By U. Onatas. Cazenovia College.

Good writing is not just a succession of facts put down in a plausible order (see leaf shuffling) 100 mg zenegra visa erectile dysfunction my age is 24, but an interesting or important message buy zenegra 100mg line impotence after prostate surgery, supported by evidence (see truth). Clichés The word comes from the French term for a printing block, and means a phrase that is reproduced so often that it is at best unoriginal, at worst tiresome. First, avoid choosing clichés that will cause your target reader (though not your false feedback loop) to ridicule you. Second, if you see a familiar phrase, ask yourself whether something more original would be a better choice. This is not normally considered the best way to develop and motivate people. Coaching is an alternative approach, based on the assumption that people do best at a task if they are allowed to get on with it themselves. In the light of this, get them to commit to the what and the when (see writing goals). Encourage them to take time to ruminate, to set their own brief – and provide support at this early stage. Encourage research on the market as well as the topic being written about (see evidence-based writing). Once the writing process has started, provide support and encouragement. Meet regularly to ensure that the deadlines are being met and, if not, work with the writer to find ways of getting the work moving again. When (and if) the time comes for you to look at the manu- script, ask why you are being asked to read it – for silly mistakes, for instance, for major factual omissions or for potential political problems? Follow the example of successful sports coaches – and celebrate whenever you achieve your goals. Create a culture where winning – as defined by the writer in advance – is celebrated. BOOKLIST: coaching • The coaching pocketbook, by Ian Fleming and Allan JD Taylor, Alresford: Management Pocketbooks, 1998. Entertaining and versatile, part of an excellent series that also includes books on time management and personal development. Ostensibly for those who are setting 21 THE A–Z OF MEDICAL WRITING out to write a thesis, this is perhaps even more useful for super- visors. An interesting book from two journalists in Florida with important lessons for those working with writers. Co-authors As a general rule, the greater the number of co- authors, the greater the problems. The manuscript over which you have been sweating for months is torn apart by others, who believe that they are failing if they are not pumping out as many criticisms as they can think of. The poor author is then left, manuscript and confi- dence in tatters, with a pile of alternative suggestions, many of them conflicting. You will be pleased to know that there are some techniques that can ease the pain. Agree who the co-authors will be, what they will do, and in which order they will appear on the manuscript (see authorship). Lay down dead- lines, agree on the target journal and, more important still, get everyone to agree what the message will be (see brief setting). If all co-authors have agreed on the deadlines, you have a lever which may help to move the laggards. Send co- authors regular updates of progress; this will enable everyone to identify those who are slowing the process down. Far more important is the support and advice received as you are preparing the various drafts, and this is really the time you need sensible input from your colleagues. Keep them in touch with what you are doing, and encourage them to play the role of coach rather than critic. The sensible way through this is to judge these comments on whether they are more 22 CO-AUTHORS – or less – likely to increase the chances of publication (see evidence-based writing). Discuss those that are clearly counter productive (see negotiating changes). Keep reminding yourself that you are making progress and that this is one of the last major obstacles. This can be easier said than done, and if you are unlucky enough to be involved in such a situ- ation, seek a wise head for immediate confidential advice.

Intramuscular phenytoin is poorly absorbed and not used to treat bipolar disorder (eg zenegra 100 mg low cost erectile dysfunction caused by nerve damage, carbamazepine and val- recommended cheap 100 mg zenegra free shipping erectile dysfunction latest medicine. Phenytoin is highly bound (90%) to plasma proate) although they are not FDA-approved for this purpose. It is metabolized in the liver to inactive metabolites They are also used in the management of chronic neuropathic that are excreted in the urine. Carbamazepine is approved for treatment of the pain CNS (eg, ataxia, drowsiness, lethargy) and gastrointestinal associated with trigeminal neuralgia. Gingival hyperplasia, an over- used, but it is not approved for this indication and is not con- growth of gum tissue, is also common, especially in children. Some of the newer AEDs Serious reactions are uncommon but may include allergic re- are being tested for effectiveness in relation to bipolar, neuro- actions, hepatitis, nephritis, bone marrow depression, and pathic pain, and other disorders. Thus, it can increase the metabolism of itself and many other drugs, both AEDs and non-AEDs. Also, many other drugs can affect phenytoin metabolism and protein binding. Contraindications to Use Phenytoin is available in generic and brand name cap- sules, a chewable tablet, an oral suspension, and an injectable AEDs are contraindicated or must be used with caution in solution. The injectable solution is highly irritating to tissues clients with CNS depression. Phenytoin, carbamazepine, and special techniques are required when the drug is given gabapentin, lamotrigine, levetiracetam, oxcarbazepine, tiaga- intravenously (IV). Clients should not switch between generic bine, topiramate, and valproate are contraindicated in clients and trade name formulations of phenytoin because of differ- who have experienced a hypersensitivity reaction to the par- ences in absorption and bioavailability. If a client is stabi- ticular drug (usually manifested by a skin rash, arthralgia, and lized on a generic formulation and switches to Dilantin, there other symptoms). Phenytoin, carbamazepine, ethosuximide, is a risk of higher serum phenytoin levels and toxicity. If a lamotrigine, topiramate and zonisamide are contraindicated client takes Dilantin and switches to a generic form, there is or must be used cautiously in clients with hepatic or renal im- a risk of lower serum phenytoin levels, loss of therapeutic pairment. Additional contraindications include phenytoin effectiveness, and seizures. There may also be differences in with sinus bradycardia or heart block; carbamazepine with bioavailability among generic formulations manufactured by bone marrow depression (eg, leukopenia, agranulocytosis); different companies. All of the Fosphenytoin (Cerebyx) is a prodrug formulation that is drugs must be used cautiously during pregnancy because they rapidly hydrolyzed to phenytoin after IV or intramuscular are teratogenic in animals. It is approved for treatment of status epilep- ticus and for short-term use in clients who cannot take oral phenytoin. In contrast to other preparations of injectable INDIVIDUAL ANTISEIZURE DRUGS phenytoin, fosphenytoin causes minimal tissue irritation, can be diluted with 5% dextrose or 0. Most are metabolized in the liver; turer recommends that all dosages be expressed in pheny- a few are eliminated mainly through the kidneys. Fosphenytoin is available in 2-mL duce ataxia (impaired muscular coordination such as a stag- and 10-mL vials with 50 mg PE/mL (fosphenytoin 50 mg gering gait when trying to walk), confusion, dizziness, and PE = phenytoin 50 mg). For IV administration, fospheny- drowsiness as common adverse effects; some may cause seri- toin can be diluted to a concentration of 1. Because Carbamazepine (Tegretol) is used, in addition to seizure the drugs are so diverse, they cannot be adequately discussed disorders, to treat trigeminal neuralgia and bipolar disorder. Consequently, the drugs are described individually; It is given orally and peak blood levels are reached in about types of seizures for which the drugs are used and dosages are 1. In addition to treatment of its half-life shortens with chronic administration. Carba- seizure disorders, it is sometimes used to treat cardiac dys- mazepine is contraindicated in clients with previous bone rhythmias. Trigeminal neuralgia, 6–12 y: PO 100 mg twice • The suspension is ab- PO 200 mg daily, in- daily (tablet) or 50 mg sorbed more rapidly creased gradually to 4 times daily (suspen- and produces higher 1200 mg if necessary sion), increase to peak drug levels than 1000 mg daily if neces- tablets.

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Take your plan discount 100 mg zenegra with visa erectile dysfunction drugs sublingual, find a quiet spot for 15 minutes or so zenegra 100 mg mastercard erectile dysfunction and pregnancy, and start (see free writing), doing one section at a time. Never interrupt your flow – whether it be to go back and fiddle with the sentence you have just written, check a matter of detail with your records, or copy down the precise details of a key reference. Now you can start to work on the details, but be careful not to neglect macro-editing. Polish up the presentation of your figures and tables, and write the addi- tional items you will need – the title, the abstract, the references and the covering letter. If you have done your work well you will have a product that will meet the needs of your target journal. Yet many feel that they should now subject the draft to a barrage of detailed criticism, most of which will concern minor matters. It will be a great help at this stage if you have already agreed the market and message with your co-authors. Keep your nerve: your job is to keep the article on track for publication (see negotiating changes). The fact that you can write a scien- tific paper shows that you can write a scientific paper. It does not predict your performance as a doctor or your worth as a human being. BOOKLIST: scientific papers • Winning the publications game (2nd edition), by Tim Albert, Abingdon: Radcliffe Medical Press, 2000. Five hundred tips for success from an author who comes from the UK (as opposed to US) tradition of science writing. It is written from the US perspective and has some interesting data about what reviewers think. A broad sweep through many aspects of planning, publishing and presenting research. Includes some useful chapters on the changes brought by electronic publishing. Short articles Do not assume that they take less time than long articles. Shuffling data around One of the main preoccupations of those writing scientific papers. Slander A defamation which is spoken (as opposed to libel, which is written). Spacing after a full stop Many who trained as typists on mechanical typewriters were instructed to leave two spaces after the full stop. Word processors are more flexible when it comes to spacing, and now the convention is to have one space only. One of the problems is that English spelling has few rules, and those that do exist have exceptions. Computerized spelling checks do help, and there is no excuse for not switching them on. However, they tell us only that we have a properly spelt word, and do not tell us if we have a good word in the wrong place. One of the best ways of improving your spelling is to read clear English. You need to be familiar with the shape of words, because alarm bells will start to ring when you see an aberration. You then need a good dictionary, and the energy and self discipline to use it. Get them right and you are already doing better than others: accom- modation, corollary, diarrhoea, inoculate, occurred, ophthalmology, publicly, resuscitate, separate, unnecessary. All writers on style, however, seem to agree that this rule is based on Latin grammar and was misguided from the start. If you want to split an infinitive and it sounds right, most modern authorities say, then go ahead and split it.

It also may result from ectopic secretion of PTH by malignant Vitamin D is a fat-soluble vitamin that includes both ergo- tumors (eg generic 100 mg zenegra overnight delivery drugs for erectile dysfunction pills, carcinomas of the lung buy cheap zenegra 100mg impotence signs, pancreas, kidney, ovary, calciferol (obtained from foods) and cholecalciferol (formed prostate gland, or bladder). It functions as a hormone ment of hypoparathyroidism are the same as those of hypocal- and plays an important role in calcium and bone metabo- cemia; clinical manifestations of hyperparathyroidism are lism. The main action of vitamin D is to raise serum cal- those of hypercalcemia. It also promotes bone formation by providing adequate serum concentrations of Calcitonin minerals. It must be converted to an intermediate metabolite in Calcitonin is a hormone from the thyroid gland whose secre- the liver, then to an active metabolite (1,25-dihydroxyvita- tion is controlled by the concentration of ionized calcium in the min D or calcitriol) in the kidneys. PTH and adequate he- 368 SECTION 4 DRUGS AFFECTING THE ENDOCRINE SYSTEM patic and renal function are required to produce the active used to treat hypocalcemia and to prevent and treat osteo- metabolite. These agents are described in the following sec- Deficiency of vitamin D causes inadequate absorption of tions; names and dosages of individual drug preparations calcium and phosphorus. This, in turn, leads to low levels of are listed in Drugs at a Glance: Calcium and Vitamin D serum calcium and stimulation of PTH secretion. Drugs used for hypercalcemia include bis- this sequence of events produces inadequate mineralization phosphonates, calcitonin, corticosteroids, 0. Those used adults, vitamin D deficiency causes osteomalacia, a condition for osteoporosis inhibit bone breakdown and demineraliza- characterized by decreased bone density and strength. These drugs are described in the following sections; indications for use and dosages are listed in Drugs Calcium and Phosphorus at a Glance: Drugs Used in Hypercalcemia and Selected Bone Disorders. Calcium and phosphorus are discussed together because they are closely related physiologically. These mineral nutrients are found in many of the same foods, from which they are ab- Bisphosphonates sorbed together. They are both required in cellular struc- Alendronate (Fosamax), etidronate (Didronel), pamidronate ture and function and, as calcium phosphate, in formation and (Aredia), risedronate (Actonel), tiludronate (Skelid), and maintenance of bones and teeth. Their characteristics and zoledronate (Zometa) are drugs that bind to bone and inhibit functions are summarized in Box 26–1. Although indications for use vary among the drugs, they are used mainly in the treatment of hypercalcemia and osteoporosis. Etidronate also inhibits Bone Metabolism bone mineralization and may cause osteomalacia. Bone is mineralized connective tissue that functions as struc- These drugs are poorly absorbed from the intestinal tract tural support and a reservoir for calcium, phosphorus, magne- and must be taken on an empty stomach, with water, at least sium, sodium, and carbonate. The role of bone in maintaining 30 minutes before any other fluid, food, or medication. The serum calcium levels takes precedence over its structural func- drugs are not metabolized. The drug bound to bone is slowly tion (that is, bone may be weakened or destroyed as calcium released into the bloodstream; most of the drug that is not leaves bone and enters serum). Bone tissue is constantly being formed and broken down Calcitonin-salmon (Calcimar, Miacalcin) is used in the in a process called remodeling. In hypercalcemia, calcitonin lowers serum calcium down (resorption) as the person attains adult height and peak levels by inhibiting bone resorption. After approximately 35 years of age, resorption is effective in hypercalcemia caused by hyperparathyroidism, greater than formation. Hormonal deficiencies, some diseases, prolonged immobilization, or certain malignant neoplasms. A single injection of calcitonin decreases serum calcium lev- els in approximately 2 hours; effects last approximately 6 to Calcium and Bone Disorders 8 hours. In osteoporosis, calcitonin prevents orders discussed in this chapter are those characterized by further bone loss in the presence of adequate calcium and vi- increased resorption of calcium and loss of bone mass. In addition, calcitonin helps to control pain in clients These disorders weaken bone and lead to fractures, pain, with osteoporosis or metastatic bone disease.

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