understanding reimbursement rates and carve-outs As I explain in the preceding section, despite their differences, contracts tend to be fairly boilerplate. They may pay 110 percent or Chapter 11: Processing a Run-of-the-Mill Claim: An Overview 167 125 percent of what Medicare allows. They may even pay less than Medicare allows, which sometimes happens with large networks or payers who have so many insured members that providers risk financial disaster by not par ticipating. The providers also factor in all overhead costs (rent, utilities, staff, commodities, and salary) associated with each type of service. A contracted carve-out is a special clause in the contract that stipulates a dif ferent payment rate from the normal rate for a specified procedural code. Although they should result in a profit for the provider, they often delay correct claims pro cessing because they require special handling by the payer. Doing so lets you identify poten tial reimbursement issues in advance and know what, if any, special protocol needs to be followed. Check in the record to ensure that the referral is noted (it is usually an alpha numeric entry that must be included on the claim). The provider is the professional and in the best posi tion to understand what steps are necessary to treat the patient. Dealing with prior authorization Prior authorization (also known as preauthorization) is the process of getting an agreement from the payer to cover specific services before the service is performed. Normally, a payer that authorizes a service prior to an encounter assigns an authorization number that you need to include on the claim when you submit it for payment. To determine the correct code, check with the physician to find out what she anticipates doing. For example, if the doctor has scheduled a biopsy (which may not need prior authorization) but then actually excises a lesion (which probably does need prior authorization), the claim for the excision will be denied. No penalty is incurred when a procedure has been authorized but is not completed, so err on the side of preauthorization. This scenario most often occurs in emergency situations, due to an accident or sudden illness that develops during the night or on weekends. When this hap pens, the servicing provider must contact the payer as soon as possible and secure the necessary authorizations. Getting pre authorization takes only a few minutes, and it can save countless hours on the back end trying to chase claim payments. If the plan benefits outline specific services that are not covered and the patient seeks those services, the responsibility for pay ment falls to the patient. On the other hand, if a provider fails to authorize treatment prior to providing services to a patient and payment is denied by the insurance company, then the provider may be obligated to absorb the cost of treatment, and no payment is due from the patient. In this case, the provider has to make a decision about whether to pursue collecting the pay ment from the patient. This is yet another reason to do your homework as a coder and make sure those preauthorizations are going to go through. This usually happens when there is a termination of employment that is challenged in court or when an employer learns that a covered employee was in violation of his or her contract during employment. In these very unfortu nate situations, the patient is responsible for the medical fees, but collecting the debt can be quite difficult. In the following sections, I explain the stops and possible perils along the way, from billing software to the clearinghouses to the payer. For details on that process, head to the section Appealing to the Masses: Filing an Appeal with the Payer. It prepares the claim to be submitted to the claims clearinghouse (covered in the next section). What this means is that the clinical staff clinical enters the clinical information and pro vides additional documentation of medical necessity. Here are some other features you may encounter: Some offices use billing software that links into their electronic medi cal records, while other offices have encounter-specific information (encounter times, names of clinical staff involved in the encounter, and so on) stored in the billing software. Chapter 11: Processing a Run-of-the-Mill Claim: An Overview 171 Making sure the correct contract is loaded into the billing software Normally, payer contracts are already loaded into the office billing software so that, when you enter information, the software automatically links each procedure to the appropriate payment obligated by the payer contract. Having the correct contract loaded saves time because it facilitates payment posting on the back end of the claim. In small companies, the payment poster may be the office manager or other front office associate. Larger companies, including most billing companies, have employees whose job is limited to just posting payments to the correct accounts. From provider to clearinghouse Companies that serve as intermediaries who forward claims information from healthcare providers to insurance payers are known as clearinghouses. In what is called claims scrubbing, clearinghouses check the claim for errors and verify that it is compatible with the payer software. The clearinghouse also checks to make sure that the procedural and diagnosis codes being submitted are valid and that each procedure code is appropriate for the diagnosis code submitted with it. Most clearinghouse companies charge the providers for each claim submitted, and they also charge an additional fee to send a paper claim to a certain payer. Clearinghouses may submit claims directly to the payers, or they may have to send a claim through other clearinghouse sites before reaching the payer(s). Because of the potential difficulties caused by incompatible software, clearinghouses require an initial enrollment period prior to sending claims for the first time. During the enrollment period, which can take up to four weeks, the clearinghouse tests the compatibility between the provider software and the payer software. When using a new clearinghouse, verify the enrollment process before you actually need to submit live claims. You want to choose a clearinghouse that already has a relationship with your payers. The provider pays the clearinghouse, and the insurance companies pay the clearinghouse. This exchange takes longer to get the claim from the provider to the payer and may delay payment. Obviously, if a clearinghouse has to send a claim to other clearinghouses, the claims process takes longer. In addition, exchanges like this can perpetuate, with your claims going every which way before reaching the intended payer. And every time the claim is transferred, the chances of it being stalled or lost increases. To avoid this carousel of billing chaos, you need to know where the claims are going after they leave the provider. If you are enrolled with a clearinghouse that seems to always send the claims to other clearinghouses, shopping around may be wise. Enrolling with a larger entity may cost a little more, but doing so is usually worthwhile if it gets the payment in sooner. And on to the payer After making its way through the clearinghouse, the claim finally ends up with the payer. The payer is responsible for paying the provider for services rendered to its client, the patient. Chapter 11: Processing a Run-of-the-Mill Claim: An Overview 173 How claims are processed the payer enters the claim into its processing software. Claims that involve high dollar amounts or that need supporting documen tation usually require manual processing. Unlike most claims, which are processed by computers, claims requiring manual processing need to be reviewed by a human. In addition to simply looking at the procedures, the payer reviews the diagnosis and other applicable documentation. For exam ple, if the provider contract includes a carve-out for, say, implants (refer to the earlier section Understanding reimbursement rates and carve-outs), then the payer needs to see the invoice(s) and calculate the correct payment for that line. Or if a provider has billed an unlisted code and the contract allows payment for this code, then the payer may need to review additional information, such as an operative report, to determine which procedure the unlisted code represents. Each state has an insurance department or commissioner, and any com mercial payers who violate state prompt pay laws or contractually obligated payment timelines may be reported to the appropriate official.

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