ENVIRONMENTENVIRONMENTALAL

&&

NUTRITIONAL NUTRITIONAL

PATHOLOGYPATHOLOGY

Environmental andEnvironmental andNutritional PathologyNutritional Pathology

Environment and DiseaseEnvironment and Disease Common ExposuresCommon Exposures

EnvironmentalEnvironmental OccupationalOccupational

NutritionNutrition and Diseaseand Disease

Reported Occupational Diseases Reported Occupational Diseases

DiseaseDisease NumbeNumberr

PercentagePercentage

Repeated traumaRepeated trauma 276,60276,6000

6464

Skin disordersSkin disorders 57,90057,900 1313

Lung conditions Lung conditions due to toxic due to toxic exposuresexposures

20,30020,300 55

Physical injuryPhysical injury 16,60016,600 44

PoisoningPoisoning 5,1005,100 11

Lung disease due Lung disease due to duststo dusts

2,9002,900 11

All other illnessesAll other illnesses 50,60050,600 1212

TotalTotal 430,00430,0000

100100

Mechanisms of ToxicityMechanisms of Toxicity Threshold effectThreshold effect Absorption at portals of entryAbsorption at portals of entry

ingestioningestion inhalationinhalation skin contactskin contact

Distribution within the bodyDistribution within the body Metabolism and ExcretionMetabolism and Excretion Toxic effectsToxic effects

Xenobiotic Mechanisms Phase I Reactions (Smooth ER),

makes them less lipophilic by adding a direct polar group Cytochrome P-450-dependent

monooxygenase system Flavin-containing monooxygenase

system Peroxidase-dependent cooxidation

Phase II Reactions, combines them with other polar substances Glucuronidation Biomethylation Glutathione conjugation

Contents of Toxic Waste Dumps

Acetone DDT, DDE, DDD

Aldrin/Dieldrin 1,1 and 1,2-Dichloroethane

Arsenic Lead

Barium Mercury

Benzene Methylene chloride

2-Butanone Nickel

Cadmium Pentachlorophenol

Carbon tetrachloride Polychlorinated biphenyls

Chlordane Tri- and Tetrachloroethylene

Chloroform Toluene

Chromium Vinyl Chloride

Cyanide Zinc

Dose-response Curve Dose-response Curve

CommonCommon ExposuresExposures PersonalPersonal MedicationsMedications Outdoor Air PollutionOutdoor Air Pollution Indoor Air PollutionIndoor Air Pollution Industrial ExposuresIndustrial Exposures Agricultural HazardsAgricultural Hazards Natural ToxinsNatural Toxins Radiation InjuryRadiation Injury Physical InjuryPhysical Injury

TobaccoTobacco 440,000 premature deaths/year in 440,000 premature deaths/year in

USAUSA cancercancer cardiovascular disease cardiovascular disease respiratory diseaserespiratory disease cerebrovascular diseasecerebrovascular disease

$150 billion in health related costs$150 billion in health related costs By far the most preventable cause By far the most preventable cause

of death in the United Statesof death in the United States

Tobacco and Cancer70% of all lung cancers

30% of all cancers

Organ-Specific Carcinogens in Tobacco Smoke

Organ Carcinogen

Lung, larynx Polycyclic aromatic hydrocarbons

4-(Methylnitrosoamino)-1-(3-pyridyl)-1-buta-none (NNK)

Polonium 210

Esophagus N'-Nitrosonornicotine (NNN)

Pancreas NNK (?)

Bladder 4-Aminobiphenyl, 2-naphthylamine

Oral cavity (smoking) Polycyclic aromatic hydrocarbons, NNK, NNN

Oral cavity (snuff) NNK, NNN, polonium 210

Data from Szczesny LB, Holbrook JH: Cigarette smoking. In Rom WH (ed): Environmental and Occupational Medicine, 2nd ed. Boston, Little, Brown, 1992, p. 1211.

Relative Risks for Current Smokers of CigarettesRelative Risks for Current Smokers of Cigarettes

Disease or Condition Males Males Females Females

Coronary heart disease Coronary heart disease

Age 35–64Age 35–64 2.82.8 3.13.1

Age ≥ 65Age ≥ 65 1.51.5 1.61.6

Cerebrovascular lesions Cerebrovascular lesions

Age 35–64Age 35–64 3.33.3 44

Age ≥ 65Age ≥ 65 1.61.6 1.51.5

Aortic aneurysmAortic aneurysm 6.26.2 7.17.1

Chronic airways obstructionChronic airways obstruction 10.610.6 13.113.1

Cancer Cancer

Lip, oral cavity, pharynxLip, oral cavity, pharynx 10.910.9 5.15.1

EsophagusEsophagus 6.86.8 7.87.8

StomachStomach 22 1.41.4

PancreasPancreas 2.32.3 2.32.3

LarynxLarynx 14.614.6 1313

LungLung 23.323.3 12.712.7

Cervix Cervix 1.6 1.6

KidneyKidney 2.72.7 1.31.3

Bladder, other urinary Bladder, other urinary organsorgans

3.33.3 2.22.2

Cigarettes And The WorkplaceCigarettes And The Workplace

Similar to asbestos exposure, Similar to asbestos exposure, cigarette smoke is synergistic with cigarette smoke is synergistic with radon decay products in causing radon decay products in causing lung cancerlung cancer

Cigarette smoke exacerbates Cigarette smoke exacerbates bronchitis, asthma, and bronchitis, asthma, and pneumoconiosis associated with pneumoconiosis associated with exposure to silica, coal dust, grain exposure to silica, coal dust, grain dust, cotton dust, and welding dust, cotton dust, and welding fumesfumes

AlcoholAlcohol 15 to 20 million alcoholics in the 15 to 20 million alcoholics in the

USAUSA 100,000 deaths/year due to alcohol 100,000 deaths/year due to alcohol

abuseabuse Economic losses of $100 to $130 Economic losses of $100 to $130

billion/yearbillion/year One to two drinks/day reduces One to two drinks/day reduces

incidence of coronary artery incidence of coronary artery disease*disease** What kind of person would put this kind of

bullet on a powerpoint?

A. Drinker? B) Non-Drinker?

Definition of Alcoholism

?

Effects of Blood Alcohol Levels in the Absence of ToleranceEffects of Blood Alcohol Levels in the Absence of Tolerance Blood Level, mg/dLBlood Level, mg/dL Usual EffectUsual Effect

2020 Decreased inhibitions, a Decreased inhibitions, a slight feeling of slight feeling of intoxication intoxication

8080 Decrease in complex Decrease in complex cognitive functions and cognitive functions and motor performance motor performance

200200 Obvious slurred speech, Obvious slurred speech, motor incoordination, motor incoordination, irritability, and poor irritability, and poor judgment judgment

300300 Light coma and depressed Light coma and depressed vital signs vital signs

400400 Death Death Harrison Internal Med, 16th Ed

Metabolism Of Ethanol Metabolism Of Ethanol

ADH, alcohol dehydrogenase; ALDH, aldehyde dehydrogenase

20%

80%

LEGAL INTOXICATION

0.08%

Widmark EquationWidmark Equation C = A / (W * r)C = A / (W * r)

C = concentration of EtOH in mg/dlC = concentration of EtOH in mg/dl A = mass of alcohol ingested in gramsA = mass of alcohol ingested in grams

density of ethanol = 0.8density of ethanol = 0.8 W = body weight in gramsW = body weight in grams r = Widmark distribution for ethanolr = Widmark distribution for ethanol

0.55 mL/ g body weight for females0.55 mL/ g body weight for females 0.68 mL / g body weight for males0.68 mL / g body weight for males

Elimination of ethanol = 0.015%/h Elimination of ethanol = 0.015%/h (15mg/dl/h)(15mg/dl/h)

zero order kineticszero order kinetics

Medical measurements use mg/dl in plasma, Medical measurements use mg/dl in plasma, whereas legal definitions use percentage whereas legal definitions use percentage (mass/volume) in whole blood(mass/volume) in whole blood to estimate the alcohol level in whole blood using to estimate the alcohol level in whole blood using

the alcohol level in blood plasma, divide by 1.16 the alcohol level in blood plasma, divide by 1.16

Alcohol and the LiverAlcohol and the Liver Fatty ChangeFatty Change

present in over 90% of binge and chronic present in over 90% of binge and chronic drinkersdrinkers

liver is enlarged but patient is asymptomaticliver is enlarged but patient is asymptomatic changes are reversible with cessation of changes are reversible with cessation of

drinkingdrinking macrosteatosis w/o inflammation or necrosismacrosteatosis w/o inflammation or necrosis

Alcohol hepatitisAlcohol hepatitis only between 10 - 15% of alcoholics will only between 10 - 15% of alcoholics will

develop alcoholic hepatitisdevelop alcoholic hepatitis may have systemic symptoms and jaundicemay have systemic symptoms and jaundice hepatocellular necrosis with Mallory bodies hepatocellular necrosis with Mallory bodies

and PMNs (central hyaline sclerosis)and PMNs (central hyaline sclerosis) thought to be a precursor of cirrhosis thought to be a precursor of cirrhosis

Alcoholic cirrhosisAlcoholic cirrhosis shrunken nodular liver with uniform small shrunken nodular liver with uniform small

nodules (micronodular cirrhosis)nodules (micronodular cirrhosis)

Fatty Change BiochemistryFatty Change Biochemistry Catabolism of fat by peripheral tissues Catabolism of fat by peripheral tissues

is increased, and there is increased is increased, and there is increased delivery of free fatty acids to the liverdelivery of free fatty acids to the liver

An excess of NADH over NAD An excess of NADH over NAD stimulates lipid biosynthesisstimulates lipid biosynthesis

Oxidation of fatty acids by Oxidation of fatty acids by mitochondria is decreasedmitochondria is decreased

Acetaldehyde forms adducts with Acetaldehyde forms adducts with tubulin and impairs function of tubulin and impairs function of microtubules, resulting in decreased microtubules, resulting in decreased transport of lipoproteins from the transport of lipoproteins from the liverliver

Neurologic Manifestations of AlcoholismNeurologic Manifestations of Alcoholism

Wernicke syndromeWernicke syndrome confusion, ataxia, and diplopia from confusion, ataxia, and diplopia from

ophthalmoplegiaophthalmoplegia damage to mammillary bodies, damage to mammillary bodies,

cerebellum and periaqueductal gray cerebellum and periaqueductal gray matter of the midbrainmatter of the midbrain

due to thiamine deficiencydue to thiamine deficiency may respond to prompt thiamine may respond to prompt thiamine

replacementreplacement

Korsakov syndromeKorsakov syndrome memory loss and confabulationmemory loss and confabulation results from thiamine deficiency and results from thiamine deficiency and

direct toxicitydirect toxicity

TABLE 9-5 -- Mechanisms of Disease Caused by Ethanol Abuse

Organ System Lesion Mechanism

Liver Fatty change Toxicity

Acute hepatitis

Alcoholic cirrhosis

Nervous system Wernicke syndrome Thiamine deficiency

Korsakoff syndrome Toxicity and thiamine deficiency

Cerebellar degeneration Nutritional deficiency

Peripheral neuropathy Thiamine deficiency

Cardiovascular system

Cardiomyopathy Toxicity

Hypertension Vasopressor

TABLE 9-5 -- Mechanisms of Disease Caused by Ethanol Abuse

Organ System Lesion Mechanism

Gastrointestinal tract

Gastritis Toxicity

Pancreatitis Toxicity

Skeletal muscle Rhabdomyolysis Toxicity

Reproductive system

Testicular atrophy ?

Spontaneous abortion

?

Fetal alcohol syndrome

Growth retardation Toxicity

Mental retardation

Birth defects

Data from Rubin E: Alcohol abuse. In Craighead JE (ed): Pathology of Environmental and Occupational Disease. St. Louis, Mosby-Year Book, 1996, p. 249; and Lewis DD, Woods SE: Fetal alcohol syndrome. Am Fam Physician 50:1025, 1994.

Therapeutic DrugsTherapeutic Drugs(Medications)(Medications)

Oral Contraceptives (BCPs)Oral Contraceptives (BCPs)Hormone Replacement Hormone Replacement

Therapy (HRT)Therapy (HRT)AcetaminophenAcetaminophenAspirinAspirin

Oral Contraceptives (BCPs)Oral Contraceptives (BCPs) Breast cancer and other cancersBreast cancer and other cancers

no increase in breast cancerno increase in breast cancer decrease endometrial and ovarian cancers decrease endometrial and ovarian cancers increase in cervical cancer (?lifestyle induced)increase in cervical cancer (?lifestyle induced)

Thromboembolic events Thromboembolic events DVT and Pulmonary Embolism increasedDVT and Pulmonary Embolism increased adds to other risk factors (e.g. Factor V Leiden)adds to other risk factors (e.g. Factor V Leiden)

Cardiovascular diseaseCardiovascular disease with current low estrogen pills, risk of MI and with current low estrogen pills, risk of MI and

atherosclerosis not increased in non-smoking atherosclerosis not increased in non-smoking women < 45 ywomen < 45 y

ischemic stroke increased regardless of age or ischemic stroke increased regardless of age or smokingsmoking

Liver tumorsLiver tumors benign hepatic adenomas benign hepatic adenomas older women with prolonged useolder women with prolonged use may rupture and cause intra-abdominal may rupture and cause intra-abdominal

bleeding bleeding

Hormone Replacement Therapy (HRT)Hormone Replacement Therapy (HRT) Cancer Cancer

in women with a uterus combined in women with a uterus combined estrogen and progestin Rx necessary to estrogen and progestin Rx necessary to reduce endometrial cancerreduce endometrial cancer

WHI showed increased risk of breast WHI showed increased risk of breast cancer in women who used HRT combined cancer in women who used HRT combined therapy for 5 years therapy for 5 years

Thromboembolic eventsThromboembolic events elevated approximated twofold in HRT elevated approximated twofold in HRT

users, especially within the first 2 years users, especially within the first 2 years Cardiovascular diseaseCardiovascular disease

WHI reported 29% increased risk of WHI reported 29% increased risk of myocardial infarction, especially during myocardial infarction, especially during the first year of combined HRT use the first year of combined HRT use

Acetaminophen (Tylenol)Acetaminophen (Tylenol) Does not affect cyclooxygenase so Does not affect cyclooxygenase so

bleeding associated with aspirin does bleeding associated with aspirin does not occurnot occur

Has analgesic and antipyretic actions Has analgesic and antipyretic actions but no anti-inflammatory actionbut no anti-inflammatory action

Large doses may produce hepatic Large doses may produce hepatic necrosisnecrosis patients should not exceed patients should not exceed

recommended dose (4 grams/day)recommended dose (4 grams/day) toxic dose in adults is 15 to 25 gmtoxic dose in adults is 15 to 25 gm dose should be reduced in children with dose should be reduced in children with

fever or dehydration fever or dehydration

AspirinAspirin OverdoseOverdose

respiratory alkalosis followed by metabolic respiratory alkalosis followed by metabolic acidosis that may be fatalacidosis that may be fatal

Chronic aspirin toxicity (salicylism) Chronic aspirin toxicity (salicylism) headache, dizziness, ringing in the ears headache, dizziness, ringing in the ears

(tinnitus), mental confusion, drowsiness, (tinnitus), mental confusion, drowsiness, nausea, vomiting, and diarrheanausea, vomiting, and diarrhea

Inhibits cyclooxygenase (COX 1 & 2)Inhibits cyclooxygenase (COX 1 & 2) Erosive gastritis is a major cause of GI Erosive gastritis is a major cause of GI

bleedingbleeding May be implicated in Reye syndrome May be implicated in Reye syndrome

(fatty liver with encephalopathy) in (fatty liver with encephalopathy) in children < 15 years old, especially with children < 15 years old, especially with influenza and chicken poxinfluenza and chicken pox

Cox-1 and Cox-2 InhibitorsCox-1 and Cox-2 Inhibitors Cyclooxygenase 1Cyclooxygenase 1

constitutively expressed and active in constitutively expressed and active in the normal platelet (thromboxane A2)the normal platelet (thromboxane A2)

involved in synthesis of gastro-involved in synthesis of gastro-protective prostaglandins protective prostaglandins

Cyclooxygenase 2Cyclooxygenase 2 induced, especially in inflamed tissueinduced, especially in inflamed tissue in vessel wall produces prostacyclin in vessel wall produces prostacyclin

(PGI(PGI22))

Aspirin and other nonselective Aspirin and other nonselective NSAIDS inhibit both COX-1 and NSAIDS inhibit both COX-1 and COX-2 COX-2

Figure 2-16 Generation of arachidonic acid metabolites and their roles in inflammation. The molecular targets of action of some anti-inflammatory drugs are indicated by a red X. COX, cyclooxygenase; HETE, hydroxyeicosatetraenoic acid; HPETE, hydroperoxyeicosatetraenoic acid.

Downloaded from: Robbins & Cotran Pathologic Basis of Disease (on 15 August 2005 06:35 PM)

© 2005 Elsevier

Indoor Air PollutionIndoor Air PollutionCarbon Monoxide COCarbon Monoxide CONitrogen Dioxide NONitrogen Dioxide NO22 Wood SmokeWood SmokeFormaldehydeFormaldehydeRadonRadonManufactured Mineral FibersManufactured Mineral FibersBioaerosolsBioaerosols

RadonRadon Radon is a radioactive gas and a decay Radon is a radioactive gas and a decay

product of uranium product of uranium It is widely distributed in the soil and is It is widely distributed in the soil and is

prevalent in homes (especially in prevalent in homes (especially in basements)basements)

Radon decay products are alpha emittersRadon decay products are alpha emitters 10% of US homes have levels associated 10% of US homes have levels associated

with an increased risk of lung cancer with an increased risk of lung cancer and an estimated 10,000 lung cancers and an estimated 10,000 lung cancers per year in the United States are due to per year in the United States are due to radon. Smoking elevates risk.radon. Smoking elevates risk.

Proper venting reduces the exposureProper venting reduces the exposure

LeadLead lead is classified as a heavy metal lead is classified as a heavy metal

(others include mercury, arsenic, (others include mercury, arsenic, and cadmium)and cadmium)

Source of exposureSource of exposure lead paintlead paint lead solder in plumbing (older houses)lead solder in plumbing (older houses) lead-glazed ceramicslead-glazed ceramics industrial exposureindustrial exposure

Route of exposureRoute of exposure inhalation with industrial exposureinhalation with industrial exposure ingestion with household exposureingestion with household exposure

Lead Distribution and ExcretionLead Distribution and Excretion Lead is a divalent cation that is Lead is a divalent cation that is

taken up by bone and developing taken up by bone and developing teeth in children (80% to 85%)teeth in children (80% to 85%) Half-life of lead in bone is 30 yearsHalf-life of lead in bone is 30 years

Blood accumulates 5% to 10% of Blood accumulates 5% to 10% of lead, but lead is rapidly cleared from lead, but lead is rapidly cleared from the bloodthe blood lead in blood indicates recent exposurelead in blood indicates recent exposure blood level does not allow the blood level does not allow the

determination of total body burden determination of total body burden Remainder is distributed in the soft Remainder is distributed in the soft

tissuestissues Excretion is via the kidneysExcretion is via the kidneys

Effects of LeadEffects of Lead High affinity for sulfhydryl groupsHigh affinity for sulfhydryl groups

inhibition of heme biosynthesis with inhibition of heme biosynthesis with hypochromic anemia and basophillic hypochromic anemia and basophillic stippling of erythrocytesstippling of erythrocytes

Competition with calcium ionsCompetition with calcium ions As a divalent cation, lead competes with As a divalent cation, lead competes with

calcium and is stored in bone. calcium and is stored in bone. It also interferes with nerve transmission and It also interferes with nerve transmission and

brain development. brain development. Inhibition of membrane-associated Inhibition of membrane-associated

enzymesenzymes Lead inhibits 5'-nucleotidase activity and Lead inhibits 5'-nucleotidase activity and

sodium-potassium ion pumps, leading to sodium-potassium ion pumps, leading to decreased survival of red blood cells decreased survival of red blood cells (hemolysis), renal damage, and hypertension. (hemolysis), renal damage, and hypertension.

Consequences of lead exposure

“RADIATION” T ½ Curie vs. Becqerel IONIZING vs. NON-IONIZING PARTICULATE vs. NON-

PARTICULATE (Photons) ENERGY: Kev, Mev

(~Wavelength) Linear Energy Transfer (LET),

Relative Biologic Effect (RBE) LD50@60d

This is the single most

RADIOSENSITIVE CELL

In your body

Radiation DosimetryRadiation Dosimetry Roentgen:Roentgen: unit of charge produced by x-rays or unit of charge produced by x-rays or

gamma rays that ionize a specific volume of air gamma rays that ionize a specific volume of air

RADRAD (radiation absorbed dose):(radiation absorbed dose): the dose of the dose of radiation that will produce absorption of 100 ergs radiation that will produce absorption of 100 ergs of energy per gram of tissue; 1 gm of tissue of energy per gram of tissue; 1 gm of tissue exposed to 1 roentgen of gamma rays is equal to exposed to 1 roentgen of gamma rays is equal to 93 ergs 93 ergs

GrayGray (Gy): the dose of radiation that will produce (Gy): the dose of radiation that will produce absorption of 1 joule of energy per kilogram of absorption of 1 joule of energy per kilogram of tissue; 1 Gy corresponds to 100 rad (SI unit for tissue; 1 Gy corresponds to 100 rad (SI unit for absorbed dose)absorbed dose)

REMREM (radiation equivalent man):(radiation equivalent man): the dose of the dose of radiation that causes a biologic effect equivalent radiation that causes a biologic effect equivalent to 1 rad of x-rays or gamma rays to 1 rad of x-rays or gamma rays

SievertSievert (Sv): the dose of radiation that causes a (Sv): the dose of radiation that causes a biologic effect equivalent to 1 Gy of x-rays or biologic effect equivalent to 1 Gy of x-rays or gamma rays; 1 Sv corresponds to 100 rem (SI gamma rays; 1 Sv corresponds to 100 rem (SI unit)unit)

Acute Effects of Ionizing RadiationAcute Effects of Ionizing Radiation Free radical generationFree radical generation

Ionizing radiation + HIonizing radiation + H220 → H0 → H3300++ + OH· + OH· DNA DamageDNA Damage

double-stranded DNA breaks needed to double-stranded DNA breaks needed to kill cell (mammalian cells can repair kill cell (mammalian cells can repair single stranded breaks)single stranded breaks)

cross-linking of DNA strands, cleavage cross-linking of DNA strands, cleavage of sugar-phosphate bondsof sugar-phosphate bonds

Tumor-suppressor gene Tumor-suppressor gene p53p53 activationactivation cell cycle arrest in presence of cell cycle arrest in presence of

damaged DNAdamaged DNA repair of DNA damage or apoptosisrepair of DNA damage or apoptosis

Acute Whole Body RadiationAcute Whole Body Radiation LD50 @ 6 wks 2.5 to 4.0 Gy (250 to 400 LD50 @ 6 wks 2.5 to 4.0 Gy (250 to 400

rad)rad) HematopoieticHematopoietic

200–600 REM200–600 REM Maximum neutrophil and platelet depression Maximum neutrophil and platelet depression

in 2 wk in 2 wk GastrointestinalGastrointestinal

l600–1000 REMl600–1000 REM Nausea, vomiting, diarrhea Nausea, vomiting, diarrhea Hemorrhage and infection in 1–3 wkHemorrhage and infection in 1–3 wk

Central nervous systemCentral nervous system >1000 REM>1000 REM Intractable nausea and vomitingIntractable nausea and vomiting Confusion, somnolence, convulsions Confusion, somnolence, convulsions death in 14–36 hrdeath in 14–36 hr

Therapeutic RadiationTherapeutic Radiation External radiation is delivered to External radiation is delivered to

malignant neoplasms at fractionated malignant neoplasms at fractionated doses up to 40 to 70 Gy (4000 to 7000 doses up to 40 to 70 Gy (4000 to 7000 rad), with shielding of adjacent normal rad), with shielding of adjacent normal tissues tissues

Therapeutic radiation alone seems to add Therapeutic radiation alone seems to add little risk of AML but can increase the little risk of AML but can increase the risk in people exposed to alkylating risk in people exposed to alkylating agentsagents

Fatigue, nausea and vomiting frequentFatigue, nausea and vomiting frequent Bone marrow suppression may occur Bone marrow suppression may occur

especially with chest or abdominal especially with chest or abdominal radiationradiation

Delayed Radiation InjuryDelayed Radiation Injury Carcinogenesis (atom bomb survivors)Carcinogenesis (atom bomb survivors)

myeloid leukemias peak 5 to 7 years after myeloid leukemias peak 5 to 7 years after exposureexposure

breast and thyroid cancers may show breast and thyroid cancers may show greater latency greater latency

no germline mutations noted in progeny no germline mutations noted in progeny of survivorsof survivors

Vascular effectsVascular effects endothelial necrosis followed by intimal endothelial necrosis followed by intimal

and medial fibrosisand medial fibrosis capillaries may become thrombosed and capillaries may become thrombosed and

obliterated or ectaticobliterated or ectatic Parenchymal atrophy and fibrosisParenchymal atrophy and fibrosis

Radiation effects on TISSUE

ACUTE (vasculitis, possibly “fibrinoid” necrosis)

CHRONIC (fibrosis)

Physical InjuryPhysical Injury AbrasionAbrasion

basically a scrapebasically a scrape superficial epidermis is torn off by friction or superficial epidermis is torn off by friction or

forceforce regeneration without scarring usually occursregeneration without scarring usually occurs

Laceration vs. IncisionLaceration vs. Incision a laceration is an irregular tear in the skin a laceration is an irregular tear in the skin

produced by overstretching. The wound margins produced by overstretching. The wound margins are frequently hemorrhagic and traumatizedare frequently hemorrhagic and traumatized

an incision is made by a sharp cutting object. The an incision is made by a sharp cutting object. The margins of the incision are usually relatively margins of the incision are usually relatively clean clean

ContusionContusion an injury caused by a blunt force that damages an injury caused by a blunt force that damages

small blood vessels and causes interstitial small blood vessels and causes interstitial bleeding, usually without disruption of the bleeding, usually without disruption of the continuity of the tissue (continuity of the tissue (cfcf ecchymosis) ecchymosis)

Adult Mortality Rates in the United States, Ages 25–44, in 1998

Rate per 100,000 population

Cause Hispanic Black WhiteUnintentional injuries 33.4 40.1 31.6

Cancer 16.8 38.0 25.3

Homicide 13.1 36.2 4.7

Human immunodeficiency virus 12.1 43.3 4.8

Heart disease 10.3 43.5 18.3

Suicide 7.8 — 17.0

Total 130.2 303.7 139.4Data from CDC Fact Book, 2000/2001, Department of Health and Human Services, Centers for Disease Control and Prevention.

GUNSHOT WOUNDEntrance Vs. ExitFar range Vs. Close range

BURNS 1st, 2nd, 3rd, 4th “Degree” FULL vs. PARTIAL Thickness Survival

PERCENT of body using the rule of NINES

DEGREE (i.e., Depth) Respiratory Tract Involvement AGE Speed of access to Burn Unit Immune System (Pseudomonas, S.

aureus, Candida)

HYPER-THERMIA HEAT

CRAMPS: Electrolyte loss via sweat EXHAUSTION: Water depletion

and lack of cardiovascular compensation

“STROKE”: Extensive peripheral vasodilatation, i.e., “shocky”, very serious, T>106º, over 110º have been reported

HYPO-THERMIAOften in setting of homelessness or alcoholism or both< 90º often fatal, assoc. w. BRADYCARDIA ATRIAL FIBRILLATION

LIGHTNING/ELECTRICAL ELECTRIC DISTURBANCES

NEURAL EKG

THERMAL INJURY, depends upon a particular tissue’s RESISTANCE to electrical flow

“LIGHTNING” MARKS

ATMOSPHERIC PRESSURE

Altitude IllnessBlast InjuriesDecompression Injuries

ALTITUDE ILLNESS Caused by LOW Oxygen Tension

HIGH ALTITUDES (>4000 m) OBTUNDATION INCREASED CAPILLARY

PERMEABILITY ACUTE PULMONARY EDEMA (HAPE)

Q: What is the name of the base camp at Mt. Everest

A: Pulmonary Edema

BLAST INJURIES

RELATED TO RAPID ATMOSPHERIC PRESSURE CHANGES LUNGS VISCERA, especially GAS filled viscera

Rupture, Hemorrhage, etc. IMMERSION BLAST also possible,

causing more of a total body compression syndrome

DECOMPRESSION Related to GAS SOLUBILITY in divers

ascending rapidly, especially the more NON-SOLUBLE gasses, like NITROGEN, and, to a lesser extent, XENON

AIR EMBOLISM is the common pathology ACUTE:

“BENDS” (peri-articular), acute “CHOKES” (lungs), acute “STAGGERS” (inner ear), acute

CHRONIC: ASEPTIC NECROSIS: humeri, femurs

NUTRITIONNUTRITION & DISEASE& DISEASE Food SafetyFood Safety

AdditivesAdditives ContaminantsContaminants

Nutritional DeficienciesNutritional Deficiencies VitaminsVitamins MineralsMinerals

ObesityObesity Diet and DiseaseDiet and Disease Chemoprevention of CancerChemoprevention of Cancer

Vitamin Deficiency and ExcessVitamin Deficiency and Excess Fat soluble vitaminsFat soluble vitamins

A, D, E, KA, D, E, K readily stored in body fatreadily stored in body fat poorly absorbed in digestive disorders poorly absorbed in digestive disorders

involving malabsorbtion of fatinvolving malabsorbtion of fat Water soluble vitaminsWater soluble vitamins

remaining vitaminsremaining vitamins readily excreted in urinereadily excreted in urine

Vitamin storesVitamin stores vitamins B-12 and A: stores sufficient vitamins B-12 and A: stores sufficient

for 1 yearfor 1 year folate and thiamine may become folate and thiamine may become

depleted within weeks when eating a depleted within weeks when eating a deficient diet deficient diet

Vitamin D MetabolismVitamin D Metabolism

Absorption of vitamin D in the gut or Absorption of vitamin D in the gut or synthesis from precursors in the skin synthesis from precursors in the skin

Binding to a plasma α1 -globulin (D-Binding to a plasma α1 -globulin (D-binding protein) and transport to liver binding protein) and transport to liver

Conversion to 25-hydroxyvitamin D, Conversion to 25-hydroxyvitamin D, 25(OH)D by 25-hydroxylase in the liver 25(OH)D by 25-hydroxylase in the liver

Conversion of 25(OH)D to 1,25(OH)Conversion of 25(OH)D to 1,25(OH)22 D D by α1-hydroxylase in the kidney; by α1-hydroxylase in the kidney; biologically this is the most active biologically this is the most active form of vitamin Dform of vitamin D. .

Functions of Vitamin DFunctions of Vitamin D

Stimulates intestinal absorption of Stimulates intestinal absorption of calcium and phosphorus calcium and phosphorus

Collaborates with PTH in the Collaborates with PTH in the mobilization of calcium from bone mobilization of calcium from bone

Stimulates the PTH-dependent Stimulates the PTH-dependent reabsorption of calcium in the distal reabsorption of calcium in the distal renal tubulesrenal tubules

1,25(OH)1,25(OH)2 2 D, the biologically active D, the biologically active form of vitamin D, is best regarded form of vitamin D, is best regarded as a steroid hormone which acts by as a steroid hormone which acts by binding to a high-affinity receptor binding to a high-affinity receptor

Vitamin D DeficiencyVitamin D Deficiency

Holick et al (2005) reported the Holick et al (2005) reported the results of a large North American results of a large North American study that assessed the vitamin D study that assessed the vitamin D status of postmenopausal women status of postmenopausal women receiving therapy to treat or prevent receiving therapy to treat or prevent osteoporosisosteoporosis

52% of 1536 women had inadequate 52% of 1536 women had inadequate [25(OH)D] levels (<30 ng/mL)[25(OH)D] levels (<30 ng/mL)

36% and 18% had levels less than 25 36% and 18% had levels less than 25 and 20 ng/mL, respectively. and 20 ng/mL, respectively.

Holick MF et al: J Clin Endocrinol Metab 90:3215, 2005

Vitamin D DeficiencyVitamin D Deficiency Childhood: RicketsChildhood: Rickets

epiphyses are openepiphyses are open cartilage overgrowthcartilage overgrowth

Adults: osteomalaciaAdults: osteomalacia bone matrix is not calcifiedbone matrix is not calcified vs osteoporosis (matrix vs osteoporosis (matrix

reduced)reduced)

Vitamin KVitamin K

Clotting factors VII, IX, and X and Clotting factors VII, IX, and X and prothrombin (II) all require prothrombin (II) all require carboxylation of glutamate residues carboxylation of glutamate residues for functional activityfor functional activity anticoagulant coumadin is a Vitamin K anticoagulant coumadin is a Vitamin K

antagonistantagonist Activation of anticoagulant proteins Activation of anticoagulant proteins

C and S also requires glutamate C and S also requires glutamate carboxylationcarboxylation

SourcesSources endogenous intestinal bacterial floraendogenous intestinal bacterial flora dietdiet

Vitamin K DeficiencyVitamin K Deficiency CausesCauses

fat malabsorptionfat malabsorption reduced gut bacterial florareduced gut bacterial flora

administration of wide specturm antibioticsadministration of wide specturm antibiotics neonatal period before gut is colonizedneonatal period before gut is colonized

liver disease with reduced recycling of liver disease with reduced recycling of vitamin Kvitamin K

Effects of vitamin K deficiencyEffects of vitamin K deficiency bleeding diathesisbleeding diathesis estimated 3% prevalence of vitamin K-estimated 3% prevalence of vitamin K-

dependent bleeding diathesis among dependent bleeding diathesis among neonates warrants routine prophylactic neonates warrants routine prophylactic vitamin K therapy for all newborns vitamin K therapy for all newborns