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If you have a clear idea of your readers order cialis professional 20 mg without a prescription impotence fonctionnelle, you can research what style and structure works for them (see evidence based writing) buy cialis professional 20mg amex erectile dysfunction statistics us. Although there are some excellent practitioners, the system has failed to take off. One of the main reasons is that employing someone who knows about writing is helpful only if those who employ them are equally as informed. This is because the way editors tend to define it is at odds with the way it is defined by the authors themselves. Editors are vehemently opposed to the practice of listing people as co-authors when they have contributed little or nothing (gift authorship). Participation solely in the acquisition of funding or the collection of data does not justify authorship. One useful technique is to agree on the number and role of the co-authors before 7 THE A–Z OF MEDICAL WRITING the article is written (see brief setting). This should limit the practice of people jumping aboard once all the work has been done. The real cause of the trouble is the fact that authorship is now one of the main international performance indicators for scientists and, less obviously, for doctors. There is no reason to believe that the ability to publish in an English language journal should predict the clinical performance of a Dutch doctor, but that is currently a fact of life, and until the system is reformed conflicts will exist between those who want some easy points (and perhaps get back to their proper jobs) and editors who feel that this is somehow not playing the game. Meanwhile, the current trend is for journals to add lists explaining who did what. If this is the style of your target journal, then follow it (see evidence-based writing). Bad writing I take a pragmatic view and define bad writing as writing that fails to get the desired message across to the target audience (see brief setting). The writing may read easily and appear plausible but, alas, the arguments depend on facts that appear to be, or later turn out to be, not true (see scientific fraud). The author has chosen words and constructions with which the audience is not familiar (see jargon). This can be fixed by altering sentences and paragraphs, though it takes considerable time and is difficult to do well. These are those pieces of writing that you gamely wade through, but by the 8 BAD WRITING end have no idea why (see brief setting; message). If the writer cannot define a clear message, then the reader will be unable to, and the writing will be doomed to fail. Balanced feedback When people ask us to comment on their writing, we tend to shower them with criticism (see correcting the work of others). Whenever you are asked your opinion on a piece of writing, first establish the audience for which is intended. Read the piece quickly, after which you will be in a position to make up your mind on the following key questions. Is the message in an appropriate place (look in particular at the first and last sentences). These are macro-editing issues, and you should be able to find at least one area where the writer has done well. Write a short note, drawing attention to what you think is already good – and what you think the writer needs to work on. The argument became a little difficult to follow between the fifth and eighth paragraphs – and you may wish to insert some key sentences so that the reader can see why you have included this information. You will have put them in context as fairly minor amendments (or nit-picking stuff). If possible, arrange your schedule so that you can write during these periods: your writing is unlikely to be fresh and attractive if you are fighting an overwhelming desire to take a nap. Blurb A piece of writing that puffs itself or praises another, as on the outside of this book cover (I hope). Science journals increas- ingly carry blurbs (or short summaries of interesting articles) on an early editorial page.

Then menstrual cycle and give 10–15 mg daily for ending on 25th d maintenance order 20 mg cialis professional overnight delivery erectile dysfunction doctor philadelphia. Progesterone Amenorrhea buy 20mg cialis professional free shipping erectile dysfunction drug samples, dysfunc- tional uterine bleeding: IM 5–10 mg for 6–8 consecutive d Drugs at a Glance: Noncontraceptive Estrogen-Progestin Combinations Trade Name Estrogen Progestin Indications for Use Routes and Dosage Ranges Activelle Estradiol 1 mg Norethindrone 0. Premphase Conjugated estrogens Medroxyprogesterone Menopausal symptoms; PO 1 tablet of estrogen-only 0. It is reportedly effective in relieving vasomo- Assessment tor instability. Most information is derived from small German Before drug therapy is started, clients need a thorough his- studies using Remifemin, the brand name of a standardized tory and physical examination, including measurements of extract that is marketed as an alternative to estrogen ther- blood pressure, serum cholesterol, and triglycerides. The product apparently does parameters must be monitored periodically as long as the not affect the endometrium or estrogen-dependent cancers; drugs are taken. Animal • Assess for conditions in which estrogens and progestins are studies indicate binding to estrogen receptors and suppres- used (eg, menstrual disorders, menopausal symptoms). A study of posthysterectomy patients indicated • Assess for conditions that increase risks of adverse effects no advantage of the herb over conventional ERT. Other or are contraindications for hormonal therapy (eg, throm- trade names include Estroven, Femtrol, and GNC Menopause boembolic disorders, pregnancy). Blood pressure should premenopausal women, especially with oral contracep- be monitored closely in hypertensive clients, because the tives, but are unlikely in women who are postmenopausal herb may increase the hypotensive effects of antihypertensive who are receiving physiologic replacement doses. Black cohosh is contraindicated in pregnancy and not • Check laboratory reports of cholesterol and triglyceride recommended for use longer than 6 months for menopausal levels when available. A high- Overall, this herb may be useful in clients who refuse es- fat diet increases the risks of gallbladder disease and per- haps other problems; cigarette smoking increases risks of trogen or have conditions in which estrogen is contraindicated. These are most likely to occur in women older than 35 years of age who take oral contraceptives, Choice of preparation depends on the reason for use, desired women who are postmenopausal who take combined route of administration, and duration of action. Conjugated estrogen/progestin hormone replacement therapy, and estrogen (eg, Premarin) is a commonly used oral estrogen women or men who take large doses for cancer. Nursing Diagnoses The choice of combination contraceptive product may be • Disturbed Body Image in women, related to effects of determined by the progestin component. Some progestins are hormone deficiency states more likely to cause weight gain, acne, and changes in blood • Disturbed Body Image in men, related to feminizing effects lipids that increase risks of myocardial infarction or stroke. Progestins with minimal an- • Risk for Injury related to increased risks of hypertension drogenic activity are desogestrel and norgestimate; those and gallbladder disease with intermediate activity include norethindrone and ethy- Planning/Goals nodiol; norgestrel has high androgenic effects. In addition, there are long-acting progestin contraceptive preparations The client will: such as IM depot medroxyprogesterone (Depo-Provera) that • Be assisted to cope with self-concept and body image lasts 3 months per injection, intrauterine progesterone that lasts changes 1 year, and levonorgestrel subcutaneous implants (Norplant) • Take the drugs accurately, for the length of time prescribed that last 5 years. In one regimen, the drug is progestin combination, help the client take it accurately. These regimens more and vitamin D in the diet and adequate weight-bearing ex- closely resemble normal secretion of estrogen and avoid pro- ercise to maintain bone strength and prevent osteoporosis. Evaluation • Interview and observe for compliance with instructions Effects of Estrogens and Oral for taking the drugs. Contraceptives on Other Drugs • Interview and observe for therapeutic and adverse drug effects. These drugs may interact with several drugs or drug groups to increase or decrease their effects. Estrogens may decrease the effectiveness of sulfonylurea PRINCIPLES OF THERAPY antidiabetic drugs (probably by increasing their metabolism); warfarin, an oral anticoagulant (by increasing hepatic produc- Need for Continuous Supervision tion of several clotting factors); and phenytoin, an anticon- vulsant (possibly by increasing fluid retention). Estrogens Because estrogens, progestins, and hormonal contraceptives may increase the adverse effects and risks of toxicity with cor- are often taken for years and may cause adverse reactions, ticosteroids, ropinirole, and tacrine by inhibiting their metab- clients taking these drugs need continued supervision by a olism. Ropinirole and tacrine should not be used concurrently health care provider. These examinations should be repeated at least an- drugs is taken concurrently with an oral contraceptive, in- nually as long as the client is taking the drugs. Contra- CHAPTER 28 ESTROGENS, PROGESTINS, AND HORMONAL CONTRACEPTIVES 419 CLIENT TEACHING GUIDELINES Hormone Replacement Therapy General Considerations ✔ Combined estrogen–progestin therapy may increase blood ✔ Estrogen replacement therapy relieves symptoms of meno- sugar levels in women with diabetes. This effect is attrib- pause and helps to prevent or treat osteoporosis.

In Proceedings of the 1998 IEEE International Joint Conference on Neural Networks buy generic cialis professional 40mg line erectile dysfunction treatment philadelphia. Imaging Two-Dimensional Neural Activity Patterns in the Cat Visual 3 Cortex using a Multielectrode Array David J cheap cialis professional 40 mg fast delivery impotence back pain. Normann, and Alexei Koulakov The neural mechanisms that mediate each of the complex process of sensory encod- ing, volition, perception, cognition, and memory are distributed over large numbers of individual neurons that in turn are distributed over di¤erent functional centers in the brain. A reasonable hypothesis advanced by systems-level neuroscientists is that the expression of these higher-order brain functions is a direct consequence of and is directly reflected in the coordinated spatiotemporal activity patterns of distributed neuronal ensembles. This hypothesis is beginning to be validated in studies of record- ings of activity patterns in neural ensembles in the visual pathways excited by patterned visual stimuli (Singer, 1993; Warland et al. One of the most challenging problems confronting contemporary systems-level neuroscientists is how to gain access to the responses of large numbers of neurons in order to study this distributed information processing. Two general approaches are being applied in animal models today: (1) direct visualization of neural structures that have intrinsic or extrinsically augmented optical properties that correlate with the activity patterns of neural ensembles (Blasdel and Salama, 1986; Grinvald et al. Localized regions of neural activity are expected to subtlety alter regional optical features, mediated by such factors as blood flow requirements. Accordingly, di¤erential recording of the optical properties of the cerebral cortex at two di¤erent wavelengths provides a signature that is altered by specific neural activity in a fashion that appears to be consistent with maps made with single-electrode electrophysiological techniques. Koulakov These optical visualization techniques provide virtually continuous images from the cortical surface, but these approaches su¤er from shortcomings in temporal reso- lution that today can be mitigated only by multielectrode recording techniques. Spe- cifically, single-microelectrode recordings allow the systems neuroscientist to record the responses of individual neurons (single units) with submillisecond time resolution and with single-neuron spatial resolution. This spatiotemporal resolution cannot be achieved with contemporary optical techniques. In order to extend this capability, electrophysiologists have developed arrays of electrodes that allow one to record simultaneously from large numbers of single units. In order to record from cell bodies deeper within neural tissues, Kruger (Kruger and Aiple, 1988), Wise (Wise and Najafi, 1991), Normann (Jones and Norman, 1992), Eckhorn (Eckhorn et al. These electrode arrays have enabled the simultaneous recording of multi- and single-unit activity from large numbers of neurons in anesthetized animals and in behaving animals. Furthermore, the signal-to-noise ratio of this technique allows one to directly record the neural activity patterns in limited areas of the cerebral cor- tex in real time, and in response to single presentations of sensory stimuli in only moderately restrained animals. It is hoped that the technique will allow systems-level neuroscientists to begin to understand the role of the temporal features of the ensem- ble responses in distributed neural processing. This chapter explores the use of an array of 100 penetrating electrodes (the Utah Electrode Array or UEA) to simultaneously record from large numbers of multiple and single units in the visual cortex of the anesthetized cat. This number of electrodes is su‰ciently large that imaging of the neural activity of localized regions of the ce- rebral cortex is becoming possible. While this microelectrode array currently is being used to study many di¤erent aspects of cortical information processing, we summa- rize here how it can be used to study three basic features of the cortical functional architecture: the neural representations of ocular dominance, orientation sensitivity, and spatial visuotopy. We also demonstrate its use in recording ensemble responses to single presentations of simple visual stimuli. The data obtained from these studies are directly relevant to the problems of devel- oping cortically based sensory and motor neuroprostheses where large numbers of individual neurons must be selectively recorded from or stimulated. We conclude the Imaging 2-D Neural Activity Patterns 45 chapter with a discussion of the use of these microelectrode arrays as a means for restoring a lost sensory sense in those with profound blindness. When implanted in motor pathways, these arrays could also enhance limited or lost motor function in individuals with spinal cord injury or with demyelinating disorders. Measurement Techniques and Instrumentation Experiments were performed under animal care and experimental guidelines that conformed to those set by the National Institutes of Health. Only a brief description of the animal preparation, maintenance, and surgical procedures is given here be- cause they have been fully described elsewhere (Nordhausen et al. Felines were inducted with Telazol, cannulated, intubated, and their heads immobilized. The animals were artificially ventilated and anesthesia was maintained with halothane (approximately 0.

Presynaptic inhibition of homonymous (in the inferior soleus [Inf Sol] nerve) and heteronymous (from quadriceps [Q] in the femoral nerve [FN]) Ia afferents to soleus (Sol) motoneurones (MN) is mediated through a subset of common first-order PAD interneurones (INs) cheap 40 mg cialis professional erectile dysfunction and testosterone injections. The supplementary facilitation of the reflex at the onset of contraction cialis professional 40mg discount beer causes erectile dysfunction, i. Modified from Pierrot-Deseilligny (1997)((b)–(e)), and Meunier & Pierrot-Deseilligny (1989)((f ), (g)), with permission. Changes in presynaptic inhibition at the onset of voluntary contraction of various muscles. Presynaptic inhibition of homonymous and heteronymous Ia terminals to a given motoneurone (MN) pool (Sol or Q) is mediated through common first-order PAD INs. In addition, there is corticospinal depression (thick continuous line) of PAD INs mediating presynaptic inhibition of Ia terminals on MNs involved in the contraction, and facilitation (thin dotted line) of those acting on Ia terminals on MNs not involved in the contraction. The H reflex (as a percentage of its unconditioned value, dashed horizontal line) of Q at the onset of Q (c) and Sol (f ) contractions and of Sol at the onset of Q (d ) and Sol (e) contractions. Each column represents the mean of 100 measurements in a single subject. This may be due to a balance between descending inhibitionofPADinterneuronesandtheirperipheral Time course of changes in presynaptic inhibition excitationbythenaturalfeedbackfromthecontract- At the onset of the contraction, presynaptic inhibi- ing muscle. During the first half of the ramp, it remains much less than at rest but, in Origin and functional implications the middle of the ramp, it returns to its rest level Origin (Fig. This indicates late that the selective decrease in presynaptic inhi- thatthedurationofthedecreaseinpresynapticinhi- bition of Ia terminals directed to the contracting bition of Ia terminals projecting to motoneurones motoneurone pool at the onset of contraction is due ofthecontractingmuscledependsontherampdura- to focused corticospinal drive. Indeed, the same cor- tion and not on the time elapsed from the onset of tical site both activates motoneurones of a given the contraction. The return to the rest level in the pool and depresses PAD interneurones mediating middle of the ramp always occurred when the force presynaptic inhibition of Ia terminals projecting to was increasing more slowly, because of deceleration that pool (as sketched in the wiring diagrams in during the second half of the ramp as the target level Figs. An increasedgroupIafferentdischargefromacontract- Relationship to force ing muscle could thus activate PAD interneurones The stronger the target contraction the greater was and contribute to the re-appearance of presynap- the decrease in presynaptic inhibition at the onset tic inhibition in the middle of a ramp contraction of the ramp contraction (Fig. However, the same time course time courses of the decreases were similar in the two was observed during ischaemic blockade of group I cases. These find- Tonic contraction ings suggest that the re-appearance of presynaptic Heteronymous facilitation of the soleus H reflex was inhibition after its initial decrease is centrally pre- not significantly increased during relatively strong programmed, much as is the suppression of presy- tonic contractions of soleus at 20% of MVC (Meunier naptic inhibition and the degree of suppression. In Motor tasks – physiological implications 359 other words, all of the changes in presynaptic inhibi- Ia terminals on motoneurones of synergistic mus- tion at the onset of and during a ramp contraction of cles not involved in the contraction. Thus, at the alower-limbmusclecanbeattributedtodescending onset of a selective voluntary contraction of quadri- drives, not peripheral inputs. At the beginning of a movement, when the exact Origin load is not yet known, this would allow the mono- synaptic Ia excitation to compensate rapidly and Given the time between the onset of contraction and automatically for minor errors in the programmed the contraction-induced Ib discharge (Binder et al. Later, in the middle of the ramp, the 1977)orthe Ia discharge due to the contraction- decrease in presynaptic inhibition disappears and associated increase in drive (see Chapter 3, the gain of the monosynaptic loop returns to its p. However, by that time, other mech- tributetotheincreasedpresynapticinhibitionofhet- anisms in the central nervous system would be eronymous Ia terminals from quadriceps to soleus available to maintain the desired trajectory and, motoneurones at the onset of quadriceps con- in addition, the decrease in gain is required to pre- tractions. Descending facilitation of PAD interneu- vent oscillations from developing (see Matthews, rones could be due to: (i) a facilitatory effect of 1972). This control of presynaptic inhibition, with corticospinal drives, normally hidden by an oppo- aninitialdecreaseinpresynapticinhibitionfollowed site and dominant depressive effect (see p. Ia terminals directed to motoneurones of Functional implications inactive synergistic muscles Monosynaptic Ia connections from quadriceps to soleusmotoneuronesareparticularlywelldeveloped Increased presynaptic inhibition of Ia in human subjects, where they probably play a role terminals on synergistic motoneurones in the reflex control of motor tasks, such as run- Soleus and quadriceps are linked by bidirec- ning and hopping, in which co-contraction of the tional heteronymous monosynaptic Ia connections two muscles is required (see Chapter 2,pp. The large decrease in presynaptic inhibi- ceps, there will be an enhanced Ia discharge from tion of Ia terminals on motoneurones involved in thecontractingquadriceps,duetoincreasedfusimo- a selective voluntary contraction was accompanied tor drive (see Chapter 3,pp. The 360 Presynaptic inhibition of Ia terminals (a) (b) Corticospinal 100 PAD 75 Group I INs TA Torque 50 Ia Q Sol Q MN MN 25 FN Q PTN Ia 0 Soleus 0 50 100 150 200 250 300 Time elapsed after onset of contraction (ms) Fig. Changes in presynaptic inhibition of Ia afferents to soleus motoneurones during voluntary contraction of the antagonistic muscle. This presynaptic terminals directed to soleus motoneurones, as dis- inhibition increases little during the first 80 ms of cussed on p.