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By forming a framework into which to assemble your aims generic red viagra 200mg on-line erectile dysfunction zinc deficiency, your methods red viagra 200 mg amex impotence meds, your findings, and your thoughts, you will find that all of your material falls into the correct places. The best thing about a grotty first draft is that it is a great starting point, giving you something to build later drafts on. In most journals, reporting is usually confined to the IMRAD (introduction, methods, results, and discussion) format, so begin by putting “Introduction” at the top of one page, “Methods” at the top of the next, “Results” at the top of the next, and so on. Just do one bit at a time starting with the simplest parts such as the methods and the results. A paper should be no longer than 2000–2500 words, which will occupy only 8–10 double-spaced pages in draft copy. Some journals set limits such as four or six pages for the final published copy, including the tables and figures. Do not plan to write more than 14 Getting started PLANNING STAGE Identify the questions to be answered, the analyses to be reported and the target journal/s Set framework for document (page size, headings, etc. All journals differ in their requirements but few papers are rejected because they are too short. Remember that it is neither efficient nor satisfying to write everything you know in 30 or 40 pages, and then have to prune and reorganise it yourself, or ask your reviewers to do this for you. Although this approach may foster creativity and 15 Scientific Writing Table 2. Expected length with A4 paper, font size 10–12 Question to be and 1·5 line Section answered Purpose spacing Introduction Why did you start? Summarise the 1 page context of your study and state the aims clearly Methods What did you do? Give enough detail 2–3 pages for the study to be repeated Results What did you find? Describe the study 2–3 pages sample and use the data analyses to answer the aims Tables and What do the Clarify the results 3–6 tables or figures results show? Keep in mind that your purpose in writing a scientific paper is to answer a specific research question or fulfil a specific research aim. You should provide only sufficient background about why you did the study, sufficient methods to repeat the study, and sufficient data and explanations to understand the results. Readers do not need to know absolutely everything that you know about the research area. You must limit yourself to writing only the essential information that your readers need to know about the results that you are reporting. You will need to progress your paper from your grotty first draft to a presentable second draft before you start asking coauthors and coworkers for peer review. There are many checklists available, including checklists for critical appraisal, that are a good guide to the information that you will need to include in each section of your paper. Progressing through each draft may take many small rewrites and reorganisations of sentences and paragraphs but it will ensure that the feedback you get is worth having. Once you have a presentable second draft you can sequentially ask for peer review from wider sources to improve your paper. In Chapter 4, we discuss how to manage the peer-review process effectively. Many important, even vital, messages are lost in the inappropriate translation from author to reader. Above all else, write for your intended reader; all that follows stems from this rapport. Vincent Fulginiti8 Once you have planned your paper, you will need to choose a journal in which to publish it. Over 4500 journals in 30 languages are currently listed in Index Medicus (www2) and more than 150 scientific journal articles are published each day. Despite these daunting statistics, it is always best to write with a specific journal in mind.

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In our is only instrumented in the low thoracic area cheap red viagra 200mg on line yohimbine treatment erectile dysfunction, a new ky- case we use the titanium pediatric USS instrumentation buy 200mg red viagra overnight delivery erectile dysfunction rap, phosis will develop above the instrumentation as a result as the screws and rods are rather smaller than usual and of kyphosing forces acting at this point. It is important that the kyphosis should be nial and caudal ends right up to the turning point of corrected over a prolonged section. At the cranial end, in the lordosis, otherwise the kyphosis may increase in particular, the instrumentation must continue up as close the non-instrumented section. It is important to have Experienced centers report similarly acceptable complica- a good anesthetic team with sufficient experience in tion rates [8, 19]. Particularly in patients who are unable to walk, the heart is poorly trained and has a diminished capacity 3. Thus, for example, > Definition an intraoperative cardiac arrest can occur if substantial Spinal lesions resulting in a predominantly flaccid pa- blood loss occurs, and we have sadly experienced a ralysis and causing a neurogenic scoliosis (particularly fatality in these circumstances. Given a certain risk of poliomyelitis, traumatic paraplegia and spinal muscular postoperative pneumonia, a lateral position may be ap- atrophies ). Another problem is posed by the fact that patients with severe Occurrence cerebral palsy are generally very thin and have very little Poliomyelitis used to be a very common illness, and the muscle and subcutaneous fatty tissue over the sacrum. In our own hospital, also, many scoliosis however, the complication rates are very low for a well- operations were performed for polio at the end of the established team. Today such scolioses have almost disappeared in Since 1989 we in Basel have operated on 116 patients the industrial nations, and are even very rare in the de- with neuromuscular spinal deformities, including 103 veloping world. This figure only corresponds to project in Africa that is mainly concerned with scoliosis around 3% of our patients with neuromuscular disorders. In Africa we see more idiopathic scolioses and Nine patients underwent correction in stages (primarily spinal deformities associated with systemic disorders than uninstrumented) and a combined ventral and dorsal ap- with poliomyelitis. We have suffered 2 peri- Posttraumatic scolioses associated with paraplegia oc- operative fatalities. This helps defer the opera- ralysis of the muscles results in severe scoliosis. Spinal tion until the child has reached an age when the spine muscular atrophy is an autosomal recessive hereditary dis- no longer has much growth potential left, if possible order of the anterior horn cells. The surgical procedure is similar a fairly severe form according to Werdnig-Hoffmann and to that for an asymmetrical paralysis. If the scoliosis a milder form according to Kugelberg-Welander ( Chap- angle is not too high, posterior straightening and seg- 3 ter 4. In very severe sco- lioses and kyphoses, a combined anterior and posterior Clinical features approach is necessary. A relatively high complication We can differentiate between two curve types that occur rate can be expected in patients with spinal muscular in flaccid paralyses: atrophy [1, 3]. The scolioses scoliosis due to a predominantly flaccid paralysis with el- in poliomyelitis (as with those in predominantly spastic ements of a congenital scoliosis. Moreover, a pronounced paralyses) also tend to show relatively little rotation with (muscle-related or muscle-promoted) kyphosis can occur less pronounced curves with a Cobb angle of less than as a result of the anatomical anterior displacement of the 40°, but are particularly badly distorted at higher curve dorsal muscles. Treatment If the scoliosis is associated with an asymmetrical paraly- Occurrence sis, a brace treatment should be employed from a scoliosis The prevalence of scoliosis in patients with myelomenin- angle of 20°. The brace can halt the progression of the gocele was found to be 69% in Sweden. Surgery should be incidence is not age-dependent, it is connected with the considered from a scoliosis angle of 40°. The operation level of the paralysis (at thoracic level the incidence was consists of a posterior spondylodesis with straightening 94%). Kyphoses are much rarer and observed in very few by two vertical struts and segmental wires. Still rarer are severe lordoses, which can occur patients are usually able to walk, the sacrum should not particularly in an iatrogenic context following the use of a be instrumented. The selection of an inappropriate height may promote Clinical features decompensation. A combined anterior and posterior pro- The development of a spinal deformity in myelomeningo- cedure should be employed from a scoliosis angle of ap- cele is influenced by three factors: prox. This can usually by an altered anatomical configuration of the muscles, be achieved without difficulty in poliomyelitis. The patient should therefore undergo surgery sis also applies to scoliosis caused by flaccid paralysis.

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In cases in which severe deformity is already present generic 200mg red viagra otc erectile dysfunction medications comparison, compensatory femoral osteotomies to change the angle of the femoral head in relation to the femoral shaft have been used to increase motion and length order red viagra 200mg free shipping erectile dysfunction pills, and to realign the anatomy of the upper end of the femur. There are complications associated with the basic disease as well as the treatment modalities. Avascular necrosis can be encountered in cases of acute unstable slipping regardless of treatment type; chondrolysis, 91 Juvenile–adolescent bunions (progressive joint space narrowing) may occur in the presence of untreated slipped epiphysis, in association with metallic internal fixation and also with pin penetration. The final common prognosis for all cases of slipped epiphysis will be determined in early middle age as to whether premature arthritis of the hip develops, or whether a normal pain-free hip will evolve. Treatment is designed to prevent further slipping, and to return the patient to a reasonably normal lifestyle during the growing years. Early recognition of this condition by physicians greatly facilitates urgent appropriate treatment, and reduces the need for reconstructive hip procedures at a later time. Juvenile–adolescent bunions Juvenile–adolescent bunions virtually always arise from a similar etiology. The condition of origin has been termed metatarsus primus varus with associated bunion formation, and this accurately describes the nature of the Figure 5. In nearly all cases there is a severe deformity (medial deviation) of the first metatarsal in Figure 5. Anteroposteriorradiograph showing metatarsus primus varus as relation to the second, third, fourth, and fifth the basic pathoanatomy of juvenile bunions. The first metatarsal grows more and more apart from the second and more into varus. Because of the soft tissue attachments (adductor hallucis primarily) to the proximal phalanx of the great toe, the proximal and distal phalanx of the great toe deviate laterally, producing hallux valgus. The bunion itself is a “bursitis” overlying the medial portion of the head of the first metatarsal, a consequence of contact (friction) with shoe wear. However, ill-fitting shoe wear is not the primary etiologic factor in the juvenile–adolescent bunion. The primary anatomic deformity is a consequence of the metatarsus primus varus. In fact, management of the juvenile–adolescent bunion is dependent on reducing the consistently Adolescence and puberty 92 increased intermetatarsal angle. Clinically patients present for treatment at the time of adolescence, usually between 10 and 14 years of age. The first metatarsal head is prominent and there is hallux valgus present with lateral deviation of the proximal and distal phalanx of the great toe. Frequently there is a painful bursa overlying the medial portion of the first metatarsal head. Standing radiographs will consistently reveal an increased intermetatarsal angle commonly ranging between 12 and 25 degrees. Initial management should be conservative, and is directed at altering the type of shoe wear that exacerbates the symptomatology. Patients are advised to seek whatever sort of shoe wear that will make them comfortable, and to vary the type of shoe wear until an appropriate shoe is successful. Roughly one half of all patients will fail adaptations in shoe wear, and will seek permanent alteration of the deformity. Surgical procedures are directed at removing the marked medial bony prominence of the first metatarsal, coupled with realignment procedures of the first metatarsal to reduce the metatarsus primus varus. Failure to obtain appropriate realignment of the first metatarsal will nearly always result in recurrence. The primary care physician should be aware of this condition and make appropriate orthopedic referral. Peroneal spastic flatfoot – tarsal coalition Peroneal spastic flatfoot is a term used to describe a stiff, painful foot, which appears to have accompanying flattening of the longitudinal arch. The etiology of this condition is diverse, and may occur in association with fractures of the hindfoot, rheumatoid arthritis, 93 Peroneal spastic flatfoot – tarsal coalition or bony fusion of the bones of the hindfoot (tarsal coalition). Without question, the vast majority of cases seen are associated with tarsal coalitions.

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