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Their laboratory identification methods are more complex and beyond the scope of this chapter. Pathologic gram negative rods include salmonella, shigella, yersinia, pseudomonas, etc. Most gram negative rods are covered by aminoglycosides, cephalosporins, broad spectrum penicillins, sulfonamides and quinolones. Pseudomonas is particularly resistant so it commonly emerges in patients treated with prolonged courses of antibiotics. It is usually treated with a broad spectrum penicillin such as amoxicillin, but some M. Neisseria meningitidis (also called meningococcus) is highly virulent causing meningitis and meningococcal sepsis (known as meningococcemia). All newborns receive routine eye prophylaxis with ophthalmic silver nitrate or antibiotics. They are gram negative organisms commonly called coccobacilli, or pleomorphic (variable forms) rods. Haemophilus influenzae type B (known as HiB for short) was a major cause of sepsis, meningitis, septic arthritis, pneumonia, epiglottitis and cellulitis in young children. These serious and life threatening infections from HiB have largely been eliminated from our community through widespread HiB immunization (a major public health and pediatric accomplishment). This is a polysaccharide vaccine which does not provide immunity against non-encapsulated (also called non-typable H. Thus, amoxicillin-clavulanic acid and high generation cephalosporins cover 100% of H. Most anaerobes are sensitive to penicillin with one major exception and that is Bacteroides fragilis (B. Thus, classically, the anaerobe component of aspiration pneumonia may be treated with penicillin as opposed to peritonitis due to a ruptured appendix which is likely to involve B. Bacteroides fragilis is classically treated with clindamycin, metronidazole or chloramphenicol. Some cephalosporins such a cefoxitin and cefotetan have better coverage against B. If an anaerobic infection is suspected, culture samples must be sent to the lab in special anaerobic culture/transport media. Other gram negative organisms that deserve mention include Legionella, Bordetella, Brucella, Francisella, Campylobacter, Helicobacter, Vibrio and Pasteurella. Mycoplasma and Chlamydia are similar to viruses in that they are obligate intracellular organisms. Mycoplasma and Chlamydia must be grown in cell media (similar to viruses) in labs, thus, they are difficult to culture.

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Malignant mesenchymoma these very uncommon sarcomas contain areas showing features of at least two types of sarcoma, including fibrosarcomatous tissue per the original description. This is one of the most vascular (blood vessels) sarcomas because it induces an extensive network of vessels to grow in and around the tumor. Epithelioid sarcoma this sarcoma often develops in tissues under the skin of the hands, forearms, feet, or lower legs. This sarcoma has a much higher propensity for lymph node metastasis than most sarcomas, which usually preferentially metastasize to the lung. Local recurrence is common; therefore wide resections are required for complete local eradication. Other Types of Sarcoma There are other types of soft tissue sarcomas, but they are less commonly encountered and not included in this discussion. Incidence: Soft Tissue Sarcomas Soft tissue sarcomas account for less than 1% of all cancer cases diagnosed each year, and for a similar proportion of cancer deaths in a given year. It should be noted this percentage varies from year to year based on the participation and reporting by hospitals to this voluntary database. This number excludes approximately 32,250 soft tissue sarcomas of the head and neck, thoracic, and abdominal areas; these patients are generally cared for by non-musculoskeletal specialists. This compares to the estimated 12,020 cases predicted for 2014 by the American Cancer Society. Demographics: Soft Tissue Sarcomas While soft tissue sarcomas can be found among all ages, the incidence increases after the age of 55 years. Average length of survival after diagnosis is 7 years, similar to that of breast, urinary, and nervous system cancers. White women have a slightly higher 5-year survival rate than do men, and live an average of 1 year longer after diagnosis. Staging criteria for soft tissue sarcomas are primarily determined by whether the tumor has metastasized or spread elsewhere in the body. In general, the prognosis for a soft tissue sarcoma is poorer if the sarcoma is large. The corresponding 5-year relative survival rates reported are 84% for localized sarcomas, 62% for regional stage sarcomas, 16% for sarcomas with distant spread, and 54% for unstaged sarcomas. This is a much higher proportion than found among other common cancer types, making it difficult to compare the severity of soft tissue sarcomas to other cancers. Hormone therapy, immunotherapy, and bone marrow transplant/endocrine treatments are undertaken in a small number of cases that fail standard treatments.


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Differences between laboratory and field studies (Orlans, 1988) do not negate the need for application of responsible methods for care and use of animals during field research activities. Wildlife professionals also are encouraged to publish manuscripts that document the proper care and maintenance of free-living wildlife species during field investigations. Field research study conditions for wildlife Irrespective of the species or circumstances involved, wildlife professionals should satisfy the following conditions for all field research studies. Written assurance that these conditions will be met is a prerequisite for project consideration and funding by many granting agencies. Procedures employed should avoid or minimize distress to animals consistent with sound research design. Procedures that may cause more than momentary or slight distress to animals should be performed with appropriate sedation, analgesia, or anesthesia, except when justified for scientific reasons in writing by the investigator in advance. Animals that otherwise would experience severe or chronic distress that cannot be relieved will be euthanized at the end of the procedure or, if appropriate, during the procedure. Living conditions of animals held in captivity at field sites should be appropriate for that species and contribute to their health and well-being. Specific considerations include appropriate standards of hygiene, nutrition, group composition and numbers, provisions for refuge and seclusion, and protection from weather and other forms of environmental stress. The housing, feeding, and nonmedical care of these animals must be directed by a scientist trained and experienced in the proper care, handling, and use of the species being maintained or studied. The permanent structure provides shade and has a cement floor for easy cleaning and disinfection and has a water trough the birds can swim in. For both situations, periodic inspection of the pens during each day is needed for the detection and prompt removal of dead birds. Prolonged use of the temporary hospital should be avoided because of fecal contamination that cannot be readily neutralized. By segmenting the temporary facility into separate pens, "pasture rotation" followed by treatment of vacated areas can help provide reasonably clean holding areas. A tarpaulin or other covering placed over the top of the temporary structure or placement of such structures under the shade of trees will enhance bird survival by minimizing heat stress. Christian Franson Photo by Joshua Dein Wildlife Observations and Collections General Before initiating field research, investigators must be familiar with the target species and its response to disturbance, sensitivity to capture and restraint, and, if necessary, requirements for captive maintenance to the extent that these factors are known and applicable. To the extent feasible, animals with dependent young should not be removed from the wild unless the young also are collected or removed alive and provided for in a manner that facilitates their survival beyond the period of dependency. Whenever possible, voucher specimens of animals, their tissues, and parasitic and microbial fauna collected during field investigations should be deposited in catalogued scientific collections available to others within the scientific community, to provide for maximum use of animals collected. The number of animals required for investigations depends on questions being investigated, but provision of adequate sample size is essential to assure scientific validity of results and avoid unnecessary repetition of studies. Investigator Disturbance and Impacts Potential gains in knowledge from field investigations must be balanced against the potential adverse consequences associated with the conduct of the study (Animal Behavior Society/Animal Society for Animal Behavior, 1986). A high level of sensitivity to the potential, indirect effects of investigator presence and study procedures must be maintained, and appropriate steps must be taken to minimize these effects.

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The employer requests the testing for all newly hired executives who will be working with highly sensitive government documents. Codes 96360 and 96361 report intravenous hydration infusions that include the prepackaged fluid and electrolytes. If other than a prepackaged substance is used, that substance would be reported separately. If the drugs are mixed into the saline, then only the drug is reported and the saline is bundled into the cost of the drug and not reported separately. Included in these hydration codes are the physician supervision and oversight of the staff providing the service. Code 96360 reports 31 minutes to 1 hour of intravenous infusion hydration service and 96361, the add-on code, reports each additional hour. For example, if the injection was a subcutaneous human rabies immune globulin, report 90375 for the substance and 96372 for the administration. The administration codes for vaccines/toxoids are reported with 90460/90461 or 90471-90474. Injections for allergen immunotherapy are reported with 95115/95117, not with therapeutic, prophylactic, or diagnostic injection codes. The Injection and Intravenous Infusion Chemotherapy codes (96401-96417) report subcutaneous/intramuscular, intralesional, and intravenous chemotherapy. Intra-Arterial Chemotherapy codes (96420-96425) report various forms of chemotherapy administered via the arteries. Included (not reported separately) with chemotherapy infusion or injection codes 96401-96549 are the following: 1. The initial intravenous infusion (the treatment) is reported with 96365 and each additional hour of infusion, up to 8 hours, is reported with 96366. When a concurrent (at the same time as another) intravenous therapy is provided the service is reported with 96368. Any administration that is 15 minutes or less is considered a push, not an infusion. The administration of an initial or single intravenous push is reported with 96374 and each additional push is reported with 96375. Example A patient presents for a chemotherapy intravenous infusion session and is given a 40-minute hydration prior to chemotherapy reported with 96360. For example, a patient received 1 hour of hydration before chemotherapy infusion and 40 minutes of hydration after chemotherapy.

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A mucous membrane is tissue that covers a variety of body parts, such as the tongue and the nasal cavities. Biopsy sites do not necessarily have to be closed; some are so small that they will close readily. Other sites are large enough that closure is required, and simple closure is bundled into the biopsy codes. If closure of the biopsy site is more than a simple closure, you would report the more extensive closure separately. Skin tags Skin tags are flaps of skin (benign lesions) that can appear anywhere, but most often appear on the neck or trunk, especially in older people. Skin tags are removed in a variety of ways-scissors, blades, ligatures, electrosurgery, or chemicals. The forceps grasps the column, and the physician snips the lesion off at its base. In ligature strangulation, a thread is tied at the base of the lesion and left there until the tissue dies. Whatever method of removal is used, simple closure is included in the skin tag codes, as is any local anesthesia that is used. Shaving of epidermal or dermal lesions the shaving of a lesion (11300-11313) can be performed by using a scalpel blade or other sharp instrument. Anesthesia and cauterization (electrocautery or chemical cautery) to control bleeding are included in the lesionshaving codes. Electrosurgery used in shaving a superficial lesion burns (destroys) the lesion, so the destruction code would be reported. The Shaving codes are further defined according to the location of the lesion-trunk, neck, nose-and the size of the lesion. If more than one lesion was removed, you would add modifier -51 (multiple procedures) to any codes after the first code. Many third-party payers reimburse 100% for the first lesion and 50% for the second lesion, so by placing the more intensive procedure first, you optimize reimbursement. If the closure is noted in the medical record as being more than simple (intermediate or complex), you would code the more complicated closure using a separate code from Repair subheading (12031-13160). The hidradenitis codes are based on the abscess location (axillary, inguinal, perianal, perineal, or umbilical) and the complexity of the repair (simple, intermediate, or complex). Excision-malignant lesions Codes in the Excision-Malignant Lesions subheading (11600-11646) are assigned for malignant lesions and include local anesthesia and simple closure. If you are coding a lesion removal that has been performed by a method other than excision. Instead, you would use a surgery code from the subsection Eye and Ocular Adnexa, Excision category (67800-67850).


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Advancement and withdrawal (back-and-forth movement) of the injection cannula will typically be made too slowly by the beginning injector (in a ``caulking' like motion), but as familiarity with the technique is acquired the movements can and should be made faster (in a ``spray painting' like manner). Ultimately, all other things being equal, faster movements are desirable in that if the injection cannula is constantly in motion intravascular injection is less likely, and the likelihood that an accidental bolus injection into one area will be made is reduced. Rapid back-and-forth movements insure the smoothest and most uniform infiltration of fat. How the syringe is held is also important in avoiding over-injection and controlling the volume injected with each pass. If the syringe is held in the manner one would traditionally use to give an injection with the thumb on the end of the syringe plunger, it is easy to inject too much fat if tissue or injection cannula resistance suddenly decreases. More control can generally be maintained, and over-injection more easily avoided, if the syringe is held with the end of the plunger in the palm of the hand. Held in this manner, a slight closing of the hand results in a small amount of fat only being expressed from the cannula, and over-injection of any one area can more readily be avoided. Smaller cannulas now available also help avoid bolus injection as their small size physically limits how fast fat can be extruded from the syringe. Larger amounts would be expected and may be required for un-centrifuged or ``tea strained' fat, larger female faces, male patients, and patients not undergoing facelift procedures. The strategy for determining the amount of fat needed for a given site is to rate the severity of atrophy based on what is seen in the preoperative photographs at each proposed site of treatment as ``small,' ``medium,' and ``large,' and then to use the data above to determine the amount typically needed for treatment of each area. If the defect is ``small,' one would choose an amount from the low end of the recommended range. If the defect is ``large,' one would choose an amount from the high end, and if ``medium' somewhere in between. Reprinted with permission of the Marten Clinic of Plastic Surgery How can Fat be Used to Make a Facelift Better? Fat grafts will necessarily be placed in different planes depending on the areas being treated and the problem present. In many areas where multiple tissue layers exist to inject in and overlying skin is thick, injection can be made comprehensively at the treated site from periosteum to the subdermal layer. In other areas, injections must necessarily be placed more specifically or deep due to the anatomical characteristics of the treated sites if optimal results are to be obtained and irregularities are to be avoided. These areas include the temples which are injected subcutaneously, the upper orbit, lower orbit, and ``tear trough' which should be injected in a pre-periosteal/sub-orbicularis oculi deep plane, the lips which should be injected predominantly in a submucosal plane, and the jawline which should be injected in a pre-periosteal/sub-masseteric plane of the face of the mandible. The easiest areas for the beginning injector to treat are the sites in the former category.

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Although each diagnosis code may be reported only once per encounter, each code can be reported more than once per patient. For example, a patient presents on Tuesday for an office visit and the diagnosis is pneumonia. The physician orders a culture and, based on the culture, orders a different antibiotic. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side. For the second encounter for treatment after one side has previously been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists. The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition in the previously-treated site. Some body parts and organs occur in pairs; for example, kidneys, femurs, and femoral arteries. Laterality is an important concept in diagnostic coding because it can help define the scope of the disorder. For example, the spine is a unilateral body part, but for some vertebral procedures, laterality is reported because the procedure can be performed on right, left, or both sides of the individual vertebra. The right hand is designated with character "1," the left hand is indicated by "2," and unspecified hand is indicated with "9. Her job requires her to utilize a computer keyboard for extended periods of time frequently throughout the day. During an office visit to her primary care provider, she complains of pain in her hands that wakes her up at night. TrueFalse 5 In the outpatient setting, an impending condition should be coded as if it actually exists. TrueFalse 6 When separate codes exist to identify acute and chronic conditions, the chronic code is sequenced first. TrueFalse 8 When sequencing codes for residuals and late effects, the residual is sequenced first followed by a late effect code. TrueFalse 9 A code is invalid if it has not been coded to the full number of characters available for that code. TrueFalse 10 the Official Guidelines for Coding and Reporting are updated annually. In this chapter there are many instances of combination coding and multiple coding.

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Uncharacteristic signal behavior can be seen when hemorrhages and chronic inflammation develop [11]. Due to chronic inflammation or hemorrhage, the signal intensity increases at T1W images and decreases at T2W images. Rare cells are present in the collagen sheets and appear to be fully functional fibroblasts or mesenchymal cells. As no synovial lining exists in these structures, they cannot be classified as true cysts [10]. However, it is not sensitive enough to distinguish ganglia from other nerve sheath tumors. In the literature, radial, ulnar, median, sciatic, tibial and posterior interosseous nerve involvements have been reported [15]. X ray shows as a well defined lucent lesions, with either smooth or lobulated margins and a thin sclerotic rim, arising eccentrically in the epiphysis of long tubular bones. It is frequently seen at hypointense signal intensity on T1 and T2W images, therefore, can be distinguished from the ganglion cyst by the signal intensity which have been shown in T2W images [1]. Chondroblastomas show epiphyseal settlement and differential diagnosis of intraosseous ganglion cyst from chondrosarcoma is difficult. Cutaneous nerve branches, such as the sural nerve and superficial peroneal nerve, are attached to the mass in about one third of cases, requiring meticulous dissection. Conclusion Ganglion cysts are the most common benign soft-tissue tumors in the foot and ankle. However, other cystic tumors of the foot and ankle must be considered in the differential diagnosis of ganglion cysts. Surgeons must also be precise in identifying and protecting the nerves during surgery. High recurrence can be the result of incomplete excision of the cyst wall and unrecognized and incomplete excision of the satellite lesion. The primary treatment for symptomatic intraosseous ganglion cysts is surgical excision by curettage followed by bone grafting in order to prevent any recurrence and the risk of a collapsing fracture [4]. Nikolopoulos D, Safos G, Sergides N, Safos P (2015) Deep peroneal nerve palsy caused by an extraneural ganglion cyst: a rare case. Sakamoto A, Oda Y, Iwamoto Y (2013) Intraosseous Ganglia: A Series of 17 Treated Cases. A chalazion is not caused by a virus or bacteria and therefore cannot be spread to others.

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When a person self-manipulates or receives a high velocity thrust by a health care practitioner before the muscle stiffness or spasm has been addressed a supraphysiological rotation force is applied. So it is easy to see how this can become a vicious cycle of pain, ligament laxity, muscle spasms, more pain, etc. It has been evident for many years that patients who continue to self-manipulate or receive high velocity manipulations either need many more sessions than other people receiving Prolotherapy for the same condition that did not manipulate, or they simply do not get better. When receiving Prolotherapy, you should not manipulate the body part receiving Prolotherapy or have anyone else do it either! Some of our neck patients claim to have never had neck issues until after seeing a chiropractor for an unrelated condition. This then began a pattern of receiving continued adjustments for chronically subluxing and suffering for years until they found out about Prolotherapy. By the time they reach our office, they had all the same symptoms as whiplash-associated disorder (from cervical instability): neck pain, stiffness, vertigo, dizziness, ringing in the ears, swallowing difficulty, stress, anxiety, racing heart, severe fatigue and memory issues. For those getting 20+ adjustments, our experience has been that at least one of those will be too forceful or aggravate cervical instability. The anatomical dangers can clearly be understood if we consider the movement of a joint. Our muscles move a joint from neutral to a certain point, which is called active movement. Passive movement includes the same range of motion as active movement plus a little more. Think of this as turning your head to the right, but then taking your hand to push your head a little further to look over your right shoulder. Beyond active movement and passive movement is the anatomical limit, which is where the joint should stop due to the ligament becoming taught. Active movements are those movements performed using muscular power, such as turning the head. Passive movement occurs when someone else gently pushes the head further to one direction. When a supraphysiological force (force greater than a passive movement) is applied, additional motion can occur, as in a high velocity thrust. Repeated adjustments for a hypermobile patient is not helpful because it will worsen the hypermobility and instability. If after numerous adjustments, the joint is still not staying in place after manipulation, then there is an obvious ligament injury. Treatment to stabilize the vertebrae by strengthening the Figure 17-11: Self-manipulation causing ligaments is necessary. To allow the ligaments the opportunity to repair, the treatment of choice that strengthens self-manipulation of joints must stop. It is not uncommon for patients to tell us they routinely pop their joints back in place 10 or more times per day. Self-manipulation often becomes excessive and habit-forming and may lead to the development of over-manipulation syndrome.

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Rubella, also known as German measles or 3-day measles, is caused by the rubella virus. Transmission is via inhalation of aerosolized respiratory droplets and the period of infectivity is from the end of the incubation period to the disappearance of the rash (3). Before widespread immunization, this disease was found in children younger than 15 years. Currently it occurs primarily in young adults in hospitals, prisons, colleges, and prenatal clinics. Rubella is endemic worldwide causing epidemics every 6 to 9 years during the spring. The exanthem is characterized by pink macules or papules which appear initially on the forehead, spreading inferiorly to the face, trunk, and extremities in the first day. On physical examination, lymph nodes are enlarged, particularly postauricular, suboccipital, and posterior cervical, and possibly tender during prodrome. The differential includes measles, rubella, scarlet fever, erythema subitum, enteroviral infection, and drug reactions. If antirubella antibody titers are negative in young women, rubella immunization should be given. In adolescents, pregnancy should be ruled out due to the possible adverse effects of the vaccine on the fetus. However, when rubella occurs in the first trimester of pregnancy, infection can be passed transplacentally to the fetus. Of all mothers infected during pregnancy, approximately 50% of fetuses will have manifestations of congenital rubella syndrome, including congenital heart defects, cataracts, microphthalmia, deafness, microcephaly, and hydrocephalus (2,3). The primary strain is A16 but sporadic cases have been reported with coxsackie viruses A4-7, A9, A10, B2, B5 and enterovirus 71. Highly contagious, it is transmitted from person to person by oral-oral or fecal-oral routes (3). Incubation is 3 to 6 days the age of onset is usually in children younger than 10 years old, but may occur in young and middle-aged adults. The prodrome is 12-24 hours of low-grade fever, malaise, and abdominal or respiratory symptoms. The cutaneous lesions appear on the palms or soles together or shortly after the oral lesions. Pink to red macules or papules appear, 2-8 mm in diameter, in a characteristic linear arrangement. They quickly evolve to form vesicles with a clear, watery appearance or yellowish hue. Lesions on the palms and soles usually do not rupture, but other sites may with formation of erosions and crusts (3). In the absence of an exanthem, the differential diagnosis includes herpes simplex virus, aphthous stomatitis, and herpangina. Management is symptomatic treatment, including optional topical applications of various local anesthetics to reduce oral discomfort.


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