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By L. Kalesch. Olivet College.

There are two main methods for maintaining a flow of ideas from one sentence to the next antivert 25mg discount. One method is to use conjunctions or transition words to link sentences proven 25mg antivert. Classical transition words, such as although, therefore, however, for example, etc. Nevertheless, you cannot keep using transition words throughout a paragraph. The messages of the paragraph are reasonably clear but the overload of transition words reduces rather than aids readability. Although transition words work occasionally, other skills are also needed to create flow. Therefore, prevalence rates that include reported and unreported cases more accurately describe the extent of the problem of child sexual assaults in communities. However, cases are difficult to ascertain through retrospective population studies. For example, there is an inverse association between study response rates and the estimated prevalence of child sexual abuse. Another method to create flow between sentences is to link the beginning (or subject) of the sentence to the end (or object) of the previous sentence. Linking subjects to objects between sentences helps to maintain ideas in the reader’s mind because it avoids any abrupt change of thoughts when a full stop is reached. In example 4, the reference to prevalence is moved closer to the beginning of the second sentence and the new concept, incidence, is moved to the end, clarifying the message. Being overweight is a significant risk factor for the development of cardiovascular disease. Children were at a higher risk of having respiratory infections if their parents smoked. Children with a parent who smokes are at higher risk of having respiratory infections. Unlike the incidence rate, the number of remissions and deaths that occur influences the prevalence rate. The number of remissions and deaths influences prevalence rates but not incidence rates. In addition to creating continuity by using good transitions, repeating key terms throughout a paragraph can also help to maintain thought processes. However, it is a good idea to avoid using the same word twice in one sentence because this becomes boring. Also, repeating a word in a sentence usually signals a construction problem because it does not make sense for the same word to be both the subject and the object of a 201 Scientific Writing sentence. Tight writing Cutting dross allows your information to shine more clearly. In the early 1900s, Professor William Strunk used to tell his students: “Omit needless words, omit needless words, omit needless words. Given that every book or article on writing recommends this style as a matter of course, it is surprising that so few writers aspire to this ideal. Readers love sentences and paragraphs that have a minimum number of words and that only include the information that they really need. Readers are busy people who want to be able to understand your paper quickly and do not want to spend time sorting out meanings from meandering text. All you have to do is put your thoughts down in a sentence, then be your own best critic and see how many words 202 Writing style you can leave out. Finally, when you have a series of short, concise sentences, you need to arrange them in a logical order and join them up to create flow. This is a skill that is certainly worth perfecting if you would like to publish productively. If you follow this formula, you will automatically please your readers, reviewers, and publishers. In doing this, you will also earn yourself respect as a “good writer”, which is a reputation worth striving for. If you are finding it hard to write tightly, it is a good idea to put your draft away for some time and then revisit it when you can be more objective.

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Many studies on patients with cancer pain have provided insight into the clinical pharmacology of opioids antivert 25 mg sale. Research findings support the idea that the pharmacokinetic and pharmacodynamic principles of opioids in cancer patients with pain hold true in patients with chronic buy 25 mg antivert amex, nonmalignant pain. While the use of opioids for chronic cancer pain is widely accepted, the efficacy and role of opioids in the management of chronic noncancer pain has been intensely debated. Opponents argue that there is no place for opioids in the treatment of chronic benign pain and opine that narcotics are a major impedi- ment to the successful treatment of chronic pain. This view is largely based on concerns regarding tolerance, physical dependence, addiction, and adverse affective and cognitive side effects. Much of this debate has occurred till recent years in the absence of randomized clinical trials. Although several recent studies have demonstrated that chronic pain, including neuropathic pain states such as postherpetic neuralgia, is responsive to opioids, these studies have followed patients for relatively short periods of 2 months or less. More careful studies of the long-term efficacy of opioids are needed to determine if tolerance to the analgesic effects of opioids limits its usefulness for long-term therapy. Opioid Effectiveness The appropriate use of opioids in the management of chronic pain demands individualization. That is, one opioid does not ‘fit all’ patients with a certain type of pain. In addition, we lack a mechanistic approach that would guide the management of chronic pain states with specific opioids. The goal in the management of a patient’s pain with opioids is to achieve an optimal bal- ance between the drug’s analgesic effects and any associated adverse effects. According to this strategy, the rational use of opioids should focus on achieving maximum analgesic effi- cacy while limiting toxicity. The success of this approach requires gradual titra- tion of the opioid to the point at which a favorable balance between analgesia and side effects is achieved. Finding this acceptable balance between analgesia and side effects requires frequent interactions between the clinician and patient. Several factors can influence opioid responsiveness in managing chronic pain: specifically, patient-centered characteristics, pain-centered characteris- tics, and drug-centered characteristics. Christo/Grabow/Raja 124 Patient-Centered Characteristics Patient-centered characteristics, such as a predisposition to opioid side effects, reduce opioid responsiveness, irrespective of pain syndrome type. This predisposition may derive from higher than normal plasma levels of opi- oid following a single dose (pharmacokinetic) or even from an exaggerated response to modest levels of plasma opioid (pharmacodynamic). Therefore, side effects after a given dose or doses of opioid are difficult to predict but will prevent the patient from achieving a balance between analgesia and adverse effects. Further, concurrent use of other medications with additive side effects will increase the risk of intolerable opioid side effects at doses that are inade- quate for analgesia. If patients are experiencing psychological distress, they may respond less favorably to opioid therapy. Among the cancer population, patients who receive psychological interventions or psychotropic medication achieve better analgesia with the same opioid and dose than do patients receiving no psycho- logical assistance. Similarly, poor opioid responses by addicted individuals may result from affective disturbances such as depression and anxiety. Those patients who have recently consumed large doses or escalating doses of opioids also may respond poorly to current opioid therapy. This out- come may result from disease progression among the cancer or noncancer pop- ulation or may result from tolerance. It is important to remember that patients consuming high doses of an opioid at baseline will require large incremental doses to achieve analgesia. Finally, genetic determinants may influence opioid effectiveness in patients by altering the density or proportion of opioid receptors or by chang- ing the expression of opioid isoforms. Pain-Centered Characteristics Pain-centered characteristics can influence patient responsiveness to opi- oids. For instance, the temporal patterns of pain exert a strong influence on opioid effectiveness. If pain is of rapid onset, the opioid tends to be ineffec- tive, perhaps due to our inability to deliver the drug fast enough.

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Lack of statistical power does not account for the differences be- tween these studies generic antivert 25 mg with mastercard, as the study with the largest sample size (n = 180) re- ported the most negative results (Arts et al order antivert 25 mg mastercard. These studies do not indicate whether other psychological strategies, such as brief relaxation or imagery, may have been more effective than distraction relative to the pharmacological approach. However, these studies suggest that for brief, low-intensity procedures in which simple pharmacological interventions with minimal side effects (e. Several of the most methodologically sound controlled trials, all con- ducted in children, comparing psychological interventions with a pharma- cological intervention have been reported by Jay and colleagues (1987, 1991, 1995). Results indicated that the psychological intervention re- sulted in lower pain, distress, and physiological arousal than either the Val- ium or control conditions (Jay et al. A similar follow-up RCT by these researchers revealed identical effects on pain and arousal whether patients received a psychological intervention alone or in combination with Valium (Jay et al. Results indicated that general anesthesia was associated with less procedural distress, but no dif- ferences between interventions were observed regarding self-ratings of pain provided postprocedure. Subjects, all of whom received both types of pain intervention in the within-subject design, did not indicate a significant preference for one versus the other type of intervention, and it was noted that the psychological intervention required less time (Jay et al. As a whole, results of these well-controlled studies indicate that psychological interventions are of at least comparable efficacy to standard pharmacologi- cal approaches for management of the pain associated with bone-marrow aspiration in children. It is important to note that such findings are not likely to generalize to all types of clinical acute pain. Clearly, procedures associated with more in- tense acute pain, such as even “minor” surgery, require pharmacological analgesia. However, the results reported earlier indicate that combining psychological and pharmacological approaches may have significant bene- 260 BRUEHL AND CHUNG fits to patients. MODERATORS OF RESPONSES TO PSYCHOLOGICAL INTERVENTIONS Spontaneous Coping Strategies Many individuals implement their own spontaneous pain coping strategies when faced with acute pain (Spanos et al. The possibility that externally imposed interventions may interfere with pa- tients’ implementation of effective pain control strategies already in their behavioral repertoire cannot be ruled out. Although some studies suggest that these spontaneous coping strategies may be effective for pain reduc- tion (Spanos et al. Coping Style Patients’ preferred style of coping with stress, whether Monitoring or Blunting in character, may be relevant to understanding the efficacy of spe- cific psychological acute pain interventions. Monitors, also referred to as Sensitizers or Vigilants, prefer to cope with stressful situations by seeking out information about the stimulus, and by monitoring and trying to miti- gate their responses to the stimulus (Schultheis, Peterson, & Selby, 1987). Blunters, also termed Repressors, Avoiders, Distractors, or Deniers, prefer to cope with stressful situations through avoidance and by denial of the stressor (Schultheis et al. A number of studies have hypothesized that psychological acute pain in- terventions work best if they match an individual’s naturally preferred cop- ing style. For example, providing a sensory focus intervention to a Blunter would be considered a mismatched intervention, whereas a relaxing imag- ery strategy would be considered a matched intervention for such an indi- vidual (Fanurick et al. Laboratory acute pain studies have provided some evidence indicating that interventions matched to preferred coping style result in more effective reductions in acute pain responsiveness (e. PSYCHOLOGICAL INTERVENTIONS FOR ACUTE PAIN 261 Clinical studies regarding this issue are mixed, but generally negative. Although there were no interaction ef- fects regarding pain experienced during the procedures, Monitors were found to experience less distress in the information provision condition whereas Blunters experienced greater distress (Shipley et al. Studies performed in the context of more severe acute clinical pain, on the other hand, are more negative. In a study of general surgery patients, efficacy of information pro- vision, relaxation, and no intervention was compared as a function of Moni- toring and Blunting coping styles (Scott & Clum, 1984). Blunters reported less pain and used less analgesics when provided with no intervention, which appear at least not inconsistent with the matching hypothesis. How- ever, contrary to the matching hypothesis, Monitors appeared to do best with breathing relaxation as opposed to information provision (Scott & Clum, 1984). Work by Wilson (1981) also in general surgery patients found that Blunters did not experience exacerbated pain following an information provision intervention, again failing to support the matching hypothesis. More recent work in surgical patients also indicated that efficacy of a relax- ation intervention did not differ depending on the degree to which patients preferred a Monitoring coping style (Miro & Raich, 1999). Differences in the measures used to assess coping style, types of interventions employed, and other procedural details make comparisons across studies more difficult.

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