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The Golgi tendon organ functions as a protective sensory mechanism to detect and inhibit subsequently undue strain within the muscle-tendon structure. Describe the adaptations in muscle structure with progressive resistance exercises. The major adaptation is an increase in the cross-sectional area of muscle, which is termed hypertrophy. Progressive resistive exercise involves 10 repetitions a day at 60% to 90% of maximal capacity; this results in an increase in strength by 0. There are increases in the amounts of transverse tubular and sarcoplasmic reticulum membranes as well. There are neural adaptations, which result in an increased ability to recruit high-threshold motor units. The functional significance of the morphologic change is primarily a greater capacity for strength and power development. Endurance exercise has minimal impact on the cross-sectional area of muscle and muscle fibers. The smaller cross-sectional area allows better diffusion of metabolites and nutrients between the contractile filaments and the cytoplasm and between the cytoplasm and the interstitial fluid. The number of capillaries increases around each fiber, and there is an increase in mitochondria, especially in the type I fibers. The more extensive capillary bed improves the delivery of oxygen and circulating energy sources to the fibers, whereas the products of muscle activity are removed more efficiently. The functional significance of these changes is observed during sustained exercise, in which there is a delay in the onset of fatigue. What physiologic adaptations occur if muscles are immobilized in a shortened position? List the changes that result from muscles being immobilized in a shortened position. Does muscle splitting occur, or can there be an increase in the number of cells (hyperplasia)? Individual fiber splitting may occur in specific pathologic conditions, such as neuromuscular diseases. This form of skeletal muscle atrophy is systemic and associated with metabolic and/or inflammatory factors. Apoptosis, or programmed cell death, is a regulated physiologic process critical to cellular homeostasis, which can become dysregulated,leading to disease states including muscle disease or dysfunction. Necrosis is a pathologic process caused by the progressive degradative action of enzymes that is generally associated with severe cellular trauma in muscles, leading to cell death. Before starting an exercise program, the warming-up period can have several beneficial effects. Q10 is the ratio of the rate of a physiologic process at a particular temperature to the rate at a temperature 10° C lower, when the logarithm of the rate is an approximately linear function of temperature.

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Purpose: to provide guidance for the treatment of patients with Clostridium difficile infection within Stanford Health Care. These criteria are most useful for diagnosis in the absence of obvious alternative explanations such as laxative use or recent initiation of enteral feedings. Abdominal distension and severe pain after a period of diarrhea without current stool output may be a rare finding if ileus or toxic megacolon is present. No use of laxatives (excluding docusate) within the past 48 hours or recent initiation of enteral feedings. Recent studies, including on-going projects at Stanford, have also shown that patients who are positive for C. Stage of Disease: After the diagnosis is made, it is important to stage the disease to guide treatment by both severity (ranging from non-severe to fulminant) and symptom recurrence (first recurrence to multiply recurrent). Non-Severe: Diarrhea present, systemic inflammatory response as assessed by other symptoms. Severe: Diarrhea plus systemic inflammatory response as assessed by other symptoms. Multiply Recurrent: ≥2 recurrences of disease following the initial episode with each distinct episode meeting the diagnostic criteria above. Treatment In addition to the below recommendations, unnecessary antimicrobial agents and proton pump inhibitors should be discontinued. Stanford Antimicrobial Safety and Sustainability Program Revision date 09/2018 o Note median time to symptom resolution is 5-6 days. If symptoms resolve within 7 days, 10 days of metronidazole therapy is sufficient; if ≥7 days are required for resolution, 14 days may be preferred (do not use for more than 14 days due to potential neurotoxicity). Severe Disease Likely requires hospitalization for proper management, should also consider serial abdominal X rays if abdominal distension or significant tenderness are present. Small studies had previously suggested efficacy of tigecycline,46,47 though more recent retrospective analyses did not show significant benefit. Recommend against fidaxomicin use in this setting due to risk of ileus and delayed absorption. Serum lactate may serve as a marker for severity, with operation suggested before lactate exceeds 5. Multiple studies suggest improved outcomes with early surgical intervention in fulminant colitis. Recurrent Disease 1) First Recurrence of Disease Recommended Therapy: treatment is dependent on severity and prior therapy. The total course of oral vancomycin should be at least 10 days, though completion of a vancomycin taper after initial stabilizing therapy may be more appropriate.

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Most patients presented with risk factors for biliary stasis and biliary sludge. A trigger or co-factor role of ceftriaxone related biliary precipitation cannot be discounted. Safety and effectiveness of ceftriaxone in neonates, infants and children have been established for the dosages described in section 4. In vitro studies have shown that ceftriaxone, like some other cephalosporins, can displace bilirubin from serum albumin. Caution should be exercised when considering ceftriaxone for hyperbilirubinaemic neonates, especially prematures. Ceftriaxone should not be used in neonates (especially prematures) at risk of developing bilirubin encephalopathy. Page 6 of 15 There is no evidence that ceftriaxone increases renal toxicity of aminoglycosides. No effect similar to that of disulfiram has been demonstrated after ingestion of alcohol subsequent to the administration of ceftriaxone. Ceftriaxone does not contain an N-methylthiotetrazole moiety associated with possible ethanol intolerance and bleeding problems of certain other cephalosporins. In an in vitro study antagonistic effects have been observed with the combination of chloramphenicol and ceftriaxone. In patients treated with ceftriaxone the Coombs’ test may rarely become false-positive. Ceftriaxone, like other antibiotics, may result in false-positive tests for galactosaemia. Nonenzymatic methods for the glucose determination in urine may give false-positive results. For this reason, urine-glucose determination during therapy with ceftriaxone should be done enzymatically. Reproductive toxicity studies have been performed in mice and rats at doses up to 20 times the human dose of 2 g/d (586 mg/kg/d in rats), and have not shown evidence of embryotoxocity, foetotoxicity, teratogenicity or adverse effects on male or female fertility, birth or peri and postnatal development. In primates, no embryotoxicity or teratogenicity was demonstrated at a dose approximately 3 times the human dose (84 mg/kg/d in monkeys). Breast-feeding As ceftriaxone is secreted in the breast milk at low concentrations, caution is advised in nursing mothers. During the use of ceftriaxone, the following side effects, which were reversible either spontaneously or after withdrawal of the medicine, have been observed: Page 7 of 15 Systemic side effects Gastrointestinal complaints (about 2% of cases): loose stools or diarrhoea, nausea, vomiting, stomatitis and glossitis. Haematological changes (about 2%): eosinophilia, leukopenia, granulocytopenia, haemolytic anaemia, thrombocytopenia. Skin reactions (about 1%): exanthema, allergic dermatitis, pruritus, urticaria, oedema, erythema multiforme. Other, rare side effects: headache and dizziness, increase in liver enzymes, jaundice and hepatitis, symptomatic precipitation of the calcium salt of ceftriaxone in the gallbladder, oliguria, increase in serum creatinine, mycosis of the genital tract, shivering and anaphylactic or anaphylactoid reactions and secondary infection.

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Retesting to detect therapeutic failure (tests of cure) for patients who receive recommended treatment regimens for Neisseria gonorrhoeae or C trachomatis infection is not recommended unless therapeutic adherence is in question or symptoms persist. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Repeat testing is recommended for these infections within 3 months because of the likelihood of reinfection as a result of nontreatment of a current sexual partner and/or new infection from a new sexual partner. Therefore, tests that allow for isolation of the organism and have the highest specifcities must be used. Specimens for culture to screen for N gonorrhoeae and C trachomatis should be obtained from the rectum and vagina of girls and from the rectum and urethra of boys. Specimens for culture to screen for N gonorrhoeae also should be obtained from the pharynx, even in the absence of symptoms. Culture and nucleic acid hybridization tests require female endocervical or male urethral swab specimens. Endocervical specimens for culture are not required for prepubertal girls but are required for culture of C trachomatis and N gonorrhoeae if the female is pubertal or postmenarcheal. If vaginal discharge is present, specimens for wet mount for Trichomonas vaginalis and wet mount or Gram stain for bacterial vaginosis may be obtained as well. Completion of the hepatitis B immu nization series should be documented, or the patient should be screened for hepatitis B surface antibody. Anogenital gonorrhea in a prepubertal child indicates sexual abuse in virtually every case. All confrmed cases of gonorrhea in prepubertal children beyond the neonatal period should be reported to the local child protective services agency for investigation. In an infant or toddler in diapers, genital herpes may arise from any of these mechanisms. In a prepubertal child whose toilet-use activities are independent, the new occurrence of genital herpes should prompt a careful investigation, including a child protective services investigation, for suspected sexual abuse. In a perinatally infected infant, vaginal discharge can persist for several weeks; accordingly, intense social investigation may not be warranted. However, a new diagnosis of trichomoniasis in an older infant or child should prompt a careful investigation, including a child protective services investigation, for suspected sexual abuse. Although hepatitis B virus, scabies, and pediculosis pubis may be transmitted sexually, other modes of transmission can occur. The discovery of any of these conditions in a pre pubertal child does not warrant child protective services involvement unless the clinician fnds other information that suggests abuse.

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