<link href="//maxcdn.bootstrapcdn.com/bootstrap/4.1.1/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//maxcdn.bootstrapcdn.com/bootstrap/4.1.1/js/bootstrap.min.js"></script> <script src="//cdnjs.cloudflare.com/ajax/libs/jquery/3.2.1/jquery.min.js"></script> <!------ Include the above in your HEAD tag ----------> <!-- Select Basic --> <div class="form-group"><label class="col-md-4 control-label" for="selectbasic">0. Procedure label: What is the type of neuropathic pain model? </label> <div class="col-md-4"><select id="selectbasic" name="selectbasic" class="form-control"> <option value="1">SNI</option> <option value="2">PSL or PSNL</option> <option value="3">CCI (all variants)</option> </select><em><span class="help-block">List the disease or injury that is being modelled; Provide a label to uniquely identify a disease model induction procedure within the study </span></em></div> </div> <!-- Appended checkbox --> <div class="form-group"><label class="col-md-4 control-label" for="appendedcheckbox">1. Control Procedure?</label> <div class="col-md-4"> <div class="input-group"><input id="appendedcheckbox" name="appendedcheckbox" class="form-control" type="text" placeholder="Yes" /> <span class="input-group-addon"> <input type="checkbox" /> </span></div> <p class="help-block"><em>Is this a control procedure for the disease model induction?</em></p> </div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"><label class="col-md-4 control-label" for="radios">1a. Was a sham surgery preformed?</label> <div class="col-md-4"><label class="radio-inline" for="radios-0"> <input type="radio" name="radios" id="radios-0" value="1" checked="checked" /> Yes </label> <label class="radio-inline" for="radios-1"> <input type="radio" name="radios" id="radios-1" value="2" /> No </label> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label> <em><span class="help-block">Did the animals allocated to the control group undergo a surgical procedure </span></em></div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"><label class="col-md-4 control-label" for="radios">1b. Was a naive animal used as control?</label> <div class="col-md-4"><label class="radio-inline" for="radios-0"> <input type="radio" name="radios" id="radios-0" value="1" checked="checked" /> Yes </label> <label class="radio-inline" for="radios-1"> <input type="radio" name="radios" id="radios-1" value="2" /> No </label> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label> <em><span class="help-block">Answer yes if a healthy animal that did not undergo sham surgery or treatment was used as the control </span></em></div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"><label class="col-md-4 control-label" for="radios">1c. Was the contralateral side used as control?</label> <div class="col-md-4"><label class="radio-inline" for="radios-0"> <input type="radio" name="radios" id="radios-0" value="1" checked="checked" /> Yes </label> <label class="radio-inline" for="radios-1"> <input type="radio" name="radios" id="radios-1" value="2" /> No </label> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label> <em><span class="help-block">Answer yes if the contralateral side used as the control </span></em></div> </div> <!-- Select Basic --> <div class="form-group"><label class="col-md-4 control-label" for="selectbasic">2. Was anaesthetic used? </label> <div class="col-md-4"><select id="selectbasic" name="selectbasic" class="form-control"> <option value="1">Isoflurane</option> <option value="2">KetamineL</option> <option value="3">Ketamine/Xylazine</option> <option value="4">Others</option> <option value="5">Not reported</option> </select><em><span class="help-block">List the disease or injury that is being modelled </span></em></div> </div> <!-- Text input--> <div class="form-group"><label class="col-md-4 control-label" for="textinput">2a. If others, please specify the substance from the study text</label> <div class="col-md-4"><input id="textinput" name="textinput" type="text" placeholder=" " class="form-control input-md" /> <em><span class="help-block">Please specify the substance from the study text </span></em></div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"><label class="col-md-4 control-label" for="radios">3. Was pre-operative analgesia administered?</label> <div class="col-md-4"><label class="radio-inline" for="radios-0"> <input type="radio" name="radios" id="radios-0" value="1" checked="checked" /> Yes </label> <label class="radio-inline" for="radios-1"> <input type="radio" name="radios" id="radios-1" value="2" /> No </label> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label> <em><span class="help-block">Were painkillers given pre surgery </span></em></div> </div> <!-- Text input--> <div class="form-group"><label class="col-md-4 control-label" for="textinput">3a. If yes, What analgesic drug was used?</label> <div class="col-md-4"><input id="textinput" name="textinput" type="text" placeholder=" " class="form-control input-md" /> <em><span class="help-block">Please specify the substance from the study text </span></em></div> </div> <!-- Textarea --> <div class="form-group"><label class="col-md-4 control-label" for="textarea">3b. If yes, What dosage given for the painkiller?</label> <div class="col-md-4"><textarea class="form-control" id="textarea" name="textarea">in mg/KG BW</textarea> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label></div> </div> <!-- Text input--> <div class="form-group"><label class="col-md-4 control-label" for="textinput">3c. If yes, How many times was the analgesic drug administered?</label> <div class="col-md-4"><input id="textinput" name="textinput" type="text" placeholder=" " class="form-control input-md" /> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label></div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"><label class="col-md-4 control-label" for="radios">3d. If yes, Which drug application route was used?</label> <div class="col-md-4"><label class="radio-inline" for="radios-0"> <input type="radio" name="radios" id="radios-0" value="1" checked="checked" /> i.p. </label> <label class="radio-inline" for="radios-1"> <input type="radio" name="radios" id="radios-1" value="2" /> i.v. </label> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> s.c. </label> <label class="radio-inline" for="radios-3"> <input type="radio" name="radios" id="radios-3" value="4" /> i.t. </label> <label class="radio-inline" for="radios-4"> <input type="radio" name="radios" id="radios-4" value="5" /> Others </label></div> </div> <!-- Text input--> <div class="form-group"><label class="col-md-4 control-label" for="textinput">3e. If others, please specify the route from the study text</label> <div class="col-md-4"><input id="textinput" name="textinput" type="text" placeholder=" " class="form-control input-md" /> <em><span class="help-block">Please specify the route from the study text </span></em></div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"><label class="col-md-4 control-label" for="radios">4. Was peri-operative analgesia administered?</label> <div class="col-md-4"><label class="radio-inline" for="radios-0"> <input type="radio" name="radios" id="radios-0" value="1" checked="checked" /> Yes </label> <label class="radio-inline" for="radios-1"> <input type="radio" name="radios" id="radios-1" value="2" /> No </label> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label> <em><span class="help-block">Were painkillers given during surgery </span></em></div> </div> <!-- Text input--> <div class="form-group"><label class="col-md-4 control-label" for="textinput">4a. If yes, What analgesic drug was used?</label> <div class="col-md-4"><input id="textinput" name="textinput" type="text" placeholder=" " class="form-control input-md" /> <em><span class="help-block">Please specify the substance from the study text </span></em></div> </div> <!-- Textarea --> <div class="form-group"><label class="col-md-4 control-label" for="textarea">4b. If yes, What dosage given for the painkiller?</label> <div class="col-md-4"><textarea class="form-control" id="textarea" name="textarea">in mg/KG BW</textarea> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label></div> </div> <!-- Text input--> <div class="form-group"><label class="col-md-4 control-label" for="textinput">4c. If yes, How many times was the analgesic drug administered?</label> <div class="col-md-4"><input id="textinput" name="textinput" type="text" placeholder=" " class="form-control input-md" /> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label></div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"><label class="col-md-4 control-label" for="radios">4d. If yes, Which drug application route was used?</label> <div class="col-md-4"><label class="radio-inline" for="radios-0"> <input type="radio" name="radios" id="radios-0" value="1" checked="checked" /> i.p. </label> <label class="radio-inline" for="radios-1"> <input type="radio" name="radios" id="radios-1" value="2" /> i.v. </label> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> s.c. </label> <label class="radio-inline" for="radios-3"> <input type="radio" name="radios" id="radios-3" value="4" /> i.t. </label> <label class="radio-inline" for="radios-4"> <input type="radio" name="radios" id="radios-4" value="5" /> Others </label></div> </div> <!-- Text input--> <div class="form-group"><label class="col-md-4 control-label" for="textinput">4e. If others, please specify the route from the study text</label> <div class="col-md-4"><input id="textinput" name="textinput" type="text" placeholder=" " class="form-control input-md" /> <em><span class="help-block">Please specify the route from the study text </span></em></div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"><label class="col-md-4 control-label" for="radios">5. Was post-operative analgesia administered?</label> <div class="col-md-4"><label class="radio-inline" for="radios-0"> <input type="radio" name="radios" id="radios-0" value="1" checked="checked" /> Yes </label> <label class="radio-inline" for="radios-1"> <input type="radio" name="radios" id="radios-1" value="2" /> No </label> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label> <em><span class="help-block">Were painkillers given post surgery </span></em></div> </div> <!-- Text input--> <div class="form-group"><label class="col-md-4 control-label" for="textinput">5a. If yes, What analgesic drug was used?</label> <div class="col-md-4"><input id="textinput" name="textinput" type="text" placeholder=" " class="form-control input-md" /> <em><span class="help-block">Please specify the substance from the study text </span></em></div> </div> <!-- Textarea --> <div class="form-group"><label class="col-md-4 control-label" for="textarea">5b. If yes, What dosage given for the painkiller?</label> <div class="col-md-4"><textarea class="form-control" id="textarea" name="textarea">in mg/KG BW</textarea> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label></div> </div> <!-- Text input--> <div class="form-group"><label class="col-md-4 control-label" for="textinput">5c. If yes, How many times was the analgesic drug administered?</label> <div class="col-md-4"><input id="textinput" name="textinput" type="text" placeholder=" " class="form-control input-md" /> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label></div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"><label class="col-md-4 control-label" for="radios">5d. If yes, Which drug application route was used?</label> <div class="col-md-4"><label class="radio-inline" for="radios-0"> <input type="radio" name="radios" id="radios-0" value="1" checked="checked" /> i.p. </label> <label class="radio-inline" for="radios-1"> <input type="radio" name="radios" id="radios-1" value="2" /> i.v. </label> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> s.c. </label> <label class="radio-inline" for="radios-3"> <input type="radio" name="radios" id="radios-3" value="4" /> i.t. </label> <label class="radio-inline" for="radios-4"> <input type="radio" name="radios" id="radios-4" value="5" /> Others </label></div> </div> <!-- Text input--> <div class="form-group"><label class="col-md-4 control-label" for="textinput">5e. If others, please specify the route from the study text</label> <div class="col-md-4"><input id="textinput" name="textinput" type="text" placeholder=" " class="form-control input-md" /> <em><span class="help-block">Please specify the route from the study text </span></em></div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"><label class="col-md-4 control-label" for="radios">6. Was perioperative antibiotica administered?</label> <div class="col-md-4"><label class="radio-inline" for="radios-0"> <input type="radio" name="radios" id="radios-0" value="1" checked="checked" /> Yes </label> <label class="radio-inline" for="radios-1"> <input type="radio" name="radios" id="radios-1" value="2" /> No </label> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label> <em><span class="help-block">Were antibiotica given during or immediately post surgery </span></em></div> </div> <!-- Text input--> <div class="form-group"><label class="col-md-4 control-label" for="textinput">6a. If yes, What antibiotica was used?</label> <div class="col-md-4"><input id="textinput" name="textinput" type="text" placeholder=" " class="form-control input-md" /> <em><span class="help-block">Please specify the anitbiotica from the study text </span></em></div> </div> <!-- Textarea --> <div class="form-group"><label class="col-md-4 control-label" for="textarea">6b. If yes, What dosage given for the anitbiotica?</label> <div class="col-md-4"><textarea class="form-control" id="textarea" name="textarea">in mg/KG BW</textarea> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label></div> </div> <!-- Text input--> <div class="form-group"><label class="col-md-4 control-label" for="textinput">6c. If yes, How many times was the antibiotica administered?</label> <div class="col-md-4"><input id="textinput" name="textinput" type="text" placeholder=" " class="form-control input-md" /> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label></div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"><label class="col-md-4 control-label" for="radios">6d. If yes, Which application route was used?</label> <div class="col-md-4"><label class="radio-inline" for="radios-0"> <input type="radio" name="radios" id="radios-0" value="1" checked="checked" /> i.p. </label> <label class="radio-inline" for="radios-1"> <input type="radio" name="radios" id="radios-1" value="2" /> i.v. </label> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> s.c. </label> <label class="radio-inline" for="radios-3"> <input type="radio" name="radios" id="radios-3" value="4" /> i.t. </label> <label class="radio-inline" for="radios-4"> <input type="radio" name="radios" id="radios-4" value="5" /> Others </label></div> </div> <!-- Text input--> <div class="form-group"><label class="col-md-4 control-label" for="textinput">6e. If others, please specify the route from the study text</label> <div class="col-md-4"><input id="textinput" name="textinput" type="text" placeholder=" " class="form-control input-md" /> <em><span class="help-block">Please specify the route from the study text </span></em></div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"><label class="col-md-4 control-label" for="radios">7. Did they specify how many ligations were made in the CCI model?</label> <div class="col-md-4"><label class="radio-inline" for="radios-0"> <input type="radio" name="radios" id="radios-0" value="1" checked="checked" /> Yes </label> <label class="radio-inline" for="radios-1"> <input type="radio" name="radios" id="radios-1" value="2" /> No </label> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label> <em><span class="help-block">The number does not matter. </span></em></div> </div> <!-- Text input--> <div class="form-group"><label class="col-md-4 control-label" for="textinput">7a. If yes, How many ligatures were added to the CCI model?</label> <div class="col-md-4"><input id="textinput" name="textinput" type="text" placeholder=" " class="form-control input-md" /> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label></div> </div> <!-- Text input--> <div class="form-group"><label class="col-md-4 control-label" for="textinput">7b. If yes, What material was used for the ligatures?</label> <div class="col-md-4"><input id="textinput" name="textinput" type="text" placeholder=" " class="form-control input-md" /> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label></div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"><label class="col-md-4 control-label" for="radios">8. Was the model duration reported?</label> <div class="col-md-4"><label class="radio-inline" for="radios-0"> <input type="radio" name="radios" id="radios-0" value="1" checked="checked" /> Yes </label> <label class="radio-inline" for="radios-1"> <input type="radio" name="radios" id="radios-1" value="2" /> No </label> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label></div> </div> <!-- Textarea --> <div class="form-group"><label class="col-md-4 control-label" for="textarea">8a. If yes, What was the model duration</label> <div class="col-md-4"><textarea class="form-control" id="textarea" name="textarea">Give the time in hours from model induction to end of experiment/euthanasia </textarea></div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"><label class="col-md-4 control-label" for="radios">9. Was the the skin incision dimension described in cm?</label> <div class="col-md-4"><label class="radio-inline" for="radios-0"> <input type="radio" name="radios" id="radios-0" value="1" checked="checked" /> Yes </label> <label class="radio-inline" for="radios-1"> <input type="radio" name="radios" id="radios-1" value="2" /> No </label> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label></div> </div> <!-- Textarea --> <div class="form-group"><label class="col-md-4 control-label" for="textarea">9a. If yes, How long was the skin incision in cm?</label> <div class="col-md-4"><textarea class="form-control" id="textarea" name="textarea">in cm</textarea> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label></div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"><label class="col-md-4 control-label" for="radios">10. Was the tissue closure procedure described?</label> <div class="col-md-4"><label class="radio-inline" for="radios-0"> <input type="radio" name="radios" id="radios-0" value="1" checked="checked" /> Yes </label> <label class="radio-inline" for="radios-1"> <input type="radio" name="radios" id="radios-1" value="2" /> No </label> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label></div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"><label class="col-md-4 control-label" for="radios">10a. If yes, Was the muscular layer closed?</label> <div class="col-md-4"><label class="radio-inline" for="radios-0"> <input type="radio" name="radios" id="radios-0" value="1" checked="checked" /> Yes </label> <label class="radio-inline" for="radios-1"> <input type="radio" name="radios" id="radios-1" value="2" /> No </label> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label></div> </div> <!-- Select Basic --> <div class="form-group"><label class="col-md-4 control-label" for="selectbasic">10ai. If yes, what suture material was used to close the muscle layer? </label> <div class="col-md-4"><select id="selectbasic" name="selectbasic" class="form-control"> <option value="1">Resorbable suture</option> <option value="2">Non-absorbable suture</option> <option value="3">Others</option> </select><em><span class="help-block"> </span></em></div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"><label class="col-md-4 control-label" for="radios">10b. If yes, Was the skin layer closed?</label> <div class="col-md-4"><label class="radio-inline" for="radios-0"> <input type="radio" name="radios" id="radios-0" value="1" checked="checked" /> Yes </label> <label class="radio-inline" for="radios-1"> <input type="radio" name="radios" id="radios-1" value="2" /> No </label> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label></div> </div> <!-- Select Basic --> <div class="form-group"><label class="col-md-4 control-label" for="selectbasic">10bi. If yes, what suture material was used to close the muscle layer? </label> <div class="col-md-4"><select id="selectbasic" name="selectbasic" class="form-control"> <option value="1">Resorbable suture</option> <option value="2">Non-absorbable suture</option> <option value="3">Tissue glue</option> <option value="4">Staples</option> <option value="5">Others</option> </select><em><span class="help-block"> </span></em></div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"><label class="col-md-4 control-label" for="radios">11. Were the skin sutures removed?</label> <div class="col-md-4"><label class="radio-inline" for="radios-0"> <input type="radio" name="radios" id="radios-0" value="1" checked="checked" /> Yes </label> <label class="radio-inline" for="radios-1"> <input type="radio" name="radios" id="radios-1" value="2" /> No </label> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label></div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"><label class="col-md-4 control-label" for="radios">11a. If yes, Were an anaesthic preformed?</label> <div class="col-md-4"><label class="radio-inline" for="radios-0"> <input type="radio" name="radios" id="radios-0" value="1" checked="checked" /> Yes </label> <label class="radio-inline" for="radios-1"> <input type="radio" name="radios" id="radios-1" value="2" /> No </label> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label></div> </div> <!-- Textarea --> <div class="form-group"><label class="col-md-4 control-label" for="textarea">11b. If yes, On what postoperative day were the sutures removed??</label> <div class="col-md-4"><textarea class="form-control" id="textarea" name="textarea">in days</textarea> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label></div> </div> <!-- Textarea --> <div class="form-group"><label class="col-md-4 control-label" for="textarea">12. What was the operative experience of the surgeon?</label> <div class="col-md-4"><textarea class="form-control" id="textarea" name="textarea">in months</textarea> <label class="radio-inline" for="radios-2"> <input type="radio" name="radios" id="radios-2" value="3" /> Not reported </label></div> </div>