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By Z. Leon. California Institute of the Arts.

Bath chairs typically had two large wheels in the rear and a smaller wheel in front purchase amitriptyline 75mg amex. While an atten- dant pushed the chair from behind, its occupant steered using a handle connected to the front wheel, offering everything “which the safety of in- valids requires” (Kamenetz 1969, 20). Wheelchairs first appeared in America to transport wounded soldiers during the Civil War. Made of wood and cane, these heavy chairs had large wooden wheels up front, and designs changed relatively little over ensuing decades. At the time of Franklin Delano Roosevelt, Rather than struggle with such a contraption, Roosevelt had a chair built to his own specifications and design. To the seat and back of a common, straightback kitchen chair he had a sturdy base attached, with two large wheels in front, two small ones in back.... Rather, he used it to scoot from his desk chair to a couch, from the couch to the car. Everest, a min- ing engineer, became paraplegic following an industrial injury. They founded a company in Los Angeles that, in 1933, manufactured the first folding metal wheelchairs, weighing 50 compared to the usual 90 pounds (Shapiro 1994, 215). A consumer had finally assumed control of wheelchair design and production. Their company, Everest and Jennings (E&J), dominated the market for the next fifty years. With size and success came complacency as E&J catered increasingly to institutional clients, such as hospitals and nursing homes, rather than con- 202 W heeled Mobility sumers. Unhappy with existing wheelchairs, she challenged her friends and fellow glider pilots Don Helman and Jim Okamoto to build an ultralight wheelchair from aluminum tubing, as used in their gliders (Shapiro 1994, 211). The resulting wheelchair weighed 26 pounds instead of the standard 50 and sold under the name “Quickie. The customer could personalize a chair in candy apple red, canary yellow, or electric green....

In addition discount amitriptyline 50 mg line, many states have significantly reduced funding for DME and related services (Karp 1998, 28). Even the phrase “power operated vehicle” suggests a car or other mode of voluntary transportation, rather than a wheelchair a person requires for mobility. Medicare covers power wheelchairs only when necessary based on the beneficiary’s “medical and physical condition. Medicare accepts prescriptions for these wheelchairs only from specialists in physical medicine, orthopedic surgery, neurology, or rheumatology (or from the bene- ficiary’s regular physician if specialists are distant or the person’s medical con- dition prevents travel to a specialist). Vendors must have physicians’ prescrip- tions in hand before they supply the equipment. Medicare makes coverage decisions at the national level for important new technologies with widespread implications (for other new interventions, the dozens of contractors that process Part A and B claims around the country make decisions). Major national coverage decisions involve analyzing medical evidence and posting proposed rules in the Federal Register, soliciting public comment. Medicare’s decision to cover liver transplants, for example, took four to five years. Local Medicare billing contractors make decisions more idiosyncratically, often relying on regional medical opinions rather than ex- plicit evidence. Although Medicare’s policies are still evolving, proposed rules for mak- ing coverage decisions echo medical necessity standards, following four se- quential steps (HCFA 2000b, 31127). Step 1—medical benefit: Does sufficient evidence demonstrate that the item or service medically benefits a defined population? Step 2—added value: For this defined patient population, do medically benefi- cial alternatives exist that are currently covered by Medicare and within the same clinical modality? Step 3—added value: How does the benefit of the item or service compare to the Medicare-covered alternative? Step 4—added value: Will costs of the item or service be equivalent or lower for the Medicare population than the Medicare-covered alternative?

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Hippus may be a normal phenomenon; it may be observed during recovery from an oculomotor (III) nerve palsy buy amitriptyline 50 mg free shipping, but otherwise is of no localizing significance. Hitselberg Sign Hypoesthesia of the posterior wall of the external auditory canal may be seen in facial paresis since the facial nerve sends a sensory branch to innervate this territory. Cross References Facial paresis Hocquet Diabolique - see HICCUPS Hoffmann’s Sign Hoffmann’s sign or reflex is a digital reflex consisting of flexion of the thumb and index finger in response to snapping or flicking the distal phalanx of the middle finger, causing a sudden extension of the joint. Although sometimes a normal finding, for example in the presence of generalized hyperreflexia (anxiety, hyperthyroidism), it may be indica- tive of a corticospinal tract lesion above C5 or C6, particularly if pres- ent unilaterally. Cross References Trömner’s sign; Upper motor neurone (UMN) Syndrome - 154 - Holmes’s Tremor H Hoffmann-Tinel Sign - see TINEL’S SIGN Holmes-Adie Pupil, Holmes-Adie Syndrome The Holmes-Adie, or tonic, pupil is an enlarged pupil which, in a dark- ened environment, is unresponsive to a phasic light stimulus, but may respond slowly to a tonic light stimulus. Reaction to accommodation is preserved (partial iridoplegia), hence this is one of the causes of light-near pupillary dissociation (q. A Holmes-Adie pupil is usually unilateral, and hence a cause of anisocoria. Holmes-Adie pupil may be associated with other neurological fea- tures (Holmes-Adie syndrome). These include loss of lower limb ten- don reflexes (especially ankle jerks); impaired corneal sensation; chronic cough; and localized or generalized anhidrosis, sometimes with hyperhidrosis (Ross’s syndrome). Pathophysiologically Holmes-Adie pupil results from a peripheral lesion of the parasympathetic autonomic nervous system and shows denervation supersensitivity, constricting with application of dilute (0. Philadelphia: Lippincott Williams & Wilkins, 2002: 135-146 Martinelli P. London: Imperial College Press, 2003: 249-251 Cross References Anhidrosis; Anisocoria; Hyperhidrosis; Light-near pupillary dissocia- tion; Pseudo-argyll robertson pupil Holmes’s Tremor Holmes’s tremor, also known as rubral tremor, or midbrain tremor, has been defined as a rest and intention tremor, of frequency < 4. The rest tremor may resemble parkinsonian tremor, and is exacerbated by sus- tained postures and voluntary movements. Hence there are features of rest, postural and kinetic (intention) tremor.

Alternatively discount 75 mg amitriptyline mastercard, pacing may be the sole function of a dedicated external pacing unit. The pacing electrodes are attached to the patient’s chest wall after suitable preparation of the skin, if time allows. The cathode should be in a position corresponding to V3 of the ECG and the anode on the left posterior chest wall beneath the scapula at the same level as the anterior electrode. This configuration is also appropriate for defibrillation and will not interfere with the subsequent placement of defibrillator External pacemaker with electrodes electrodes in the conventional anterolateral position, should this be necessary. Both defibrillation and pacing may be performed with electrodes placed in an anterolateral position, but the electrode position should be changed if a high pacing threshold or loss of capture occurs. It is important to ensure that the correct Pacing procedure electrode polarity is employed, otherwise an unacceptably high ● Switch on unit pacing threshold may result. Modern units with integral cables ● Select pacing rate that connect the electrodes to the pulse generator ensure ● Choose demand mode if available the correct polarity, provided the electrodes are positioned ● Select fixed rate mode if significant correctly. If electrical ● Pacing artefact appears on ECG when interference is substantial (as may arise from motion artefact), capture occurs problems with sensing may occur and the unit may be ● Minimum current to achieve capture is the inappropriately inhibited; in this case it is better to select the pacing threshold fixed rate mode. The fixed rate mode may also be required if the patient has a failing permanent pacemaker because the temporary system may be inhibited by the output from the permanent generator. The pacing current is gradually increased from the minimum setting while carefully observing the patient and the ECG. A pacing artefact will be seen on the ECG monitor and, when capture occurs, it will be followed by a QRS complex, which is, in turn, followed by a T wave. Contraction of skeletal External pacing can be extremely uncomfortable for a conscious patient and muscle on the chest wall may also be seen.