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He 120 Evaluation of the Low Back Pain Practice Guideline Implementation believes that a guideline champion must have "protected time" from other duties to work on implementation discount extra super levitra 100 mg with mastercard erectile dysfunction smoking. Attitudes Toward the Low Back Pain Guideline The attitudes of providers and ancillary staff toward the low back pain guideline continued to be generally positive extra super levitra 100 mg discount erectile dysfunction self injection. According to par- ticipants in the site visit, the guideline "provides specific guidance, for the first time, for when to refer a patient for more definitive diag- nostic procedures," and it also provides "an effective way to quickly evaluate patients. The red-flag conditions were singled out as being extremely useful for appropriately triaging patients, particu- larly in the ER. Ancillary staff found the guideline "beneficial to ex- plain the problem and treatment plan to patients. There was consensus, however, that a greater effort should be made on prevention of low back pain in the field, most particularly in basic training and in physical training. Some physicians and PAs, mostly from TMCs, consider the guideline "cookbook medicine" and will not use it. The overall strategy that Site A defined for implementing the low back pain guideline had not changed since it was first developed at the kickoff conference. Site A’s focus was on improving care for active duty personnel with acute low back pain, emphasizing patient education and self-care. The long-term goal was to prevent recurrence of low back pain episodes and reduce the need for referrals to specialists. Consistent with this approach, the main focus of changes in practices was to increase access and referrals of patients to back classes. Actions related to other components of the guideline tended to be left to the discretion of providers in the vari- ous clinics and TMCs. With one exception, the implementation team for the low back pain guideline remained the same as the one Reports from the Final Round of Site Visits 121 that attended the kickoff meeting. The exception was a new facilita- tor—an Army staff person who replaced the civilian who had served as facilitator since the start of the demonstration. The implementa- tion team has 19 members, with one or two representatives from each clinic or TMC, one representative each from the operations and deployment medicine branch and PT, three representatives from QM/QI, and the champion. About one-half of this implementation team is expected to rotate to other assignments in the summer of 2000. To the extent that the team intended to continue operating past that time, the loss of personnel could compromise its viability. The implementation team proved difficult to manage because of the large number of members and their decentralized locations. For ex- ample, many team members were unaware of the changes made to the MEDCOM documentation form 695-R, methods for ordering additional brochures on patient self-care, the availability of informa- tion about the guideline on the MEDCOM QM web page, and the availability of the standard profile form developed at another demonstration site. In addition, the champion and other team mem- bers were not aware of CME opportunities for provider education on the low back pain guideline. These examples raise questions regard- ing communication within the Site A implementation team, as well as between MEDCOM and the demonstration sites. An initial effort was made in the spring of 1999 to train existing providers on the low back pain guideline, after which no further education was provided for newly arrived providers or for retraining of existing providers. In addition, ancillary staff were not provided any training or orientation on the guideline, even though the site had identified a need for such train- ing during our first evaluation site visit. Thus, subsequent to the ini- tial provider training on practices recommended by the guideline, whatever the new providers and ancillary staff learned about the guideline was obtained strictly through on-the-job training. Respondents to our survey at the site visit were unanimous in rec- ognizing that a capacity for ongoing provider and ancillary staff edu- cation was the key to successful implementation of any guideline. The implementation team saw introduction of guidelines at graduate medical education schools as a key to successful implementation of guidelines in the long term. Clinics and TMCs at Site A had to make "minor adjustments" to their routine procedures to include use of documentation form 695-R in processing patients during clinic visits. Two clinics and one TMC reported that, at the front desk, they hand the form 695-R to patients coming in for low back pain and ask them to fill it out prior to going to the screening room.
After needle placement purchase 100mg extra super levitra mastercard impotence and diabetes, 4 to 5 mL of contrast is injected 100 mg extra super levitra with amex erectile dysfunction from adderall, followed by anterior and lateral (or steep oblique) filming to document dispersal within the epidural space (Fig- ure 9. We do not inject local anesthetic into the cervical or upper thoracic epidural spaces because it could result in the complication of high cervical anesthesia and potential respiratory suppression. Cervical epidural injections are safest at the C7-T1 level, where the dorsal epidural space is most capacious. The injected materials typically will migrate cephalad into the cervical epidural compartment, as demon- strated by the distribution of contrast media. Selective Nerve Blocks Selective lumbar nerve root injections are performed by using the tech- nique described for transforaminal epidural injections. The undersur- face of the pedicle is profiled from a posterior oblique angle (Figure 9. For a selective nerve root block, however, the goal is to avoid re- fluxing the therapeutic injectate into the epidural space. Rather, mini- mal epidural reflux is achieved by directing the needle slightly lateral to the 6 o’clock position relative to the pedicle. In this fashion, a lim- ited amount of the mixture of contrast and therapeutic agents is in- jected to achieve primarily nerve sheath infiltration with minimal epidural reflux (Figure 9. After contact with the lamina for depth control, the needle is guided over the su- perior margin of the lamina into the dor- sal epidural space. The films are obtained in the AP and oblique projections to doc- ument distribution of contrast media prior to the installation of local anesthetic and water-soluble steroid suspension. Usually, less than 2 mL of the therapeutic mixture is injected to avoid significant epidural reflux. If there is significant epidural reflux, selectivity is lost, and a positive re- sponse cannot reliably be attributed to blockade of the intended nerve. Therefore, if contrast injection reveals significant epidural reflux, the nee- dle should be repositioned more laterally and additional contrast injected prior to filming and the injection of therapeutic substances. An S1 nerve block is performed by using the technique described for a transforaminal S1 injection (Figure 9. A limited amount of the mix- ture of contrast and therapeutic agents is injected, however, to avoid significant epidural reflux. Cervical nerve blocks should be performed only by proceduralists who have significant experience performing other spinal injection pro- cedures. Precise needle positioning is critical because there are struc- tures immediately adjacent to the nerve sheath that must be avoided. C At the infralateral aspect of the neural foramen, the cervical nerve sheath can be safely injected. If a lateral approach to the fora- men is utilized, it is not difficult to place the needle within the spinal canal, which may result in spinal cord damage. Thus we use an an- terolateral approach, which does not allow direct access to the spinal canal through the foramen. As in the lumbar spine, bony landmarks are used as a visual aid and for tactile response provided by needle placement on the bone for depth control and anchoring prior to injec- tion of contrast and therapeutic materials. If the vertebral artery is in- advertently encountered, the injection of a small amount of contrast will reveal the untoward placement. It is important to recognize this, since a subintimal injection could result in vertebral artery occlusion. Even worse, intra-arterial injection of the therapeutic mixture could re- sult in seizures, stroke, or even death. Therefore, a radiculogram is es- sential for assuring accurate needle placement prior to the injection of therapeutic substances (Figure 9. Typically, less than 1 mL of con- trast is necessary to confirm needle positioning and opacify the nerve sheath. After filming and confirmation of the needle position, 1 to 5 mL of a therapeutic mixture is injected. Patients are monitored for 20 to 30 minutes after the injection for initial response. The response is rated for therapeutic efficacy by asking the patient to provide a per- centage improvement from 0 ("RO") to 100% ("R2"). Radiographs following injection of contrast medium demonstrate opacification of cervical and upper thoracic epidural compartment bilaterally: (A) oblique and (B) AP views. Complications Generally, complications following fluoroscopically guided injections are minor and resolve without morbidity.
If you would like the form ula for calculating confidence intervals for diagnostic test features cheap extra super levitra 100 mg on-line erectile dysfunction holistic treatment, see G ardner and Altm an’s textbook Statistics with confidence buy extra super levitra 100mg without a prescription erectile dysfunction pills online. W e want to know if our result is "okay" or not, but the doctor insists on giving us a value such as "142/92". If 140/90 were chosen as the cutoff for high blood pressure, we would be placed in the "abnorm al" category, even though our risk of problem s from our blood pressure is very little different from that of a person with a blood pressure of 138/88. Quite sensibly, m any practising doctors advise their patients, "Your blood pressure isn’t quite right, but it doesn’t fall into the danger zone. N evertheless, the doctor m ust at som e stage m ake the decision that this blood pressure needs treating with tablets but that one does not. D efining relative and absolute danger zones for a continuous physiological or pathological variable is a com plex science, which 115 H OW TO READ A PAPER should take into account the actual likelihood of the adverse outcom e which the proposed treatm ent aim s to prevent. This process is m ade considerably m ore objective by the use of likelihood ratios (see section 7. For an entertaining discussion on the different possible m eanings of the word "norm al" in diagnostic investigations, see Sackett and colleagues’ textbook,5 page 59. Question 10 Has this test been placed in the context of other potential tests in the diagnostic sequence for the condition? In general, we treat high blood pressure sim ply on the basis of the blood pressure reading alone (although we tend to rely on a series of readings rather than a single value). Com pare this with the sequence we use to diagnose stenosis ("hardening") of the coronary arteries. First, we select patients with a typical history of effort angina (chest pain on exercise). N ext, we usually do a resting ECG , an exercise ECG , and, in som e cases, a radionuclide scan of the heart to look for areas short of oxygen. M ost patients only com e to a coronary angiogram (the definitive investigation for coronary artery stenosis) after they have produced an abnorm al result on these prelim inary tests. If you took 100 people off the street and sent them straight for a coronary angiogram , the test m ight display very different positive and negative predictive values (and even different sensitivity and specificity) than it did in the sicker population on which it was originally validated. This m eans that the various aspects of validity of the coronary angiogram as a diagnostic test are virtually m eaningless unless these figures are expressed in term s of what they contribute to the overall diagnostic work up. In such circum stances, it can be preferable to express the test result not as "norm al" or "abnorm al" but in term s of the actual chances of a patient having the target disorder if the test result reaches a particular level. Take, for exam ple, the use of the prostate specific antigen (PSA) test to screen for prostate cancer. Each table would use a different definition of an abnorm al PSA result to classify patients as "norm al" or "abnorm al". From these tables, we could generate different likelihood ratios associated with a PSA level above each different cutoff point. Then, when faced with a PSA result in the "grey zone", we would at least be able to say "This test has not proved that the patient has prostate cancer, but it has increased [or decreased] the odds of that diagnosis by a factor of x". In other words, there is no value for PSA that gives a particularly high likelihood ratio in cancer detection. As Sackett and colleagues explain at great length in their textbook,5 the likelihood ratio can be used directly in ruling a particular diagnosis in or out. For exam ple, if a person enters m y consulting room with no sym ptom s at all, I know that they have a 5% chance of having iron deficiency anaem ia, since I know that one person in 20 has this condition (in the language of diagnostic tests, this m eans that the pretest probability of anaem ia, equivalent to the prevalence of the condition, is 0. A m oderately reduced serum ferritin level (between 18 and 45 (µg/l) has a likelihood ratio of 3, so the chance of a patient with this result having iron deficiency anaem ia is generally calculated as 0. Likelihood ratio nomogram Pretest Likelihood Post-test probability ratio probability Figure 7. The lines A, B, and C, drawn from a pretest probability of 25% (the prevalence of sm oking 118 PAPERS TH AT REPORT D IAG N OSTIC OR SCREEN IN G TESTS am ongst British adults) are respectively the trajectories through likelihood ratios of 15, 100, and 0. In sum m ary, as I said at the beginning of this chapter, you can get a long way with diagnostic tests without referring to likelihood ratios. But if you put aside an afternoon to get to grips with this aspect of clinical epidem iology, I predict that your tim e will have been well spent. D iagnostic criteria for diabetes m ellitus and other categories of glucose intolerance: 1997 criteria by the Expert Com m ittee on the D iagnosis and Classification of D iabetes M ellitus (AD A), 1998 W H O consultation criteria, and 1985 W H O criteria. A m odel for early diagnosis of Type 2 diabetes m ellitus in prim ary health care.
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