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Given that both force and time components are relevant to medicine 2015 discount 5mg dulcolax maximizing power medications prescribed for pain are termed buy dulcolax, training to symptoms emphysema order dulcolax 5mg overnight delivery increase muscle power requires two general loading strategies. First, heavy resistance training recruits high-threshold fast-twitch muscle fibers that are necessary for strength. When performing explosive weight-training exercises, the athlete moves as fast as possible throughout the range of motion, resulting in losing contact with the ground in an explosive squat or losing contact with the bar in a bench press. Aging causes a loss of functional capacity resulting from a decrease in muscle mass (sarcopenia). By the seventh decade of life, some muscles may have only half the number of motor units and 75% of the total number of fibers compared with muscles of young adults. Several studies have determined that strength improvements in the elderly are coupled with cellular and whole muscle hypertrophy. The greater the intensity of activity the patient wants to return to, the greater the intensity the rehabilitation or training, or both, should be. Eccentric actions are characterized by an ability to achieve high muscle forces and an enhancement of the tissue Chapter 13 Strength Training Concepts in the Athlete damage that is often associated with muscle soreness, and perhaps require unique control strategies. A common human movement strategy is to combine concentric and eccentric actions into a sequence called the stretch-shorten cycle. Under electron microscope it has been shown that sarcomeres will become out of register and extended, and z-line streaming is evident, along with a regional disorganization of the myofilaments and t-tubule damage. When one performs an eccentric bout of exercise, a repeated bout effect adaptation will protect the muscle against further damage from subsequent eccentric bouts. Recently the adaptations have been broken down into three categories: cellular, mechanical, and neural. On the neural level there is still discussion whether adaptation is on the central or local level. Research shows that with a high enough velocity, there is cross education to the contralateral limb, which means there is definitely a central connection. With eccentric strengthening and adaptations, there are increases in strength, cross-sectional areas, and neural activation. This seems to depend on whether there is actually a muscle spindle injury (increase flexed position) or if there is just sarcomere disruption (decreased flexed position) and the former happening with high-intensity strengthening. When a muscle can overcome an opposing force and shorten while being activated, this is called a concentric contraction. When the force generated is equal to the opposing force and there is no movement, this is called an isometric contraction. Typically, eccentric contractions can generate two to three times more force than concentric contractions. Many studies show an increase, decrease, or no change in functional performance, concentric strength, and eccentric strength after eccentric training. The degree of that strength gain is relative to the volume/intensity and velocity of the eccentric exercise. In the majority of the studies the load used was appropriate to induce failure in the muscle. The actual volume does vary, but there is a study that supports the use of low-volume eccentric exercise. Other research has shown that to get the greatest hypertrophy and strength gains, one must work eccentrically 180 degrees per second over the range. Differences also seem to occur in relation to eccentric strength across genders and lifespan. Lindle et al79 found that concentric peak torque decreased more with age than did eccentric peak torque for both men and women. In another study they found that women tended to better preserve muscle quality with age for eccentric peak torque. Most athletes use a combination of eccentric, concentric, and isometric contractions. Because of the need to control a load when returning it to the starting position, most strengthening studies have used a combination of eccentric and concentric actions. As previously noted, the stretch shorten cycle is initiated by an eccentric action followed by a concentric contraction, while an 228 Sports-Specific Rehabilitation current research, it is known that in order to train an athlete for eccentric movements, they must perform eccentric movements. In the definition of a stretch-shorten cycle, an eccentric contraction is a low-amplitude and moderate- to high-velocity contraction. Eccentric isotonic training must produce forces two to three times greater than their concentric counterparts to have the proper intensity.
A bottom-up approach from educated communities with adequate support from reliable government and national institutions will be key for sustainable interventions medicine zofran buy generic dulcolax on line. Building Links with Community and Local Health Facilities Primary care services need to treatment tmj 5mg dulcolax amex be well linked with the community medicine sans frontiers purchase dulcolax online pills, and effective communication must be present along with feedback mechanisms so that community concerns may be conveyed to higher authorities. We have developed an evidence-driven framework based on a continuum of care model for reproductive, maternal, neonatal, and child health (figure 14. Community-Based Care to Improve Maternal, Newborn, and Child Health 275 as successfully reaching communities and providing the best possible interventions. Unless these two elements can work together effectively, neither can benefit from the available resources and Figure 14. Community mobilization, home visitation, social marketing, community intervention packages, and community-based programs can be the bridge between these two levels. Once the links are firmly established, the health care system can gain substantially from the resources and support provided by national and local governments and nongovernmental organizations. The introduction of community-based interventions requires personnel, resources, training, management, and infrastructure. A similar finding is noted in a review of the cost-effectiveness of lay health workers delivering vaccines (Corluka and others 2009). Scaling up the intervention from 2011 to 2020 was considered cost-effective at Figure 14. The main cost drivers relate to the intensity of the intervention and the numbers covered. Even in cases in which intensive resources are required, the cost per capita can be quite low. It is important to support routine implementation research while programs are being implemented and to identify hurdles and review and revise programs as necessary. Even with the expansion of health care systems, resources may be limited or facilities may be inaccessible to increasing segments of the population. Maternal, neonatal, and child mortality and morbidity continue to be persistent challenges, particularly in rural areas. Issues of cultural barriers, political instability, poverty, and poor educational systems contribute to ill health. Improving reproductive, maternal, newborn, and child health requires successful community engagement. A combination of efforts is required to mobilize communities to take charge of their own needs, as well as to provide outreach activities to bring care to communities. The integration of community care subsystems into the primary care health system will have wide-ranging effects on the sustainability, effectiveness, and longevity of community health systems, bringing all closer to achieving the Millennium Development Goals. Yet numerous research gaps exist that, if studied, could have a significant impact on the delivery of health care. The studies available for review are mostly program evaluations without comprehensive and high-quality study designs. Additional Information on the Effect of Select Community-Based Interventions on Neonatal Health Indicators. Disease Control Priorities (third edition): Volume 8, Child and Adolescent Development. Family Health Division, Department of Health Services, Ministry of Health, Government of Nepal. These editions also provided justification, including by calculating cost-effectiveness ratios, for prioritizing the particular interventions (Jamison and others 1993; Jamison and others 2006). There was, however, little discussion of which service delivery platforms could be used to deliver the prioritized health care services. We discuss different ways of organizing service delivery, including innovative approaches and their impacts on the quality of services delivered. We examine coverage gaps and efforts to boost coverage, and we describe innovations to improve quality. Although evidence exists regarding the benefits of increasing coverage with innovative methods, little support is available on the effects of this increased coverage on quality. This paucity of data is due partly to a lack of an agreed-upon methodological framework, as well as to the poor quality of studies that do attempt to evaluate the innovative interventions. For women, these indicators are the percentage of births being attended by skilled health staff and the percentage of pregnant women receiving antenatal care. For women, this is the percentage of married or in-union women ages 1549 years having an unmet need for contraception.
Simple refeeding can lead to medicine 50 years ago buy dulcolax 5 mg cheap high rates of mortality medications known to cause pancreatitis generic dulcolax 5 mg without a prescription, and cases can be especially difficult to symptoms 6 days post embryo transfer buy cheap dulcolax on line manage if additional medical complications are present (discussed further under "Treatment of Severe Acute Malnutrition"). Specific guidelines, supported by available evidence and expertise, have been developed for managing these cases and are discussed later in this chapter. Malnutrition has serious physiological consequences, including reductive adaptation, marked immunosuppression, and concurrent infection (Collins, Dent, and others 2006). The relationship between malnutrition and infection is often described as a vicious cycle that begins with infections, especially diarrhea, and progresses to undernourishment. The undernourishment, in turn, increases the risk of prolonged illness and the susceptibility to additional infection. Disease prevention strategies are important in breaking the infection-malnutrition cycle, particularly related to diarrhea and repeated respiratory infections (Bhutta, Das, Walker and others 2013). The evidence on effective approaches to preventing malnutrition focuses on stunting and underweight as outcomes and may not be completely transferrable to prevention of wasting. However, an integrated approach to optimizing healthy growth in infants and children can have an important impact on reducing rates of wasting. Therapeutic Foods for Preventing and Treating Acute Malnutrition Treatment approaches are discussed in detail in subsequent sections; here we introduce some of the commonly used specially formulated therapeutic foods. F75 is given in the stabilization phase of inpatient treatment; children are provided with approximately 80100 kilocalories per kilogram per day (kcal/kg/d) spread over 812 meals per day for three to seven days. These products are more nutrient dense than available home foods and do not require preparation; they typically have very low moisture content and are resistant to microbes. The nutrient composition of some common formulated foods for treatment and prevention of acute malnutrition are shown in table 11. Therapeutic foods are often a significant program cost and could be less expensive to produce in-country. Research is ongoing with respect to the treatment effectiveness and cost-effectiveness of alternate formulations. In general, because wasting results in a loss of body mass relative to height, the standard practice has been to provide the child with additional energy and nutrient-dense foods to promote weight gain. The selection of the particular management approach is context specific; different approaches are warranted for populations that are more stable and food secure than for populations experiencing significant food insecurity or humanitarian emergencies. These strategies include the promotion of appropriate breastfeeding and complementary feeding practices, access to appropriate health care for the prevention and treatment of disease, and improved sanitation and hygiene practices. Additionally, although micronutrient deficiencies are most commonly linked to stunted linear growth, these deficiencies can also contribute to wasting, for example, through the malnutrition-infection cycle. Undernourished children Strategies for Treatment Research is ongoing with respect to optimal treatment approaches. In situations of food shortage, supplementary foods have been supplied with suboptimal effectiveness. Food-Secure Populations In food-secure populations, caregivers can be counseled and supported in using high-quality, home-available foods to promote recovery in acutely malnourished children (Bhutta, Das, Rizvi, and others 2013). Two systematic reviews (Lazzerini, Rupert, and Pani 2013; Lenters and others 2013) find no significant differences in mortality between the provision of any type of specially formulated food and standard care, which consists of medical care and counseling without food provision. Children provided with food were significantly more likely to recover, based on two studies in the meta-analysis 210 Reproductive, Maternal, Newborn, and Child Health (Lazzerini, Rupert, and Pani 2013). This systematic review could not identify any trials investigating the effect of improving the adequacy of local diets. However, because this study assessed nutritional status using weight-for-age, children who were not wasted may have been included in the study. The authors conclude that messages tended to be vague and were unlikely to be effective. However, this review does not contain a meta-analysis; the studies included are a mix of quasi-experimental and observational data and employ a variety of indices to measure malnutrition. A blanket approach provides supplemental food to everyone within a defined population, regardless of whether children are acutely malnourished; a targeted approach provides supplemental rations only for malnourished children meeting program cut-off criteria. These findings are echoed in the systematic review conducted by Lenters and others (2013) as part of the Lancet series on maternal and child nutrition, as well as in a review conducted by the Food Aid Quality Review group (Webb and others 2011). Livelihood diversification, social protection schemes, and conditional cash transfers are some of the approaches being explored in these contexts (Bhutta, Das, Rizvi, and others 2013). Fewer children in the target locality presented in need of therapeutic care than in previous years; however, it was not possible to rule out overall improvements in food security in the absence of a comparison group in the study. The intervention led to Management of Severe and Moderate Acute Malnutrition in Children 211 an estimated 36 percent difference in the incidence of wasting and a 58 percent difference in the incidence of severe wasting (Isanaka and others 2009).
Offering support to symptoms rheumatic fever cheap dulcolax 5mg otc as wide a range of smokers as possible is likely the best approach to medications blood donation buy dulcolax 5mg on line increase quit attempts and successful quitting treatment herniated disc order discount dulcolax on line. However, more research is needed on such an approach, including unintended consequences. For example, offering widespread support could reduce cost-effectiveness, as interventions could be given to more numbers of smokers who are not ready and, as a result, would not quit. Considerations for Subpopulations As the prevalence of cigarette smoking in the general U. In some cases, certain populations or conditions may warrant specific cessation interventions and/or lack an indication for or have certain considerations or contraindications related to cessation medication. This section outlines the evidence and considerations for cessation interventions across specific populations and/or conditions for which existing interventions are not indicated and/or are less effective. Rates of smoking during pregnancy are higher among younger women, women with lower levels of education, economically disadvantaged women, and women who have not planned their pregnancy (Mosher et al. Pregnant women and women of reproductive age who smoke are also more likely to live in low-resource environments that potentially subject them to high levels of stress (Coleman-Cowger et al. This context provides important insights into the potential challenges of providing smoking cessation treatment during pregnancy. The Clinical Practice Guideline concluded that there was insufficient evidence for the effectiveness of smoking cessation medications in pregnant women (Fiore et al. More research is needed before definitive guidance can be provided on this topic (Fiore et al. Furthermore, pregnancy can offer an opportunity to quit smoking because pregnant women are highly motivated to take actions to protect the health of their babies (DiClemente et al. The literature indicates that, among American women who smoked during the 3 months before they became pregnant, about 50% quit during pregnancy (Tong et al. However, rates of postpartum relapse among women who quit smoking during pregnancy may be as high as 50% (Tong et al. Large variations in Interventions for Smoking Cessation and Treatments for Nicotine Dependence 537 A Report of the Surgeon General date (Wisborg et al. Pregnant smokers should be encouraged to attempt cessation using educational and behavioral interventions before using pharmacologic approaches. However, these decisions should be made in consultation with a physician after carefully considering the specific circumstances and weighing the risks of using medication against the risks of continued smoking (Fiore et al. Recent studies have suggested that social support is highly predictive of successful smoking cessation during pregnancy (Smedberg et al. In addition, intervention approaches that address the health of the mother and the health of the fetus may increase long-term abstinence (Flemming et al. Cessation interventions that are more intensive, are tailored, and go beyond advice to quit are more effective in this population (Fiore et al. Quitline counseling may be a useful cessation intervention for pregnant smokers, but more research is needed on the specific features that make this intervention optimally effective. A growing body of evidence suggests that incentives and contingency management techniques (reviewed in detail elsewhere in this chapter) are effective cessation interventions for pregnant women (Higgins et al. The same review concluded that such programs improve abstinence while the incentives remain in place. Despite these promising results, more evidence is needed to fully understand the effectiveness of incentive interventions in producing sustained cessation outcomes in pregnant women who smoke. Although it may be challenging to convince payers to implement incentive interventions on a population scale, they may be more willing to consider doing so in this case, given the high costs of smoking-related adverse birth outcomes and the short-term cost savings associated with preventing these outcomes. In 2015, gay, lesbian, and bisexual adult smokers, as a group, reported a lower prevalence of cessation counseling and/or medication use (14. In addition, transgender adults report higher use of cigarettes and other tobacco products than cisgender persons (people whose gender identity matches the sex they were assigned at birth). Although data are not available on the use of tobacco cessation treatments by transgender adults, as a group they are more likely to postpone general medical care and to report barriers in accessing care, primarily because they encounter discrimination when seeking care and cannot afford care (Grant et al.
The peak power of women (in watts per kilogram of body weight) is similar to medicine world buy dulcolax 5mg amex the mean power of men medications known to cause hair loss discount dulcolax line. The fatigue index does not show a significant sex difference medicine in the civil war purchase dulcolax 5mg amex, indicating that both sexes tire at the same rate. The same factors implicated in the mechanisms for differences between maturing boys and girls operate between adult males and females. The young male adds muscle during maturation under the influence of testosterone, whereas the young female is adding fat under the influence of estrogen. Therefore both absolutely and relatively, the male has greater muscle mass than the female. Both males and females exhibit the same pattern, with the absolute values of females being considerable lower than those of males. In a study of 111 male and 57 female runners from 40 to 70 years of age, the lactate threshold increased from approximately 65% to 75% across the decades. The reason is undoubtedly a combination of caution on the part of researchers and uncertain motivation on the part of subjects when faced with the necessarily high-intensity exercise. What data are available indicate that anaerobic variables show a common aging pattern; that is, there is typically a peak in the second or third decade and then a gradual decline into the sixth decade. Despite this, the elderly can still participate successfully in basically anaerobic activities. One must always remember when interpreting aging results, however, that no one knows how much of the reduction is a direct result of aging, how much is the result of detraining that accompanies the reduced activity level of the elderly, and how much is the result of disease. Mechanical Power and Capacity the average peak power value obtained on a stair climb test declines precipitously over the 20- to 70-year-old age range. In this case peak power represents an instantaneous value rather than a 5-second value. Mean power is still the average of 30 seconds of pedaling but at a controlled rate of 60 rev. The results from this study show a decline of approximately 6% for each decade of age for sedentary individuals of both sexes. However, the absolute values for the females are consistently lower than those for the males. Indeed, in the Makrides et al study the peak power of the females coincides with the mean power of the males. For both sexes lean thigh volume was found to be closely related to peak power and mean power, but it did not account for all the variation in the values or in the decline with age. The decline was greatest (and curvilinear) in the weight lifting tasks that required not only explosive coordinated movements but also high-balance skills. The overall decline in the power lifts was rectilinear and similar in males (-40%) and females (-50%). Accumulation of Lactate On average, resting levels of blood lactate are remarkably consistent across the entire age span, varying only from 1 to 2 mmol. Lactate values during the same absolute submaximal work tend to be higher for individuals older than the age of 50. Between the ages of 30 and 70 years almost 25% of muscle mass is lost in both males and females. A, Average peak power ratings determined from the Margaria-Kalamen stair climb test are higher for males than females across the age span from adolescence to middle adulthood. Males and females show steady and parallel declines in peak power during the adult years. Instantaneous peak power and mean power show rectilinear and parallel declines with age in males and females. Each line was calculated from the experimentally determined equations associated with that line on the graph. American College of Sports Medicine Roundtable: the physiological and health effects of oral creatine supplementation, Med Sci Sports Exerc 32:706-717, 2000. Stallknecht B, Vissing J, Galbo H: Lactate production and clearance in exercise: effects of training. Sahlin K, Fernstrom M, Svensson M, et al: No evidence of an intracellular lactate shuttle in rat skeletal muscle, J Physiol 541:569-574, 2002. Van Praagh E: Development of anaerobic function during childhood and adolescence, Pediatr Exerc Sci 12:150-173, 2000. Bahr R: Excess postexercise oxygen consumption- Magnitude, mechanisms and practical implications, Acta Physiol Scand (Suppl) 32:396-402, 2000.
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