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Maddocks and Cases: Australian rules football players buy discount glucotrol xl 10 mg online diabete 500, sports 5 days Prognostic factors: concussion and Phase I cohort: Headache and nausea had Saling 1996 concussion (n=10) preinjury test scores (for cases) resolved at 5 days but cases had mild Controls: age and education matched umpires Outcomes: symptoms and cognitive deficits generic 10 mg glucotrol xl with amex qigong diabetes type 1. Summary of studies of cognitive effects of mild traumatic brain injury (continued) Authors Setting and subjects Follow-up Prognostic factors/outcomes Design and findings Matser et al order 600 mg trileptal. Players None Prognostic factors: number of Cross-sectional: Number of headers was had median 500 headers (10th percentile=70; headers, concussions, adjusted associated with deficits in focused attention 90th percentile=1,260) in a season and a median for age, education, alcohol, and visual/verbal memory, number of soccer- of 1 concussion (90th percentile was 12) during history of general anesthesia, related concussions associated with deficits career (n=84) nonsoccer concussions in sustained attention and visuoperceptual Outcomes: cognitive tests processing. Slowed disturbance of vision or equilibrium (n=23) duration of symptoms and Digit Digit Substitution Test at 15 minutes; 43% Symbol Substitution Test returned to play same day and all returned within 2 weeks. At 3 months, symptoms had (n=136) Outcomes: cognitive and resolved in most and no differences in Controls: minor other injuries not requiring surgery behavioral or psychological cognitive functioning. Factors associated with delayed recovery/poor outcome Indicator Representative reference(s) Comment Increased age at injury Dikmen et al. Selected polymorphic alleles McAllister (2005, 2008; Chapter 3, Genetic Several large ongoing studies should shed further light (e. Expectation of poor outcome or severity of (2007) complications associated with poor recovery. How- pears to play a role in terms of both symptoms and neu- ever, if one defines poor outcome in terms of performance ropsychological function (Dikmen et al. Furthermore, it seems that Limiting conclusions from most of these studies is the fact novel or more difficult cognitive tasks, or tasks performed that preinjury baseline data are typically not available and under mild degrees of physiological stress, can negatively thus the most definitive data, change scores, are not avail- influence the performance of patients with mild injury able. It is possible that specific ge- effort on preseason testing so as to minimize any apparent netic profiles contribute to response to neurotrauma and effects of a concussion during the season. Perhaps more cognitive outcomes (see Chapter 3, Genetic Factors, in this important, given the large number of individuals who do volume; see also McAllister et al. A theme in the literature is that compensation seeking 2006), one does not really know what the denominator is. Some of the studies on Certain factors appear to predict a poorer prognosis this topic are drawn from largely medicolegal referral (see Table 15–6). The presence of For example, Rutherford (1989) reported on a series of pa- psychiatric conditions (Mooney and Speed 2001; Mooney tients with mild brain injury involved in litigation. Approximately one- count for much of the distress in individuals who also suf- third of those who had symptoms at that time did not have 252 Textbook of Traumatic Brain Injury symptoms at the time of settlement approximately 1 year norms obtained from populations with known severe neu- later, and virtually all of the patients who were symptom- rological disorders, suggest a negative response bias (Iver- atic at the time of settlement remained symptomatic 1 year son and Binder 2000; Meyers et al. Litigation and com- parent poor effort or negative response bias on tests of pensation proceedings are frequently highly adversarial, cognitive function, and malingering should not be imme- prolonged ordeals, and it would be naive to expect that diately assumed. Inconsistent performance must be inter- this kind of psychosocial stress would not affect symptom preted within the context of such factors as fatigue, medi- presentation. Unfortunately, many seem recovery, along with regular monitoring of clinical status, to conclude from these associations that the interest in be- can reduce symptoms after injury (Minderhoud et al. Related to this, some have suggested that the Other motivational factors may also play a role in func- expectation of symptoms might play a role in outcome tional level and cognitive performance.

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Rashes unrelated to pregnancy cheap glucotrol xl uk diabetes symptoms early, such Other conditions as eczema purchase glucotrol xl from india diabetic recipes, psoriasis order nitrofurantoin in india, and lichenoid skin disease, are Lower urinary tract infection usually presents with discussed in Itching in pregnancy and Vulval itching. However these symptoms are less prominent in Rashes directly related to the pregnancy. However, once familiar with the condi- mester is common, and therefore the diagnosis is tions (and once seen, they are rarely forgotten), the usually made by routine dipstick of a urine sample nomenclature and its potential confusion become that shows proteinuria. Apart from impetigo herpetiformis, they urine would then confrm a urinary tract infection are all pruritic, and it is the itching rather than the with the growth of 105 organisms per mL of urine. Clinical examination usually fails to elicit tender- ness over the symphysis pubis. Tere is no abnor- Polymorphic eruption of pregnancy mality of gait, and abduction of the thigh is normal. Tis intensely itchy condition is thought to be asso- Rapid symptomatic relief is obtained with appropri- ciated with the exposure of skin antigens from the ate antibiotic therapy. Hence it is commoner in the third trimester, multiple pregnan- References cies, and polyhydramnios. Symphysis appears as urticated (nettle-rash-like) lesions in pubis dysfunction: a cause of signifcant stretch marks and spares the umbilicus (Fig. J Matern Fetal Neonatal Med reassurance that the condition is unlikely to recur in 2004; 16(6): 349–54. Symphysis pubic dysfunction: a practical Pemphigoid gestationalis approach to management. Obstetrician and Pemphigoid gestationalis, also known (unhelpfully) Gynaecologist 2006; 8: 153–58. Characteristically, unlike Useful website any other pregnancy-related rash, there are true fu- id-flled blisters, as the pathophysiology is immu- www. It is intensely itchy, may afect the periumbilical skin, and may appear in the second and third trimester. Unfortunately, even though delivery is curative, the child may be born with a similar rash, although this is very rarely dangerous. The mother’s rash may per- sist for several weeks, and the condition typically recurs in subsequent pregnancies. Treatment is with systemic steroids – the lowest dose to suppress the condition with treatment of itch. Box 1 Management of itching in pregnancy Emollients (into the bath or on to the skin) ● bath additives containing lauromacro- gols (e. Aveeno®) may be additionally antipruritic ● topical emollients range from creamy (e. Try to keep to the lowest strength possible (usually clobetasone or betamethasone 0. In fact, the condition looks like, and is fre- quently mistaken for, eczema (excoriations, papules and redness, ofen over the extensors) and scabies.

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