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If a journal asks the authors to make substantial changes to their paper in response to your comments buy actonel 35mg with amex medications containing sulfa, you may receive the paper for a second round of reviewing after it has been amended generic actonel 35mg free shipping symptoms quadriceps tendonitis. At this time, you will be required to consider the authors’ responses to your comments and to perform a new review of the paper. This process may take more time than the original review but is essential in the review process. If you are too busy to undertake a review, you may choose to pass the manuscript on to a more junior staff member for comment, as is allowed and often suggested by editors. Before the review is returned, it is important that you approve the comments made. You must also acknowledge this contribution when returning the manuscript to the editor. In this way, the junior researcher receives the credit deserved, and this, in turn, can help to ease them gently into the system and to foster their reputation. As a reviewer, you can contact the editor at any time to request information about the progress of a paper. Once a decision has been made about publication, many journals send a copy of the reply to the authors and copies of all reviewers’ comments to each reviewer. Some journals may ask you to write an editorial, leading paper, or comment for the same edition in which the paper will appear. This brings a bonus of an immediate and ensured publication on a current hot topic. Writing review comments As an editor, David [David Sharp, former editor of Lancet] worked on all sections of the Lancet. He believed in plain language … As a teacher, he had exacting standards. Many an overconfident doctor arrived at the Lancet sure that aptitude with a scalpel 140 Review and editorial processes rendered the pen a trivial challenge, only to be shown the true meaning of humility. Richard Horton21 Being a good reviewer is something that experts, or experts in training, are automatically expected to know how to do. Once you have established your research reputation, you will be asked to review papers that fall within your own area of expertise. The journal editor may give you some ideas of what to be on the look out for, will ask you to rank the quality of the paper in various ways, or may even send you a checklist. You may be asked to rank your feedback under general comments, or under comments that recommend major or minor revisions. You must ensure that your comments are listed on the comment summary sheets and your ratings on the rating summary sheets. Writing comments on the pages of the paper is not useful since most editors will not want to inspect every page of every copy that they send out for review22 and they do not send marked-up copies back to the authors. As a reviewer, you can make general comments about style but do not need to address specific problems with punctuation, grammar, spelling, etc. These problems will be addressed by the editor in deciding whether to accept the paper and by the copy editors when typesetting the paper. It is important that external reviewers treat these issues sensitively especially for authors who are from a non-English speaking background. Nevertheless, you will need to take a general overview of the presentation, the spelling, and the grammar, since this will give you some insight as to whether the writer has paid attention to detail and whether the paper can be made interesting and readable if the writing is improved. Lack of attention to detail is not a good quality in scientific research. Most of your review comments should deal with the more substantive issues of content, science, and interpretation. If you are unsure whether the statistics are sound, you can ask 141 Scientific Writing the editor to call a biostatistician into the process. Although your review will be anonymous, you should write as though you were being made known to the authors.

Although the latter finding is contentious (McQuay buy 35mg actonel visa symptoms 16 weeks pregnant, 1992; McQuay generic 35mg actonel mastercard symptoms of pregnancy, Carroll, & Moore, 1988), the conclusions by Bach et al. The evidence that postoperative pain is also reduced by premedication with regional and/or spinal anesthetic blocks and/or opiates (McQuay et al. Whether chronic postoperative problems such as painful scars, postthoracotomy chest-wall pain, and phantom limb and stump pain can be reduced by blocking noci- ceptive inputs during surgery remains to be determined. Furthermore, ad- ditional research is required to determine whether multiple-treatment ap- proaches (involving local and epidural anesthesia, as well as pretreatment with opiates and anti-inflammatory drugs) that produce an effective block- ade of afferent input may also prevent or relieve other forms of severe chronic pain such as postherpetic neuralgia and reflex sympathetic dystro- phy. It is hoped that a combination of new pharmacological developments, careful clinical trials, and an increased understanding of the contribution and mechanisms of noxious stimulus-induced neuroplasticity, will lead to improved clinical treatment and prevention of pathological pain. THE MULTIPLE DETERMINANTS OF PAIN The neuromatrix theory of pain proposes that the neurosignature for pain experience is determined by the synaptic architecture of the neuromatrix, which is produced by genetic and sensory influences. The neurosignature 32 MELZACK AND KATZ pattern is also modulated by sensory inputs and by cognitive events, such as psychological stress. Furthermore, stressors, physical as well as psycho- logical, act on stress-regulation systems, which may produce lesions of muscle, bone, and nerve tissue, thereby contributing to the neurosignature patterns that give rise to chronic pain. In short, the neuromatrix, as a result of homeostasis-regulation patterns that have failed, may produce the de- structive conditions that give rise to many of the chronic pains that so far have been resistant to treatments developed primarily to manage pains that are triggered by sensory inputs. The stress regulation system, with its complex, delicately balanced interactions, is an integral part of the multiple contributions that give rise to chronic pain. The neuromatrix theory guides us away from the Cartesian concept of pain as a sensation produced by injury or other tissue pathology and to- ward the concept of pain as a multidimensional experience produced by multiple influences. These influences range from the existing synaptic ar- chitecture of the neuromatrix to influences from within the body and from other areas in the brain. Genetic influences on synaptic architecture may determine—or predispose toward—the development of chronic pain syn- dromes. Multiple inputs act on the neuromatrix programs and contribute to the output neurosignature. They include (a) sensory inputs (cutaneous, vis- ceral, and other somatic receptors); (b) visual and other sensory inputs that influence the cognitive interpretation of the situation; (c) phasic and tonic cognitive and emotional inputs from other areas of the brain; (d) in- trinsic neural inhibitory modulation inherent in all brain function; and (e) the activity of the body’s stress regulation systems, including cytokines as well as the endocrine, autonomic, immune, and opioid systems. We have traveled a long way from the psychophysical concept that seeks a simple one-to-one relationship between injury and pain. We now have a theoretical framework in which a genetically determined template for the body-self is modulated by the powerful stress system and the cognitive functions of the brain, in addition to the traditional sensory inputs. Phantom limb pain in amputees during the first 12 months following limb amputation, after preoperative lumbar epidural blockade. Contribution of central neuro- plasticity to pathological pain: Review of clinical and experimental evidence. Changes in the effects of stimula- tion of locus coeruleus and nucleus raphe magnus following dorsal rhizotomy. Pre-emptive lumbar epidural anaesthesia reduces postoperative pain and patient- controlled morphine consumption after lower abdominal surgery. Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Pre- emptive analgesia: Clinical evidence of neuroplasticity contributing to postoperative pain. Characteristics of the bursting pattern of action potential that occurs in the thalamus of patients with central pain. Abnormal single-unit activity recorded in the somatosensory thalamus of a quadri- plegic patient with central pain. Spread of saphaneous somatotopic projec- tion map in spinal cord and hypersensitivity of the foot after chronic sciatic denervation in adult rat. Post-operative orthopaedic pain—The effect of opiate premedication and local anaesthetic blocks. Prolonged relief of pain by brief, intense transcutaneous somatic stimula- tion.

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Paragraph 1: What we know Paragraph 2: What we don’t know Paragraph 3: Why we did this study Figure 3 actonel 35 mg generic treatment ulcerative colitis. Topic sentences purchase actonel 35mg on-line medications look up, especially for the first introductory sentence, are a great help. Richard Smith, editor of the BMJ, stresses the importance of trying as hard as you can to hook your readers in the first line. Few readers want to plough through a detailed history of your research area that goes over two or more pages. In the introduction section, you do not need to review all of the literature available, although you do need to find it all and read it in the context of writing the entire paper. In appraising the literature, it is important to discard the scientifically weak studies and only draw evidence from the most rigorous, most relevant, and most valid studies. Ideally, you should have done a thorough literature search before you began the study and have updated it along the way. This will be invaluable in helping you to write a pertinent introduction. You should avoid including a lot of material in the introduction section that would be better addressed in the discussion. You should never be tempted to put “text book” knowledge into your introduction because readers will not want to be told basic information that they already know. For example, the sentence, Asthma is the most common chronic disease of childhood, must be one of the most overused phrases in the last decade. All scientists working in asthma research and most people in the community already know this and don’t want to be told it yet again. Similarly, a phrase that defines the problem such as, Asthma is a condition in which the airways narrow in response to commonly occurring environmental stimuli, is not appropriate, except in a paper about the mechanisms of airway narrowing. It is much better to put your study in the context in which it will be published. For example, an introductory sentence such as, The mould Alternaria occurs ubiquitously in dry regions and is thought to be important in exacerbating symptoms of asthma, defines the background behind this particular research study. In this sentence, the focus of the study and the cause of the 52 Writing your paper exacerbations (Alternaria) rather than the disease itself (asthma) is the topic of the sentence, as it should be. Do not be tempted to begin your introduction by quoting the literature but omitting to say what was found. For example, an introduction that begins with, Previous studies have reviewed injury rates in Australian Army and RAAF recruits undergoing basic training. However, the lack of information about what was actually found does not help readers to put your work in the context of what has gone before. It is always better to quote the findings from previous studies rather than the name of the first author and the details of the aims or methods. For example, you could write, Injury rates in Australian Army and RAAF recruits undergoing basic training were 12% per year in 1997 but were much higher at 47% in Navy recruits who were unable to complete basic training. This sentence explains the prevalence of injuries at a specific point in time and, as such, quotes the science and not the scientist. Before you can begin writing, you need to have an aim or a research question that is both novel and worth answering. The most essential part of the introduction is the last paragraph, which gives details of your aim or hypothesis. This is where the sentence that will dictate the content of the remainder of your paper should be found. This sentence sets up the expectations for the rest of the paper and should be the very first sentence that you write in collaboration with your coauthors. This is also a good place to tell your readers, in a few words, the type of study design that you used to test your hypothesis. Finally, you should never end the introduction section with a quick summary of your own results. For example do not write, We have undertaken a study to define the characteristics of children who become overweight.

Blind clamping of guidelines with attention to early cardiopulmonary bleeding vessels and tourniquet application (with the resuscitation (CPR) and defibrillation as indicated purchase actonel 35 mg free shipping treatment algorithm. An possible exception of a traumatic amputation) are not equally important task for the FP is to identify those recommended actonel 35mg without prescription treatment trends. Strong consideration toms, and what may at first appear to be an atraumatic 14 SECTION 1 GENERAL CONSIDERATIONS IN SPORTS MEDICINE incident may actually have been caused by recent unno- even if the initial examination is completely normal, ticed or unwitnessed trauma (Blue and Pecci, 2002 ). Consideration should be the three most commonly used systems assess sever- given to starting crystalloid fluids, although there is ity based on the presence or absence of an LOC and/or some debate as to whether or not aggressive fluid posttraumatic amnesia, as well as the duration of post- resuscitation may actually be more detrimental to concussive symptoms (PCS). No athlete should return to play while any symp- toms are still present either at rest or with exertion. No athlete should return to play on the same day if POTENTIAL LIFE THREATENING/ the concussion involved an LOC (even if brief) or DISABLING INJURIES if postconcussive symptoms are still present 15–20 min after the injury. An athlete with a mild concussion (Grade 1) with no LOC and resolution of PCS within 15–20 min Head injuries in sports are quite common and often both at rest and with provocative exertional maneu- provoke anxiety and uncertainty. Fortunately, the vers may safely return to play that same day, pro- most common head injury in sports is a concussion vided this was the first concussion. Regardless of whether an athlete returns to play or loss of consciousness (LOC) (McAlindon, 2002; is disqualified from play for that day, frequent Harmon, 1999). The FP must learn not only how to reevaluation and serial examinations are absolutely recognize them (which is not always easy) and mandatory. Assessment temporoparietal region and is associated with a skull for potential spine injury should be done, and once on fracture 80% of the time. Athletes will often experi- the sidelines, a full neurologic examination performed, ence a brief LOC followed by a lucid interval which including a full sensory, motor, and cranial nerve may last up to several hours, and then progress to examination as well as cognitive functioning and rapid neurologic deterioration and eventually coma memory testing. Treatment is surgical and Obvious signs of skull fracture or intracerebral bleed- immediate transfer to a medical facility is required. It must be emphasized that the symptoms of a first head injury have resolved. CHAPTER 4 FIELD-SIDE EMERGENCIES 15 A controversial topic, it is a catastrophic injury that Although there are no definitive guidelines as to may occur because of a loss of cerebral autoregulation which athletes with neck injuries are safe to return to caused by the initial injury (Harmon, 1999; Crump, play, it is generally agreed on that only those players 2001; Graber, 2001). When the second injury occurs, with absolutely no neck pain or neurologic symptoms and it is often a very mild injury, cerebral edema rap- and with completely normal examinations may return idly develops with subsequent brainstem herniation to play safely, with repeated evaluation being within a matter of seconds to minutes. Treatment con- absolutely necessary (Haight and Shiple, 2001; sists of immediate intubation and hyperventilation, McAlindon, 2002). Despite aggressive treatment, mortality and morbidity are around 50% OPHTHALMOLOGIC INJURY and 100% respectively (Cantu, 1998; 1992). Examination of the eyes should include an assessment of visual Neck injuries, although relatively uncommon and acuity, visual fields, the eyelids and periorbital bony usually self-limited (McAlindon, 2002), represent structures, the surface of the globe (conjunctiva, one of the most feared and potentially catastrophic sclera, cornea), the pupils (size, shape, reactivity), injuries in sports. The FP must promptly recognize extraocular movements, and fundoscopic examination the potential for spine injury, adhere strictly to spinal and possibly intraocular pressure measurement as precautions (discussed previously in this chapter), indicated (Cuculino and DiMarco, 2002 ). EYELID LACERATIONS Indications for spinal immobilization include a post- Any lacerations involving the lid margin or lacrimal traumatic LOC, subjective neck pain or bony tender- system or those with significant tissue loss should be ness on examination, significant neck/upper back repaired by an ophthalmologist. Diagnosis is by fluoroscein examination and injuries thus determining which athletes may safely treatment consists of topical antibiotics, analgesia, return to play after a neck injury. Removal can diate onset of burning pain radiating down the arm usually be accomplished with slit-lamp assistance and is usually unilateral in distribution and often asso- under topical anesthesia. It is typically CORNEAL LACERATION self-limiting with most cases resolving in a matter of Many of these are self-sealing and difficult to visu- minutes, although some symptoms may persist for alize, thereby requiring a high index of suspicion. Examination may show a teardrop pupil, hyphema, A“burner” should not be considered as an initial diag- or flat anterior chamber. The eye should be covered nosis if an athlete has any of the following: with a hard shield and the athlete told not to move a. Any lower extremity involvement ured and immediate ophthalmology consult is c. The size of the hyphema should be noted, the carefully looked for is a septal hematoma, which is a eye shielded, and immediate ophthalmology consult red-blue, bulging mass on the nasal septum. Fluoroscein staining may reveal a positive Seidel sign, EAR INJURY a washing away and streaking of fluoroscein as aque- ous humor leaks out of the globe. The eye should be An auricular hematoma is a subperichondral accumu- shielded, intraocular pressure measurements avoided, lation of blood following blunt trauma.

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