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Summary reports of the results of the final round of site visits for the four participating MTFs are presented in Appendix B purchase speman 60 pills man health news disqus. The purposes of the analysis of the effects of guideline implementa- tion were to (1) document the extent to which intended actions were actually implemented by the MTFs; (2) monitor short-term effects on service delivery methods and activity buy 60pills speman with mastercard prostate cancer zometa, and where feasible, on client outcomes; and (3) develop metrics and measurement methods that can be adopted by the MTFs and MEDCOM for routine monitoring of progress. An interrupted time series comparison-group design was used to as- sess the effects of the low back pain guideline demonstration. Quar- xx Evaluation of the Low Back Pain Practice Guideline Implementation terly administrative data on service utilization and medication pre- scriptions were collected for low back pain patients served by the demonstration and comparison (control) sites, which provided trend information both before and after introduction of the guideline in the Great Plains Region. The comparison group allowed us to control for temporal trends that might account for changes in the indicators. The measures were appropriate choices for this demonstration because most of the participating MTFs focused their implementation actions on service delivery for acute low back pain (rather than chronic low back pain). The patient population for this study was limited to active duty Army personnel who received care for acute low back pain at one of the demonstration or comparison sites during the time period of the study. This design was selected because we could not obtain com- plete pharmaceutical data for all patients using these MTFs. The pharmacy data constraint was important because use of pain medi- cations is a major aspect of care for acute low back pain patients, and one-half of the indicators selected for the study are measures of pain medication use. Because acute low back pain is one of the major causes of lost duty days for active duty personnel, this study provides useful information even though it is limited to this population. We encourage expansion of the analysis to also include family members and retirees as other service utilization and pharmaceutical data be- come available. KEY FINDINGS FROM THE DEMONSTRATION This first demonstration to field test methods for implementation of clinical practice guidelines yielded rich insights even as the MTFs struggled to achieve lasting new practices. The performance of the demonstration and control MTFs on the six hypotheses for acute low back pain care (listed in the previous section of this summary) varied significantly at baseline (the six-month period before MTFs started working with the guideline). Introducing the guideline had few mea- surable effects related to those hypotheses. Despite these weak find- ings, the demonstration made a considerable contribution to im- Summary xxi provements in methods for subsequent guideline demonstrations, and ultimately, for implementation of the low back pain guideline in all Army health facilities as of January 2000. Two of the six critical success factors (see the previous section) emerged as the most important issues for the demonstration with re- spect to the limited success of the participating MTFs in improving low back pain care practices. Serious progress in practice improve- ment cannot happen without (1) having fully committed leadership at all levels and (2) establishing a credible monitoring and reporting system to provide accountability for desired improvements. The re- maining four critical success factors contribute to the effectiveness and timeliness of actions, but they are not expected to support ex- tensive progress in change if the leadership and monitoring are not in place. Effects on Clinical Practices At baseline, we found not only substantial variation across the demonstration and control MTFs on all six hypotheses, but also high levels of use of muscle relaxants, despite the guideline advice that muscle relaxants are not indicated. Muscle relaxants were prescribed for almost one-half of the acute low back pain patients. This baseline performance argues for proactive changes in practices for low back pain care to reduce variations and achieve the evidence-based prac- tices specified in the practice guideline. The implementation activities had only limited effects on care for low back pain patients during the first year the demonstration sites worked with the practice guideline. Also, the effects that were achieved were for service delivery rather than for prescribing of pain medications. The only overall effect for the demonstration was a decline in physical therapy referrals during the demonstration pe- riod. This effect was the result of large reductions in physical therapy referrals by two facilities that had established this goal as a priority in their implementation action plans. The changes in service delivery that we observed typically could be identified with individual sites and were consistent with the site’s implementation strategies. The strongest of these were the Site A strategy to use back classes to reduce use of physical therapy, which xxii Evaluation of the Low Back Pain Practice Guideline Implementation was observed in the data as declines in physical therapy referrals; and the Site D strategy to establish the physical medicine depart- ment as gatekeeper and reduce inappropriate specialty referrals, which was observed in the data as shifts of referrals to the physical medicine department from other specialties. Performance on the Six Critical Factors Research on practice guideline implementation has documented that a commitment to the implementation process, including use of multiple interventions, is required to achieve desired changes to clinical practices. This demonstration had mixed performance in the extent to which the six critical factors were realized, which affected the MTFs’ progress in implementing practice improvements. The AMEDD central and regional leadership ex- pressed strong support for the demonstration, but initial verbal sup- port was not followed by actions to provide resources to support the work or require active monitoring and reporting of the sites’ perfor- mance in implementing new practices. Furthermore, the level of commitment by local MTF commanders varied, and changes in command further eroded support over time. This mixed response was understandable, given that this was the first demonstration in a new MEDCOM initiative and there were concerns regarding its ef- fects on MTF workloads and costs.

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Terminations of trigeminal afferents are ipsilateral but some PAs with midline receptive fields terminate in the contralateral STNc (Pfaller and Arvidsson 1988; Jacquin et al discount speman 60 pills mastercard man health en espanol. Many trigeminal PAs reach the paratrigeminal nucleus and solitary nucleus (Usunoff et al cheap speman 60 pills online man health zinc. The structure of STNc is very similar to the spinal DH (Olszewski and Baxter 1954), and since Gobel et al. It has a laminar arrangement with a marginal layer (laminaI),substantiagelatinosa(laminaII),andamagnocellularlayer(laminaeIII, IV). Lamina I is polymorphic, with few large, multipolar neurons (Gobel 1978a; Li YQ et al. The GABAergic interneurons innervate the glutamatergic projection neurons, and the latter emit collaterals to the GABA-containing cells (DiFiglia and Aronin 1990). Thus, in the STN there is a reciprocal modulation between the excitatory trigeminothalamic tract (TTT) neurons and the inhibitory interneurons. At the lateral border of the STN, especially in STNc, there are interneurons that immunoreact for NOS (Dohrn et al. In all probability, the MDH is the main, but not the sole part of the trigeminal nuclear complex responsive for nociception. However, the PAs of these regions reach all components of the trigeminal nuclear complex (Marfurt and Echtenkamp 1988; Barnett et al. The rostral parts of the STN also respond to noxious stimulation, and nociceptive responses persist in ventral posteromedial thalamic nucleus (VPM) after trigeminal tractotomy at the obex (Dallel et al. One was scalloped, with densely packed clear vesicles of variable size, dark axoplasm, and occasional mitochondria (Figs. These terminals, which contacted sev- eral postsynaptic dendrites, correspond to the central terminals of type 1 glomeruli (C1) described by Ribeiro-da-Silva and Coimbra (1982). Terminals of the second type were also scalloped, but with loosely packed clear vesicles of uniform size, light ax- oplasm and many mitochondria (Figs. These terminals, contacting several postsynaptic profiles and involved in axo-axonic contacts with symmetric active zones, correspond to the central terminals of type 2 glomeruli (C2) described by Ribeiro-da-Silva and Coimbra (1982). C1 terminals are concentrated in lamina IIo and dorsal IIi, whereas C2 terminals are concentrated in ventral lamina IIi (Bernardi et al. Glomeruli make only about 5% of the synapses in substantia gelatinosa (Ralston 1979). The majority of synapses in this region are axo-dendritic, and it is hard to relate them to a particular afferent input. The ma- jority of dome-shaped terminals are believed to originate from intrinsic neurons. Frequently, axo-axonic terminals contain flattened or pleomorphic vesicles (Kerr 1975). Glutamate Receptors in the Superficial Laminae of the Spinal Cord The superficial laminae of the SC are of particular interest because of their role in hosting the first brain synapse involved in pain processing. Therefore, the question persists of how spinal neurons decode the convergent inputs at the level of the first synapse. Providing a better understanding about the nature of the synaptic processing in superficial laminae of the SC will directly improve our knowledge and strategies on howtotreatabnormalpain. Fromapharmacologicalpointofview,afirstpossibility derives from a speculation that different submodalities are mediated by different neurotransmitters. The pharmacological diversity seems to play a role since the SG neurons giving rise to C-fibers contain substance P, which was not found in cell bodies of normal SG giving rise to A-fibers. Moreover, substance P-positive axons in this area co-localize with µ-opioid receptor (Ding et al. On the other hand, all PA terminals in the superficial laminae of the SC appear to contain glutamate (Rustioni and Weinberg 1989; Salt and Herrling 1995); nevertheless, the amount of glutamate available in different anatomical classes of terminals may vary (De Biasi and Rustioni 1988; Merighi et al. Termination in the Spinal Cord and Spinal Trigeminal Nucleus 13 In general, a large variety of pre-, post-, and extrasynaptic factors may shape the timing and magnitude of glutamatergic transmission.

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Metastatic neo- Metastatic tumors are more common (66%)than pri- plasms (66%) mary spinal tumors (30%); the remaining 4% are pre- vertebral tumors invading the spinal canal 60pills speman otc androgen hormone norepinephrine. The frequency of skeletal metastases is much higher for some tumors: 84% for prostatic cancer and 74% of breast cancer! Meningioma Represent approximately 25% of primary spinal tumors; 90% of spinal meningiomas are purely intra- dural speman 60pills mastercard prostate cancer female, and the remaining 7–10% may be extradural. Among the spinal meningiomas, 17% are in the cervi- cal spine, 75 –81% in the thoracic spine and 2–7% in the lumbar region! Intramedullary metastasis Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Thoracic Pain 199 Metabolic – Osteoporosis with ver- tebral collapse – Osteomalacia – Paget’s disease Inflammatory – Ankylosing spondylitis – Rheumatoid arthritis – Arachnoiditis Deformity – Scoliosis – Kyphosis Visceral referred pain Heart T1–5 roots; pain referred to chest and arm Stomach T5–9 roots; pain referred to manubrial xiphoid Duodenum T6–10 roots; pain referred to xiphoid to umbilicus Pancreas T7–9 roots; pain referred to upper abdomen or back Gallbladder T6–10 roots; pain referred to right upper abdomen Appendix T11–L2 roots; pain referred to right lower quadrant Kidney, glans T9–L2 roots; pain referred to costovertebral angle penis Dissecting aortic T8–L2; pain referred to costovertebral angle aneurysm Nonorganic causes Psychiatric causes Malingering Substance abuse Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Causes include: Traumatic spinal injuries Tumor Metastatic carcinoma, lymphoma Multiple sclerosis Vascular disorders Spinal epidural hema- Secondary to anticoagulation therapy toma Spinal abscess Intervertebral disk her- niation Parainfectious or post- vaccinal syndromes Neurological manifes- tations Sensory disturbances – Loss of all sensory modalities below the level of the lesion, e. Pain that is worse when recumbent and better when sitting or standing is common with spinal malignancies Motor disturbances – Paraplegia or Initially flaccid and areflexic, due to spinal shock; three tetraplegia to four weeks later, becomes hypertonic and hyperre- flexic. Complete and lower spinal cord lesions result in flexion at the hip and the knee, whereas incomplete and high spinal cord lesions result in extension at the hip and knee – Absent superficial abdominal and cremasteric reflexes – Lower motor neuron Paresis, atrophy, fasciculations, and areflexia signs at the level of lesion Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Spinal Cord Lesions 203 i j spastic paralysis spastic paralysis hypesthesia cerebellar ataxia sensory ataxia, position sense, vibration k l spastic paralysis thermoanestesia, analgesia hypesthesia sensory ataxia, position sense, vibration sensory ataxia, spastic paralysis position sense, vibration flaccid paralysis hyperesthesia m n flaccid paralysis spastic paralysis spastic paralysis thermoanestesia, analgesia all sensory modalities sensory ataxia, position sense, vibration Fig. Interruption of the peripheral reflex arc leads additionally to hypotonia and hypo- or areflexia. Also tactile and postural hallucinations (as if walking on cotton wool), temporal and spatial disturbance of the extemities sensory gait ataxia (worse in darkness or with eyes closed), and a Roberg’s sign. Patients often develop lancinating pains in the legs, urinary incontinence, and areflexia of the patellar and ankle stretch reflexes. Characteristically this re- sults in bilateral "vest–like" thermoanesthesia and analgesia with preservation of soft touch sensation and proprioception (i. Ante- rior extension with involvement of the anterior horns results in segmental neuro- genic atrophy, paresis, and areflexia. Dorsal extension involves the dorsal columns causing ipsilateral position sense and vibration loss. Lateral extension causes ipsi- lateral Horner’s syndrome (C8–T2 lesions), kyphoscoliosis, and spastic paralysis below the level of damage. Ventrolateral extension affects the spinithalamic tract resulting in thermoanesthesia and analgesia below the spinal cord lesion with sacral sparing due to its lamination (cervical sensation medial, and sacral lateral). If the nuclei of the medullary cranial nerves are involved, there will be explosive dysarthria dysphagia (bulbar or pseudobulbar paralysis). The disease commences with loss of position sense, discrimination, and stereognosis, leading to ataxia and Romberg’s sign. Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Paraplegia or tetraplegia below the level of the lesion, initially flaccid and areflexic due to spinal shock but progressively hypertonic and hyperreflexic. Segmental lower motor neuron signs (paresis, atrophy, fasciculations, and areflexia). Urinary and anal spincter dysfunc- tion, sexual dysfunction, anhidrosis, skin changes, and vasomotor instability. Functional facial anesthesia includes the angle of the mandible and may stop at the hair line; functional loss of upper extremity sensation usually cuts off transversely at the wrist, elbow, or shoulder; functional loss of lower extemity sensation cuts off at the inguinal line ventrally, or at a joint or the gluteal fold dor- sally, or it may cut off transversely at any lower level. Autonomic disturbances below the level of the lesion – Urinary and rectal sphincter dysfunction – Anhidrosis – Trophic skin changes – Temperature control impairment – Vasomotor instability – Sexual dysfunction Hemisection (Brown–Sequard Syndrome) (Fig. Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Loss of pain and temperature sensation con- bances tralateral to the lesion, usually one or two seg- ments below the level of the lesion! Ipsilateral loss of proprioception, especially vibra- tory and position sense, whereas tactile sensation may be normal or minimally decreased – Motor disturbances! Neurological manifestations Impaired vibration and position sense Reduced tactile localization Tactile and postural hallucinations Temporal and spatial disturbances Sensory ataxia (ataxic gait or "double tapping" is characteristic) Lhermitte’s sign (when the lesion is at the level of the cervical cord) Anterior Horn Cell Syndromes (Fig.

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