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Objectives: To summarize the clinical characteristics and outcomes of pediatric sports-related concussion (SRC) patients who were evaluated and managed at a multidisciplinary pediatric concussion program and examine the healthcare resources and personnel required to meet the needs of this patient population. Methods: We conducted a retrospective review of all pediatric SRC patients referred to the Pan Am Concussion Program from September 1st, 2013 to May 25th, 2015. Initial assessments and diagnoses were carried out by a single neurosurgeon. Return-to-Play decision-making was carried out by the multidisciplinary team. Results: 604 patients, including 423 pediatric SRC patients were evaluated at the Pan Am Concussion Program during the study period. The mean age of study patients was 14.30 years (SD: 2.32, range 7-19 years); 252 (59.57%) were males. Hockey (182; 43.03%) and soccer (60; 14.18%) were the most commonly played sports at the time of injury. Overall, 294 (69.50%) of SRC patients met the clinical criteria for concussion recovery, while 75 (17.73%) were lost to follow-up, and 53 (12.53%) remained in active treatment at the end of the study period. The median duration of symptoms among the 261 acute SRC patients with complete follow-up was 23 days (IQR: 15, 36). Overall, 25.30% of pediatric SRC patients underwent at least one diagnostic imaging test and 32.62% received referral to another member of our multidisciplinary clinical team. Conclusion: Comprehensive care of pediatric SRC patients requires access to appropriate diagnostic resources and the multidisciplinary collaboration of experts with national and provincially-recognized training in TBI.
Against medical advice, head and neck cancer (HNC) patients have been shown to continue to smoke and misuse alcohol post-diagnosis and treatment. This study aimed to better understand the barriers to and facilitators of health behavior change (HBC) in HNC patients.
We conducted nine focus groups following a standard protocol. Eligible patients were diagnosed less than three years previously with a primary HNC and selected using maximum variability sampling (gender, age, cancer stage, smoking, and alcohol misuse). Thematic analysis was conducted using NVivo 10 software.
Participants were mostly men (79%), 65 years of age (SD = 10.1), and married/common-law (52%, n = 15). Mean time from diagnosis was 19 months (SD = 12.3, range = 5.0–44.5), and most had advanced cancer (65.5%, n = 19). Participants provided a larger than anticipated definition of health behaviors, encompassing both traditional (smoking, drinking, diet, exercise, UV protection) and HNC-related (e.g., dental hygiene, skin care, speech exercises, using a PEG, gaining weight). The main emerging theme was patient engagement, that is, being proactive in rehabilitation, informed by the medical team, optimistic, flexible, and seeking support when needed. Patients were primarily motivated to stay proactive and engage in positive health behaviors in order to return to normal life and reclaim function, rather than to prevent a cancer recurrence. Barriers to patient engagement included emotional aspects (e.g., anxiety, depression, trauma, demoralization), symptoms (e.g., fatigue, pain), lack of information about HBC, and healthcare providers' authoritarian approach in counseling on HBC. We found some commonalities in barriers and facilitators according to behavior type (i.e., smoking/drinking/UV protection vs. diet/exercise).
Significance of Results:
This study underlines the key challenges in addressing health behaviors in head and neck oncology, including treatment-related functional impairments, symptom burden, and the disease's emotional toll. This delicate context requires health promotion strategies involving close rehabilitative support from a multidisciplinary team attentive to the many struggles of patients both during treatments and in the longer-term recovery period. Health promotion in HNC should be integrated into routine clinical care and target both traditional and HNC-related behaviors, emphasizing emotional and functional rehabilitation as key components.
There has been a recent renewal of interest in the extracranial repair of cerebrospinal fluid rhinorrhea because of the relatively high morbidity associated with the transcranial approach. The authors describe an extracranial approach that involves packing of the sphenoid and ethmoid sinuses on the side of the CSF leak. A case of successful treatment of CSF rhinorrhea by this method is presented. The extracranial approach may be advantageous for the repair of CSF rhinorrhea and the authors advocate an increase in its utilization by neurosurgeons and otolaryngologists working as a team.
We have criticized medical writers, but praise is due to those who write well, and there are many who do. It is not so easy to find their writing because there are not the indicators to good writing that there are to bad. We started our dissection of style with Watson and Crick’s description of DNA (see p. 25), but their article is now 60 years old. With kind permission of the author and of the publishers, we reproduce here a Viewpoint from the Lancet from 2013 that is a model of clarity. We are not asking you to read some deep theory about an arcane disease interesting only to a handful of sub-specialists. It is an essay about type 2 diabetes, a condition so common and important that it will interest almost all medical writers. Now, of course, most research projects are of only limited interest, but the writers’ messages would come across better by reflecting the succinctness and flow of this essay rather than the polysyllables and discursion of too many research articles.
The essay is reproduced here in full, after which we make comments. But a preliminary comment is that the essay does not start by telling us that type 2 diabetes is a disease of epidemic proportions: the author wastes no words telling us what we already know; he tells us right away what he wants to say. And a general comment is to note, as you read through, how few of the words and constructions that appear in our index appear in the essay.
People who write obscurely are either unskilled in writing or up to some mischief.
(Sir Peter Medawar, 1915–1987, British biologist. The threat and the glory, D. Pyke, ed., Oxford, Oxford University Press, 1990.)
Literary devices and figures of speech are not prominent in routine research papers, but are more likely in editorials and opinion pieces. Used properly, they enliven writing, which is why columnists – both in newspapers and magazines and in their medical equivalents – use them.
Metaphor is the most important and widespread figure of speech, and is (COD) the application of name or descriptive term to an object or action to which it is imaginatively but not literally applicable. It suggests a shared property. It is metaphorical when we write that a drug ‘locks onto’ a receptor, suggesting that drugs and receptors are like keys and locks. In previous chapters we have mentioned drawback (its original meaning now less well-known than its metaphorical one), elevated from bishop to archbishop, falling into groups, hormones having a role, a graveyard full of failed treatments, focusing a service, examining cars in depth, and a cocktail of drugs.
There are two reasons to be wary of metaphors: first, readers may misinterpret them, especially EAL readers, who may not understand them at all; and second, metaphors have a tendency to descend pretty quickly to cliché. Metaphors are intended to enliven writing; clichés, because they are overused, deaden it. There is no strict definition of cliché; nor is there a list in which to check whether a chosen metaphor has degenerated to cliché. As The Economist’s guide (see reference books) points out, ‘clichés weren’t always clichéd. The first person to use window of opportunity . . . was justly pleased with himself. [It] is a strong, vivid expression – or was. The trouble is that such expressions have been copied so often that they have lost their vividness.
If words fall into disrepair, what will substitute? They are all we have.
(T. Judt. The memory chalet. London, Vintage, 2011.)
A medical writer, when asked why he had used the words ‘were haemorrhaged’ instead of ‘were bled’, replied that he thought haemorrhaged was more scientific. Sometimes we do need to use a term more precise than the one in common usage, but bled is a perfectly good word, and haemorrhaged tells us no more about the process.
Haemorrhaged is also incorrect grammatically. To bleed (COD) can be transitive or intransitive, in other words may or may not have an object: you can bleed someone to death, or you can yourself bleed to death. To haemorrhage is intransitive and so cannot have an object: you can only bleed to death yourself; you can’t haemorrhage someone else to death.
During Alice’s adventures through the looking glass, the birds held a meeting.
‘In that case,’ said the Dodo solemnly, rising to its feet, ‘I move that the meeting adjourn, for the immediate adoption of more energetic remedies –’
‘Speak English!’ said the Eaglet. ‘I don’t know the meaning of half those long words, and what’s more, I don’t believe you do either!’ And the Eaglet bent down its head to hide a smile: some of the other birds tittered audibly.
Resist the urge to use less familiar words. There is danger that the unfamiliar will contribute to confusion; or to put it another way, inflated language often sets out to confuse. Most of the words in the lists that follow can be replaced by words that are more common.
Doctors, nurses, paramedical workers and medical scientists need to communicate their ideas effectively. Writers in the field of medicine tend to use unfamiliar words in tortuous constructions, particularly when writing reports for submission to learned journals. Research can often be judged only by its final written report. A meticulous study can be let down by poor writing, which may lead a reviewer to wonder if lack of attention to detail in the writing indicates lack of attention to detail in the research. Certain usually superfluous words and phrases occur again and again in medical papers. Once able to recognize these, writers should be able to delete them or to find more appropriate constructions, guided by the suggestions made in this book.
Most of the examples are quotations from medical books and journals, though some, particularly those from more specialized texts, have been modified.
Words or phrases whose use in medical writing is discussed specifically in the text are in capitals:
(a) where they occur as the ‘heading’ to a main entry, i.e. where the discussion takes place;
(b) in cross-references to main entries, for example ‘(see regime)’;
(c) in the index.
Superscript numbers in the text refer to articles and books listed sequentially in the reference list at the end of the book. There is also a list of the standard texts to which we refer frequently, and these texts are identified by author’s name or by an obvious shorthand: for instance, Greenbaum and Whitcut are the latest revisers of Sir Ernest Gowers’ The complete plain words, and this is referred to as Gowers. COD is the Concise Oxford Dictionary. OED is the CD-ROM version of the Oxford English Dictionary.
I see you have an interesting paper in the latest number of Brain. When is the English translation coming out?
(Remark by Sir Francis M. R. Walshe, 1885–1973, British neurologist, to a London physician on the publication of a somewhat obscure paper, and taken from an out of print book, Familiar medical quotations, edited by Maurice B. Strauss (ed.), Boston, Little, Brown and Company, 1968.)
Scientific writing in general, and medical writing in particular, is muddied by superfluous words. These masquerade as part of convention but are actually just catch-phrases or padding: the literary equivalent of ums and ahs. We select as common culprits basis, case, conditions, essentially, feature, function, grounds, instance, nature, situation and type. These words usually add nothing; they are words for words’ sake. When you can recognize them as such, delete them and restructure the sentence.
Absence occurred in one in 40 PubMed® articles, mostly in the phrase the absence of . . . . It may be better to write there were no . . . instead, but the phrase is not as redundant as the presence of.
. . . and this correlated with the presence or absence of competence genes . . .
This might be mediated by the reduced stretch of the hip capsule, because of the absence of increased uterine pressure . . .
In the absence of mediastinal lymph node metastases surgery is the treatment of choice.
The first example is correct. The second is correct, but awkward – an absence of an increase is confusing. Try, . . . because the uterine pressure was not increased. The third is better as If there are no mediastinal lymph node metastases . . . .
(D. R. Appleton. Cross words. BMJ. 1994; 309: 1737.)
Number: singular or plural?
Errors in which singular subjects govern plural verbs, or vice versa, are examples of what grammarians refer to as errors of concord. Concord – agreement – between subject and verb is the most important type. Mistakes occur most commonly with either . . . or, neither . . . nor, none, in lists, and with collective nouns (particularly when the noun is separated from the verb by a long clause). The error that many people seem to know about, but that is of little importance, is the one made with the word data.
EITHER . . . OR, NEITHER . . . NOR, EACH
In Either Mr A is a liar, or Ms B is psychotic the verb is repeated and there is no confusion: the verb is singular. It is also singular if one or the other is the subject of the same verb: Either Mr A or Ms B is psychotic. Neither behaves the same: Neither Mr A nor Ms B is psychotic. These constructions cannot be applied to more than two choices.
When one of the choices is singular and the other plural, write the plural noun second: Neither the doctor nor the nurses are responsible . . . . The plural noun then governs the verb by the principle of proximity.
In speech, the plural is more natural when either . . . or or neither . . . nor is used.
Each implies a consideration of things taken one at a time and is singular: Each patient was asked . . . . The mistake is likely with the construction Each of the patients . . . when were is more natural but was is correct. Correcting the error of style (. . . of the . . . is unnecessary) makes the mistake less likely and is a good example of how good style can lead naturally to correct grammar.
(One of many versions, easily found on the internet, of what originated as ‘Candidate for a Pullet Surprise’, by Mark Eckman and Jerrold H. Zar: see http://grammar.about.com/od/spelling/a/spellcheck.htm.)
No one can pretend that English spelling is easy. French and Italian lose letters that are not pronounced, but are otherwise phonetic. German and Welsh are phonetic. We marvel that those whose first language does not even use English characters ever learn to spell in English. There have been efforts over the years to simplify English spelling, but none has succeeded; nor will they – and nor should they, but this is not the place to present the arguments. Bill Bryson writes of spelling reform (see reference books) that, ‘It is hard to say which is the more remarkable, the number of influential people who became interested in spelling reform or the little effect they had on it.’ According to George Bernard Shaw, the Irish playwright who on his death in 1950 left a bequest to help to reform English spelling, the letters ghoti spelled fish. The bequest had no effect whatsoever, and how ghoti spells fish is revealed at the end of this section. British spelling of English may slowly lose out to American spelling, but that is a different matter. Both spellings occur in this book (see layout of fourth edition), and there are comments where appropriate in the text, as well as a glossary (see appendix).
. . . the unfortunate memory of the numerous dry, badly written papers one inevitably has to read as background to the research one is presenting.
(Kerry Emanuel, b. 1955, Professor of Atmospheric Science, Massachusetts Institute of Technology.)
Nouns, adjectives and prepositions do not change their endings in English to indicate how they relate to each other. Words can be stressed in speech, but although underlining and italics will indicate stress in writing they are devices to use sparingly. Some journals will not accept italicized emphases. In written English, meaning is determined first by the positions, or presumed positions, of words, phrases and clauses, and second by the punctuation between them. (Chapter 17 contains a more general consideration of word order, aimed at EAL writers.)
Consider this simple example.
The policy was changed after a near clinical disaster.
Readers expect near to qualify the word next to it, clinical. Although it takes only a moment to realize that the sense is of a clinical near-disaster and not of a disaster that was nearly clinical, the expression is a jolt to the flow of understanding. The example is better as The policy was changed after there was nearly a clinical disaster.
Sometimes the interpreted meaning may be far from the intended one, as in this letter from a firm of solicitors to a general practice:
We feel it can only improve our service to clients, particularly as many of our personal injury/domestic violence clients seek our assistance after visiting your health centre.
Note the lazy slash, which is better replaced with and.
The word only needs careful placement.
Noun clusters and stacked modifiers
In our opinion, to realize the problems produced by strings of unfamiliar modifiers is the simplest single way to improve medical writing. (And not just medical writing: did The Guardian newspaper really mean to describe a member of a pop group as a ‘fake tan-loving singer’?) There have been many examples in the preceding chapters.
Judicious punctuation of the strings helps the editor and readers to sort out what is meant, but often the difficulty of placing sensible punctuation shows that all is not well. Somehow we doubt if this example from an advert in the medical press could have been made less dubious or offensive by punctuation: ‘Wanted: brown fat research assistant.’ (And see the problems for Swedish writers, p. 250.)
As stated on p. xii we have used British English spelling except where examples were originally written in American English. This appendix lists words from our text that are commonly spelled differently in these two versions of English, plus a few other important words. The spelling in one may or may not be acceptable in the other. For instance, acknowledgement is usually spelled with an ‘e’ after the ‘g’ in British English but without the ‘e’ in American English (acknowledgment), but both spellings are acceptable in both languages. Judgement and judgment are likewise spelled differently but judgement (with an ‘e’) is not an accepted alternative in American English (see also p. 39).
Sometimes a spelling listed in one language version is used for another purpose in the other. For example, British English demands analogue; the American dictionary Merriam-Webster OnLine lists analogue for the noun, but spells the adjective analog.
Spelling differences sometimes indicate more complex differences in usage: the adjectival endings ‘ic’ or ‘ical’ are cases in point. They can be interchangeable – for instance, the adjectives histopathologic and histopathological are listed in the Merriam-Webster OnLine – but not necessarily consistent: only pathological is listed. The COD has only histopathological, and has pathological, US also pathologic. One of the versions of a word may be more common in British or American English, or can be more common with a particular noun: electrical cord is seen more often than electric cord and electric eel more often than electrical eel. Some adjectives have different meanings in their ‘ic’ and ‘ical’ versions: economic (COD) relates primarily to the economy and secondarily to being good value; so whereas an economic enterprise may be either a gathering of economists or a project that doesn’t cost too much, an economical procedure is one that costs less (see HISTORIC, HISTORICAL).
It does not matter how clever a chap may be, or how earth-shattering his discovery – if he cannot convey it to others, in clear, lucid prose, he might just as well not have bothered.
(Anon. In England now. Lancet 1992; 339: 737. [We will excuse the sexism, just as we did for Popper, see p. 1.])
This section has been titled Circumlocution since the first edition, for no reason other than it is a pleasing word, but is now a separate chapter. Edith Schwager’s similar section (see reference books) is titled Tautology, ‘rather than Redundancy, because any –ology sounds much more learned. However, we could have used Superfluity, Verbosity, Verbiage, Periphrasis, or Prolixity.’
Many circumlocutions in medical writing accompany or are the result of using the words and phrases listed earlier in this book, for example, may have the potential to meaning could. But there are many circumlocutions that will not be found by computer searches. They may be spotted by friends and colleagues if you ask them to read your draft, but you must ask them – sincerely – to be critical, and you must not then take offence if they are. Otherwise, the only way to spot circumlocutions is to go through your text carefully, asking yourself whether this word or that phrase is really necessary. (Is ‘really’ necessary?) After a while, you will become sensitive to unnecessary verbiage, and trimming will bring great satisfaction. Expressing a message more succinctly is useful not just for good style, but also when there is a word limit – for instance when submitting abstracts. Shorter papers will endear you to editors. The current on-line advice from the journal Diabetologia advises that if your paper is not 25% shorter after the eradication process, which should include ‘any phrase you think particularly clever’, you go back and start again.
Allow is a common word in medical writing and the mistakes that EAL authors make when using it are also common. The word demands detailed consideration because it flits between prepositions changing its meaning as it goes. Allow is usually used in the context of to let something happen, when it has to be followed by a direct object in English: We allow analysis immediately. Mistakes arise because, in some other languages, allow does not need a direct object and is often immediately followed by to.
An additional aim was to find an indicator that would allow to follow-up ovarian stimulation.
. . . the transgenic mice allowed to visualize the corresponding glomerulus and to stimulate with a known ligand.
These sentences are incorrect, and are cured by adding the direct object us: allow us to follow-up, allowed us tovisualize (used correctly).
The object in medical writing is often a noun formed from a verb by a suffix: – ‘ment’ or ‘ion’ or ‘ing’; this last form is grammatically a gerund. In these cases the object is followed by of.
There is no specific questionnaire that allows evaluating treatment-induced changes in QoL.
The simple way to correct the grammar is allows the evaluating of . . . or (better) allows the evaluation of . . . , but the object of the wanted questionnaire is the changes not the evaluation. The sentence is better rephrased: There is no specific questionnaire that measures changes in QoL caused by treatment. (QoL is quality of life.)