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Most researchers will never be able to emulate the importance of the findings of Watson and Crick discount kamagra chewable 100 mg visa, although we may strive to emulate their concise writing style buy kamagra chewable 100mg amex. There is no doubt that good writing skills will bring you a more rewarding research career because fewer keyboard hours will need to be spent on each published paper. Long hours spent at the computer rearranging pages of print are not the best way to achieving a happy and healthy life. By reducing the time it takes from first draft to final product, good writing skills are a passport to both academic success and personal fulfilment. By definition, reviewers are experts in their field who are asked to assess the scientific validity of submitted papers or grant applications. Being an experienced reviewer also leads to invitations to participate in advisory bodies that make decisions about the scientific merit of proposed studies, that judge posters or presentations at scientific meetings, or that have the responsibility of marking a postgraduate thesis. All of these positions are rewarding recognition that you have that certain talent that has an important currency in the scientific community. To achieve this, it is important to develop good time management skills that enable you to distinguish between the urgent and the important issues in your working day. It’s a matter of addressing the crises, completing the deadlines, and getting the pressing matters off your desk and out of your mind. It is also a good idea to be aware of, and minimise, the urgent but unimportant matters such as unnecessary mail and meetings that tend to waste the day away. If you let the unimportant matters fill up your day, you will never find enough time to write. Committed researchers need the skills to programme dedicated writing time into their working week. In an excellent book on time management, the focus on important tasks is described as spending time on “quadrant II activity”. By definition, quadrant II activities are not urgent but they have to be acted upon because they are important to career success. By minimising the amount of time you spend on the urgent and important activities in quadrant I and by avoiding non-important activities in quadrants III and IV, you can spend more time on prime writing and thereby become more productive. It is prudent to remember that there is no such thing as having no time to write. We all have 24 hours each day and it is up to each of us to decide how we allocate this time. If you are serious about wanting to publish your work, you need to schedule adequate time for the activity of writing in the “important but non-urgent” quadrant. By rising at 5am every morning and writing for several hours every day, Anthony Trollope completed more than fifty books and became one of England’s 5 Scientific Writing Table 1. Urgent Not urgent Important Quadrant I Quadrant II Crises, deadlines, Research, writing, patient care, teaching, reading, professional some meetings, development, physical preparation health, and family Not important Quadrant III Quadrant IV Some phone calls, Junk mail, some phone emails, mail, meetings, calls and emails, time and popular activities, wasters, and escape for example morning activities, for example and afternoon teas internet browsing, playing computer games, reading magazines, watching TV most renowned 19th century novelists. Although many of us would argue that Jane Austen or Thomas Hardy wrote much more interesting novels, no one can doubt that Trollope’s commitment to his writing and his time management skills led to greater productivity. When you are researching, scheduling time for quadrant II activities ensures that you can give priority to designing the study, collecting the data, analysing the results, and writing the papers. Many researchers have no problem finding time to conduct the study but have difficulty in finding time for writing. The good news is that constructing a paper will be more rewarding if you develop good writing skills and you will come to enjoy using your “quadrant II” activity time more effectively. Once your data analyses are underway and the aims of the paper are decided, you should begin writing in earnest. Ideally, you will have presented your results at departmental meetings, at local research meetings, or even at a national or international conference. This will have helped you to refine your ideas about how to interpret your data. You may also have a feel for the topics that need to be addressed in the discussion. With all this behind you and with good 6 Scientific writing writing skills, putting the paper together should be a piece of cake. Achieving creativity You should allow yourself to get into a writing mood. Finish the background reading, the review of the literature, and the work to date. Anthony David1 To write effectively, you need to find a physical space where you can both work and think. This space is probably not going to be the same office from which you conduct consultations, direct staff, take phone calls and answer endless emails and voicemails in the course of everyday business. For most people, a clear, thinking space needs to be a place where interruptions are minimal and so, by necessity, will be away from your daily work environment. Your thinking space needs to be a place where you can feel comfortable and relaxed, where you don’t have to power dress if you don’t want to, and where you can play thinking music if you find that helps you to write. If it helps, award yourself a mufti day and choose some appropriate music. For some people baroque or flute music is ideal, for others Mark Knoffler or Red Hot Chilli Peppers does the job perfectly. Italian opera is definitely too dramatic and blues or jazz may leave you focused on some of the sadder events in life. You need music that will relax but not distract you – the choice is entirely up to you. To write effectively, you must also tune in to your creative day and your creative hour. For some people, Thursdays, Fridays, and Saturdays are best because most of the urgent processes of the week are over. Others may find the pending excitement of the weekend distracting and thus prefer to begin writing refreshed on a Monday.

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The alternative to hip re- cess since it cannot ensure dynamic stabilization of the construction is to leave the hip dislocation and adapt the hip order 100mg kamagra chewable overnight delivery. This involves stabilization of the hip with an orthosis and cheap 100mg kamagra chewable fast delivery, for a unilateral dislocation, offset-! Treatment with the Pavlik harness is contraindicated ting the leg-length discrepancy. In muscular dystrophies and spinal muscular atrophies, muscle power is progressively lost. The patients therefore Dislocations at 3 years of age or older: While the inherent require hyperextension at the hip in order to be able to ability to walk does not correlate with the centering of the stand passively in the ligamentous apparatus. Flexion hips [16, 20, 44], patients with successfully operated hips contractures are disabling at this stage as they can lead to show functional improvement. Unilateral hip disloca- the premature loss of the ability to walk and stand. These tions can lead to a pelvic obliquity requiring treatment must be corrected, concurrently with other contractures, [13, 20]. Functional deformities in muscular dystrophies Deformity Functional benefit Functional drawbacks Treatment Abduction/ – Loss of ability to walk and stand Campbell operation external rotation Flexion – Flexion contracture Physical therapy ⊡ Table 3. Structural deformities in muscular dystrophies Deformity Functional benefit Functional drawbacks Treatment Flexion contracture – Crouching position (loss of ability Lengthening of hip flexors to walk and stand), hyperlordosis Hip dislocation – Instability, restricted mobility, Head resection, Schanz osteotomy pelvic obliquity padding. In such cases, corresponding bedding will suf- fice to alleviate the pain. Post-polio syndrome Functional deformities The commonest functional deformities are contractures, particularly flexion contractures. These restrict the pa- tient’s ability to walk and increase the energy expended during walking because the knee flexion position requires compensatory postural work by the knee extensors to maintain an upright posture. These contractures usually have to be considered in connection with other problems of the lower extremity (knee flexion) so that a correspond- ing strategy that deals with all the problems together can be prepared. AP x-ray of the pelvis in spinal muscular atrophy with left hip dislocation Structural deformities As a result of the reduced usage, the skeleton of the af- fected extremities becomes thinner and smaller. Since it Structural changes is incredibly robust, however, fractures do not occur with Hip dislocations occur as a result of the failure of the greater frequency. But otic spinal deformity is another possible causative factor, provided no functional restriction results, such structural hence also the benefit of early correction of the spinal deformities are of no concern. Abel MF, Damiano DL, Pannunzio M, Bush J (1999) Muscle-ten- don surgery in diplegic cerebral palsy: functional and mechanical pressure between the head and pelvis, the Schanz angula- changes. J Pediatr Orthop (United States), May-June, 19 (3) 366–75 tion osteotomy or head resection is the method of choice. Alman BA, Bhandari M, Wright JG (1996) Function of dislocated These procedures can produce freedom from pain with hips in children with lower level spina bifida. J Bone Joint Surg little effort, even in patients who are in a generally poor 78-B: 294–8 condition. Bagg MR, Farber J, Miller F (1993) Long-term follow-up of hip subluxation in cerebral palsy patients. J Pediatr Orthop 13: 32–6 Occasionally soft tissue-related symptoms are also 4. Baxter MP, D’Astous JL (1986) Proximal femoral resection-interpo- caused by the resting of the dislocated head on the sup- sition arthroplasty: salvage hip surgery for the severely disabled porting surface in a bed or chair without corresponding child with cerebral palsy. Laplaza FJ, Root L, Tassanawipas A, Glasser DB (1993) Femoral tor- natural history of hip deformity in myelomeningocele. Lee EH, Carroll NC (1985) Hip stability and ambulatory status in of dislocated or subluxated hip joints in patients with spastic myelomeningocele. Brunner R, Baumann JU (1997) Long-term effects of intertrochan- after anterior obturator neurectomy in 42 children with cerebral teric varus-derotation osteotomy on femur and acetabulum in palsy. J Pediatr Orthop 6: 686–92 3 spastic cerebral palsy: An 11- to 18 year follow-up study. McNerney NP, Mubarak SJ, Wenger DR (2000) One-stage correc- Orthop, 17: 585–591 tion of the dysplastic hip in cerebral palsy with the San Diego 8. Brunner R, Baumann JU (2000) Die Rekonstruktion des luxierten acetabuloplasty: results and complications in 104 hips. Pathological fractures in patients bined pelvic and femoral osteotomy and transiliac psoas transfer. Mubarak SJ, Valencia FG, Wenger DR (1992) One-stage correction lum in hip dislocations due to cerebral palsy. Nene AV, Evans GA, Patrick JH (1993) Simultaneous multiple op- lum in hip dislocations caused by cerebral palsy. Outcome and functional assessment Part B, 6: 207–11 of walking in 18 patients. Onimus M, Allamel G, Manzone P, Laurain JM (1991) Prevention Behandlung der Huftluxation bei Patienten mit infantiler Zerebral- of hip dislocation in cerebral palsy by early psoas and adductors parese. Phillips DP, Lindseth RE (1992) Ambulation after transfer of adduc- gung und Gehfähigkeit von Patienten mit Myelomeningozele tors, external oblique, and tensor fascia lata in myelomeningocele. Cobeljic G, Vukasinovic Z, Djoric I (1994) Surgical prevention of (2003) Femoral derotation osteotomy in spastic diplegia. Cooperman DR, Bartucci E, Dietrick E, Millar EA (1987) Hip disloca- cal study of the results of muscle surgery in cerebral palsy. Crandall RC, Birkebak RC, Winter RB (1989) The role of hip location for stability of the hip in spastic cerebral palsy.

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In any pragmatic approach buy generic kamagra chewable 100mg line, certain patients may not fit in the protocol cheap 100mg kamagra chewable visa. In these circumstances, an individual approach needs to be implemented to provide a good outcome. Good examples include the following: Non-life-threatening burns in patients with important associated medical conditions. Medical conditions need to be addressed first to decrease the morbidity and mortality of surgery Large superficial burns with small full-thickness patches are best treated as superficial burns and full-thickness areas addressed last when the rest of the burns are healed. Patients who experience extreme pain not controlled with analgesic regi- mens may benefit from early excision and grafting to decrease daily cleansing. Small deep–partial and full-thickness burns in patients who continue work- ing and attending school are best treated conservatively and operated on as out patients procedures. Burns to the hands and feet benefit from an aggressive approach to permit the patient’s early social and work reintegration PREPARATION FOR SURGERY Burn surgery requires commitment and cooperation from the whole burn team. Treatment of massive burns is an enterprise that matches the complexity of open- heart surgery or any other major surgical procedures based on the interaction of a multidisciplinary team. It should be only attempted in major tertiary hospital facilities where the whole spectrum of specialization is available. Even though burn wound excision and grafting may seem to the novice as a simple and easy surgical procedure, a profound understanding of the burn pathophysiology, dy- namics of wounds, critical care, and wound healing is necessary to perform suc- cessful operations. Burn wound excision, either immediate/early or delayed should be considered an elective procedure and prepared and managed as such. Only emergency surgi- cal airway access and escharotomy and fasciotomy should be undertaken without formal and proper evaluation. Experienced burn anesthetists and burn surgeons only should perform burn wound excision, since minor errors may lead result in the death of patients. Anesthetic Evaluation Destruction of skin by thermal injury disrupts the vital functions of the largest organ in the body and results in a systemic inflammatory response that alters function in virtually all organ systems. All changes that occur during the resuscitation phase and postresuscitation phase should be noted and taken into account to provide safe anesthesia. Treatment of burn patients must compensate for loss of these func- tions, until the wounds are covered and healed. Preoperative evaluation of the burned patient is guided largely by knowledge of these pathophysiological changes. Good communication with the surgical team is essential in order to estimate the size and depth of the wound to be operated on. This will help in estimating the actual physiological insult to be expected during surgery. The trauma that surgery superimposes on the already increased metabolic rate of burn patients can result in it being impossible to ventilate patients during surgery. Accurate estimates of blood loss are crucial in planning the operative manage- ment of burn patients. Surgical blood loss depends on area to be excised (cm2), time since injury, surgical plan, and presence of infection. Blood loss from skin graft donor sites will also vary depending on whether it is an initial or repeated harvest. Special atten- TABLE 2 Calculation of Expected Blood Loss Time since burn injury Predicted blood loss (cc/cm2 burn area) 24 h 0. Anatomy can be distorted and range of mobility to allow enough exposure of the airway may be decreased. The patient’s hemodynamic status must be investigated to foresee any derangement that may occur during surgery and to establish the patient’s inotropic support requirements. A thorough and systematic review of all systems should follow, noting all derangements, pre-existing conditions, and expected requirements during surgery and the immediate postoperative period. Any metabolic derangement should be corrected before the patient is taken to the operating room in order to avoid unexpected problems. The following is a summary of general preparation for surgery: Establish burn size, depth, and surgical plan. Evaluate intraoperative requirements and make efforts to match requirements during surgery. Detect any physi- ological derangements and pre-existing conditions and correct them be- fore patient is taken to the operating room. Make sufficient plans for patient transport, location of initial postoperative care, and fluid management, including enteral feeding regimen. Make adequate preparation in terms of monitors, vascular access, and avail- ability of blood products, drugs, and any other medical equipment needed. Do not send for the patient until all equipment has been checked; all operat- ing room settings are complete; operating room temperature is appropri- ate; and all drugs, fluids, and blood products are physically present in the room. Success in major burn surgery requires anticipation of all possible problems. This can only be accomplished by profound knowledge of burn pathophysiology, state- of-the-art burn critical care, and good communication among burn team members. Preparation of Patients Patients and/or families should be informed of the impact of the injury and what is to be expected from the surgical procedure. Informed patients tend to present with lower levels of anxiety and their pain control is usually much better. There- fore, all efforts should be made to inform and calm patients during preparation 96 Barret and Dziewulski for surgery. It is very important to inform patients and relatives in plain words about the extent of the injury and the implications this injury will pose in their hospital stay and future rehabilitation. An important dose of optimism, compas- sion, and support will be necessary to overcome problems during the acute phase.

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