The Eyes iii

THE FACTS ON FILE ENCYCLOPEDIA OF HEALTH AND MEDICINE

IN FOUR VOLUMES: VOLUME 4

An Amaranth Book iv The Eyes

To your health!

The information presented in The Facts On File Encyclopedia of Health and Medicine is provided for research purposes only and is not intended to replace consultation with or diagnosis and treatment by medical doctors or other qualified experts. Readers who may be experiencing a condition or disease described herein should seek medical attention and not rely on the information found here as medical advice.

The Facts On File Encyclopedia of Health and Medicine in Four Volumes: Volume 4

Copyright © 2007 by Amaranth Illuminare

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The Facts on File encyclopedia of health and medicine / Amaranth Illuminare and Deborah S. Romaine. p. ; cm. “An Amaranth book.” Includes index. ISBN 0-8160-6063-0 (hc : alk. paper) 1. Medicine—Encyclopedias. 2. Health—Encyclopedias. [DNLM: 1. Medicine—Encyclopedias—English. 2. Physiological Processes—Encyclopedias—English. WB 13 R842f 2006] I. Title: Encyclopedia of health and medicine. II. Romaine, Deborah S., 1956- III. Facts on File, Inc. IV. Title. R125.R68 2006 610.3—dc22 2005027679

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CONTENTS VOLUME 4

Foreword by Maureen Pelletier, M.D., C.C.N., F.A.C.O.G. vii How to Use The Facts On File Encyclopedia of Health and Medicine ix Preface to Volume 4 xiii Preventive Medicine 1 Alternative and Complementary Approaches 51 Genetics and Molecular Medicine 109 Drugs 145 Nutrition and Diet 174 Fitness: Exercise and Health 210 Human Relations 238 Surgery 257 Lifestyle Variables: Smoking and Obesity 282 Substance Abuse 311 Emergency and First Aid 355 Appendixes: I. Vital Signs 389 II. Advance Directives 390

v vi Contents

III. Glossary of Medical Terms 391 IV. Abbreviations and Symbols 394 V. Medical Specialties and Allied Health Fields 398 VI. Resources 399 VII. Biographies of Notable Personalities 410 VIII. Diagnostic Imaging Procedures 417 IX. Family Medical Tree 420 X. Immunization and Routine Examination Schedules 422 XI. Modern Medicine Timeline 424 XII. Nobel Laureates in Physiology or Medicine 425 Selected Bibliography and Further Reading 433 Medical Advisory Review Panel 439 Cumulative Index to Volumes 1–4 443 FOREWORD

A big part of my role as a physician is educating your body in isolation from other body structures my patients about their health. I take as much and functions. Your body attempts to compensate time as each person needs to explain prevention and adjust, often without your awareness, until it measures, test results, and treatment options. I can no longer accommodate the injury or illness. encourage questions. But in the moment, sitting The symptoms you bring to your doctor may there in my office, most people do not yet know reflect this compensation, for example frequent what to ask me. By the time questions flood headaches that point not to brain tumor (as many their thoughts, they may be back at work or at people fear but is very rare) but to eye strain or home. muscle tension or sometimes to hypertension Numerous events and circumstances can chal- (high blood pressure). lenge health, and we all need to know what In my medical practice I emphasize integrative actions we can take to keep ourselves healthy as health care, embracing the philosophy that health well as to obtain appropriate treatment for health exists as the intricate intertwining of the body’s conditions that do affect us. Knowledge empow- many systems, structures, and functions. So, too, ers all of us to make informed and appropriate does the care of health. I received my medical decisions about health care. Certainly there is no degree from Tufts University School of Medicine shortage of reference material. Yet there is so in Boston, an institution noted for remaining at much information available today! Even for the forefront of the medical profession. I also physicians, it is challenging to keep up. How can completed clinical programs in Mind-Body Medi- you get to the core of what you want to know, cine at Harvard University, Integrative Medicine at reliably and to the level of detail you need? the University of Arizona School of Medicine, and The Facts On File Encyclopedia of Health and Medi- Medical Acupuncture at the University of Califor- cine is a great resource for up-to-date health infor- nia-Los Angeles (UCLA). I am a board-certified mation presented in a manner that is both obstetrician-gynecologist, a board-certified clinical comprehensive and easy to understand no matter nutritionist, and a licensed acupuncturist. I see what your level of medical knowledge. The ency- patients in my practice in Cincinnati, Ohio; I clopedia organizes entries by body system. The teach, I lecture, and I frequently go on television progression of body systems—and entries— and radio to talk about health topics. In each of throughout the encyclopedia presents topics the these areas, I encourage people to think about way you think about them. their health and health concerns from an integra- Going beyond this basic structure, however, is tive perspective. When you understand your another layer of organization that particularly health from multiple dimensions, you can better appeals to me, which is a comprehensive structure understand what to do to keep yourself as healthy of cross references that integrates entries across as possible. body systems. After all, your body functions in an I wish you the best of health for all of a long, integrated way; so, too, should a reference series satisfying life. But when the time comes that you that discusses your body’s health. Not very much must make decisions about medical care, I want that happens with your health affects one part of you to have the knowledge to make informed vii viii Foreword choices that are right for you. Whether you start Encyclopedia of Health and Medicine to be a most here and move on to more specialized resources valuable reference resource. or locate all the information you need within —Maureen M. Pelletier, M.D., C.C.N., these four volumes, you will find The Facts On File F.A.C.O.G. HOW TO USE THE FACTS ON FILE ENCYCLOPEDIA OF HEALTH AND MEDICINE

Welcome to The Facts On File Encyclopedia of Health with its surroundings and the external envi- and Medicine, a four-volume reference set. This ronment. comprehensive resource is an indispensable refer- • Volume 2 presents the cell- and fluid-based ence for students, allied health professionals, body systems that transport nutrients, remove physicians, caregivers, lay researchers, and people molecular wastes, and provide protection from seeking information about health circumstances infection. and conditions for themselves or others. Entries • Volume 3 presents the biochemical body sys- present the latest health concepts and medical tems that support cellular functions. knowledge in a clear, concise format. Readers may easily accumulate information and build a com- • Volume 4 presents topics that apply across plete medical profile on just about any health or body systems (such as “Fitness: Exercise and medical topic of interest or concern. Health”) or that address broad areas within health care (such as “Preventive Medicine”). A New Paradigm for the • The appendixes provide supportive or additional Health and Medical Encyclopedia reference information (such as “Appendix X: As the art and science of health and medicine con- Immunization and Routine Examination tinues to evolve, with complex and elegant discov- Schedules”). eries and new techniques, medications, and treatments emerging all the time, the need has Following Research Pathways arisen for a new paradigm for the encyclopedia of The Facts On File Encyclopedia of Health and Medi- health and medicine—a rethinking of the old, and cine’s organization and structure support the increasingly outmoded, presentations. Carefully reader’s and researcher’s ease of use. Many ency- researched and compiled, The Facts On File Encyclope- clopedia users will find all the information they dia of Health and Medicine offers many distinguishing desire within one volume. Others may use several features that present readers and researchers with or all four of the encyclopedia’s volumes to arrive an organization as up-to-date and compelling as the at a comprehensive, multifaceted, in-depth under- breakthrough information its entries contain. standing of related health and medical concepts Recognizing the current emphasis on present- and information. Researchers efficiently look up ing a truly integrative approach to both health information in The Facts On File Encyclopedia of and disease, The Facts On File Encyclopedia of Health Health and Medicine in several ways. and Medicine organizes content across volumes Each section’s entries appear in alphabetical within a distinctive format that groups related order (except the entries in Volume 4’s “Emer- entries by body system (for example, “The Cardio- gency and First Aid” section, which are grouped vascular System”) or by general health topic (for by type of emergency). The researcher finds a example, “Genetics and Molecular Medicine”): desired entry by looking in the relevant volume and section. For example, the entry for acne is in • Volume 1 presents the sensory and structural Volume 1 in the section “The Integumentary Sys- body systems that allow the body to engage tem” and the entry for stomach is in Volume 3 in ix x How to Use the section “The Gastrointestinal System.” The Following the path of an encyclopedic entry’s researcher can also consult the index at the back internal cross references, as shown above, can of the volume to locate the entry, then turn to the illuminate connections between body systems; appropriate page in the volume. define and apply medical terminology; reveal a Terms that appear in SMALL CAPS within the text broad matrix of related health conditions, issues, of an entry are themselves entries elsewhere in and concerns; and more. The SMALL CAPS cross ref- The Facts On File Encyclopedia of Health and Medicine. erences indicated within the text of encyclopedic Encyclopedia users can look up the entries for entries lead encyclopedia users on wide-ranging those terms as well, for further information of research pathways that branch and blossom. potential interest. Such SMALL CAPS cross references At the end of the entry for hypertension a list typically provide related content that expands of cross references gathered in alphabetical order upon the primary topic, sometimes leading the links together groups of related entries in other user in new research directions he or she might sections and volumes, such as smoking cessa- otherwise not have explored. tion in Volume 4’s “Lifestyle Variables: Smoking For example, the entry hypertension is in the and Obesity,” to provide specific, highly relevant section “The Cardiovascular System.” The entry research strings. These see also cross references also presents a comprehensive discussion of the health appear in SMALL CAPS, identifying them at a glance. condition hypertension (high blood pressure), Encyclopedia users are encouraged to look here covering symptoms, diagnosis, treatment options, for leads on honing research with precision to a risk factors, and prevention efforts. Among the direct pathway of connected entries. numerous SMALL CAPS cross references within the So, extensive cross-references in The Facts On hypertension entry are the entries for File Encyclopedia of Health and Medicine link related topics within and across sections and volumes, in • retinopathy, an entry in the section “The both broad and narrow research pathways. This Eyes” in Volume 1, which discusses damage to approach encourages researchers to investigate the eye that may result from untreated or beyond the conventional level and focus of infor- poorly managed hypertension mation, providing logical direction to relevant • blood pressure, an entry in the Volume 2 sec- subjects. Each cross-referenced entry correspond- tion “The Cardiovascular System,” which dis- ingly has its own set of cross references, ever cusses the body’s mechanisms for maintaining widening the web of knowledge. appropriate pressure within the circulatory sys- tem Using the Facts On File Encyclopedia of Health and Medicine • stroke and heart attack, entries in Volume 2’s Each section of the encyclopedia begins with an “The Cardiovascular System” about significant overview that introduces the section and its key health conditions that may result from hyper- concepts, connecting information to present a tension comprehensive view of the relevant system of the • kidney, an entry in the section “The Urinary human body or health and medical subject area. System” in Volume 3, which discusses the kid- For most body systems, this overview begins with ney’s role in regulating the body’s electrolyte a list and drawings of the system’s structures and balances and fluid volume to control blood incorporates discussion of historic, current, and pressure future contexts. • atherosclerosis, diabetes, hyperlipidemia, Entries present a spectrum of information from and obesity, entries in the sections “The Car- lifestyle factors and complementary methods to diovascular System” in Volume 2, “The the most current technologic advances and Endocrine System” in Volume 3, and “Lifestyle approaches, as appropriate. Text that is set apart or Variables: Smoking and Obesity” in Volume 4, bold within an entry gives an important health and all of which are health conditions that con- warning, or targets salient points of interest to add tribute to hypertension layers of meaning and context. Lists and tables How to Use xi collect concise presentations of related informa- • Entries for diagnostic procedures begin with a tion for easy reference. general discussion of the test or procedure and Each type of entry (mid-length and longer) then incorporate content under the subhead- incorporates consistent elements, identified by ings “Reasons for Doing This Test,” “Prepara- standardized subheadings: tion, Procedure, and Recovery,” and “Risks and Complications.” • Entries for health conditions and diseases begin with a general discussion of the condition and Entries in Volume 4’s section “Emergency and its known or possible causes and then incorpo- First Aid” are unique within the orientation of The rate content under the subheadings “Symptoms Facts On File Encyclopedia of Health and Medicine in and Diagnostic Path,” “Treatment Options and that they feature instructional rather than infor- Outlook,” and “Risk Factors and Preventive mational content. These entries do not replace Measures.” appropriate training in emergency response • Entries for surgery operations begin with a gen- and first aid methods. Rather, these entries pro- eral discussion of the procedure and then incor- vide brief directives that are appropriate for guid- porate content under the subheadings “Surgical ing the actions of a person with little or no first aid Procedure,” “Risks and Complications,” and training who is first on the scene of an emergency. “Outlook and Lifestyle Modifications.” Each volume concludes with a complete, full • Entries for medication classifications begin with index for the sections and entries within the vol- a general discussion of the type of medication ume. Volume 4 of The Facts On File Encyclopedia of and its common uses and then incorporate con- Medicine contains a comprehensive index for all tent under the subheadings “How These Med- four encyclopedia volumes that researchers can ications Work,” “Therapeutic Applications,” and use to quickly and easily determine which vol- “Risks and Side Effects.” umes contain desired sections or entries. xii How to Use

The Facts On File Encyclopedia of Health and Medicine in Four Volumes

Volume 1 Volume 4 The Ear, Nose, Mouth, and Throat Preventive Medicine The Eyes Alternative and Complementary Approaches The Integumentary System Genetics and Molecular Medicine The Nervous System Drugs The Musculoskeletal System Nutrition and Diet Pain and Pain Management Fitness: Exercise and Health Volume Index Human Relations Surgery Lifestyle Variables: Smoking and Obesity Substance Abuse Volume 2 Emergency and First Aid The Cardiovascular System Appendixes: The Blood and Lymph I. Vital Signs The Pulmonary System II. Advance Directives The Immune System and Allergies III. Glossary of Medical Terms Infectious Diseases IV. Abbreviations and Symbols Cancer V. Medical Specialties and Allied Health Fields Volume Index VI. Resources VII. Biographies of Notable Personalities VIII. Diagnostic Imaging Procedures Volume 3 IX. Family Medical Tree The Gastrointestinal System X. Immunization and Routine Examination The Endocrine System Schedules The Urinary System XI. Modern Medicine Timeline The Reproductive System XII. Nobel Laureates in Physiology or Medicine Psychiatric Disorders and Psychologic Conditions Selected Bibliography and Further Reading Volume Index Series Index: Volumes 1–4 PREFACE TO VOLUME 4

Volume 4 of the four-volume The Facts On File that uses the map of the human genome to Encyclopedia of Health and Medicine is unique in its explore new pathways for understanding disease organization and presentation of content. The sec- and illness. Through this new knowledge lies tions of Volume 4 extend across body systems and hope for preventing many of the health condi- medical disciplines to look at the larger picture of tions common today. health and health care. Though the entries in these sections cover a broad spectrum of informa- Drugs tion, the thread that connects all of these sections Pharmaceutical therapies are the basis for treat- is the individual’s participation, through lifestyle ment of many health conditions, from infections choices and informed decisions, in his or her to cardiovascular disease to cancer. The section health and health care. “Drugs” contains entries that discuss the types of medications doctors use to treat a wide range of Preventive Medicine health conditions. Entries cover classifications of The protection of a population’s overall health, prescription drugs as well as over-the-counter particularly measures to maintain health and pre- products and include cross references to alterna- vent health problems, is a major emphasis. The tive remedies. section “Preventive Medicine” examines efforts and initiatives intended to reduce the general Nutrition and Diet risks for injury or illness. Entries present both per- Nutrition (what the body requires to fuel its func- sonal and community-based perspectives. tions) comes from diet (the foods people eat). Dietary choices affect nutrition, and consequently Alternative and Complementary Approaches health, in ways that can support health and lower The section, “Alternative and Complementary the risk for disease. The entries in this section dis- Approaches” explores methods based in other sys- cuss the major categories of nutrients and explain tems of health care such as acupuncture and how dietary choices affect the body’s functions. herbal remedies. Entries present the methods within the framework of how they fit within the Fitness: Exercise and Health Western medicine model common in the United Fitness reflects a personal choice to engage in States, with cross references to comparable West- activities that maintain the body’s strength, flexi- ern approaches discusses in entries elsewhere in bility, and mobility to support optimal health. The Facts On File Encyclopedia of Health and Medicine. Many researchers consider physical inactivity to be the leading factor in the development of Genetics and Molecular Medicine chronic health conditions such as hypertension In April 2003 an international, cross-disciplinary (high blood pressure), diabetes, and obesity. The team of scientists completed the human genome entries in this section discuss the correlation sequence, unraveling for the first time the struc- between regular physical activity and key health ture of human existence. The section “Genetics conditions as well as present information about and Molecular Medicine” entries look at research how physical activity affects the body. xiii xiv Preface

Human Relations Substance Abuse Humans are social beings. Yet many social interac- Substance abuse, including alcoholism, is a signifi- tions are ones not necessarily chosen, such those cant health concern in the United States. The within school and work environments. The entries entries in this section discuss commonly abused here present discussions of behavior issues, with substances, including their short-term and long- an emphasis on understanding the influence of term effects on health. There are also entries diverse backgrounds and personal experiences. about treatment approaches and programs.

Surgery Emergency and First Aid Surgery is the treatment of choice for hundreds of The section “Emergency and First Aid” stands health conditions. The section “Surgery” presents apart from all other sections in the Facts On File entries about general topics such as anesthesia and Encyclopedia of Health and Medicine. Entries here surgery benefits and risks. Entries about specific provide instructional content and are organized by operations appear in the relevant body system sec- type of emergency, presenting the most basic tion. For example, the entry for appendectomy information for the person who has no medical (surgery to remove the appendix) appears in the knowledge or training and who happens to be first section “The Gastrointestinal System.” on the scene of a medical emergency (first respon- der). Entries are concise and directive, with cross Lifestyle Variables: Smoking and Obesity references to information-based entries through- Cigarette smoking and obesity (extreme over- out the four volumes of the encyclopedia. weight) are the leading lifestyle factors that con- tribute to serious health conditions such as Appendixes and Cumulative Index cardiovascular disease, diabetes, and cancer. In to Volumes 1-4 this section The Facts On File Encyclopedia of Health A dozen appendixes that provide supplemental and Medicine presents entries about the health information bring Volume 4 to a close. Volume 4 effects of smoking and obesity within the context also contains a comprehensive “Cumulative of lifestyle choices that are within the reach of Index” for the entire four-volume Facts On File every individual to control. Encyclopedia of Health and Medicine. PREVENTIVE MEDICINE

The medical discipline of preventive medicine covers the gamut of measures, individual and societal, that can reduce the occurrence of illness and injury. Physicians who practice in preventive medicine may be infectious disease special- ists, community health specialists, and occupational health specialists. Preventive medicine is also a mainstay of most other medical specialties, notably family practice, internal medicine, and pediatrics. The research field of epidemiology studies trends in and risks for illness and injury and explores methods for reducing health risks. Epidemiologists and preventive medicine practitioners work closely together.

This section, “Preventive Medicine,” presents an ing, and the experiments of scientists such as overview discussion of preventive medicine con- Joseph Lister, Louis Pasteur, and Robert Koch, cepts and entries about preventive health mea- whose discoveries proved the existence of sures and the public health dimensions of illness microbes and the value of antisepsis in preventing and injury. The entries in this section focus on the the spread of infection. Their work further led to larger picture of how illness and injury affect the the development of antibiotics and vaccines. health and well-being of communities and popu- These three factors—antisepsis, antibiotics, and lations. Entries in other sections of The Facts On vaccines––forever changed the perceptions and File Encyclopedia of Health and Medicine provide patterns of disease throughout the world and are detailed content about the causes, symptoms, among the most significant breakthroughs in diagnosis, treatment, and outlook for specific medical history. In less than half a century these infections and diseases. Cross-references link the discoveries dramatically reduced the occurrence entries to one another. and severity of many diseases that had for millen- nia been the leading causes of death: tetanus, Traditions in Preventive Medicine History ANTHRAX, SMALLPOX, CHOLERA, TYPHOID FEVER, DIPH- Early cultures and medical systems had their THERIA, PERTUSSIS, POLIOMYELITIS, SYPHILIS, bacterial unique variations on preventing illness and INFEC- PNEUMONIA, bacterial wound infections, INFLUENZA, TION. There is some evidence of guidelines for san- and TUBERCULOSIS. Though death due to infection itation and public health practices in ancient after CHILDBIRTH is rare in the United States today, Macedonia, and the ruins of ancient Rome’s intri- until the early 20th century childbirth fever cate aqueducts and sewage canals remain today. (puerperal fever) was a leading cause of death But for the most part the premise of public health among women of childbearing age. From 1900 to is relatively modern, emerging after a flurry of sci- 1999, maternal death in childbirth declined 99 entific discoveries in the 19th century that percent in the United States. revealed the pathogenesis (origin and progres- sion) of infection and disease. Key to these discov- EFFECTS OF VACCINATION eries were the observations of physicians such as • eradication of SMALLPOX in the United States in 1967 and Ignaz Philipp Semmelweis, who was the first to worldwide in 1977 make the connection that doctors carried the • near eradication of MEASLES in the United States in 1998 • near eradication of POLIOMYELITIS in the United States in infection of childbirth FEVER from one patient to another through blood on their hands and cloth- 2000

1 2 Preventive Medicine

Public Health age 68. These children were the first who also Improvements in COMMUNITY SANITATION, such as could expect to grow up without experiencing the sewage and garbage control, in the late 19th and CHILDHOOD DISEASES that claimed the lives of one in early 20th centuries further contained diseases five children in their parents’ generation. spread through close contact reduced pest and Epidemics and pandemics Epidemics and pan- vermin infestation and the resultant diseases, demics strike fear in the hearts of health experts including the much dreaded “black death,” and individuals alike. Epidemics are extensive but plague. Cities and towns focused effort on main- localized outbreaks of illness or infection. Pan- taining clean and safe drinking water supplies, demics are worldwide outbreaks. Despite vaccina- decreasing waterborne illnesses. The home refrig- tion efforts, annual influenza epidemics sicken erator debuted in 1913 and quickly replaced the millions and cause the deaths of 30,000 Ameri- icebox as the standard for food storage, dramati- cans. Health experts believe basic preventive cally decreasing FOODBORNE ILLNESSES. measures such as frequent hand washing and Doctors and others began to recognize, by the appropriate SNEEZE/COUGH ETIQUETTE, combined start of the 20th century, the extent to which com- with more comprehensive vaccination, could pre- munity and personal cleanliness influenced health vent most of these infections. and illness. Poor ventilation and overcrowded liv- The Spanish influenza epidemic of 1918, the ing and working conditions, especially in densely worst pandemic of modern history, claimed the lives populated cities, encouraged rampant and rapid of half a million Americans and more than 20 mil- spread of infectious diseases. In 1900 pneumonia, lion people worldwide. It also provided much learn- tuberculosis, and GASTROENTERITIS together were to ing for public health officials about how, and how blame for a third of all deaths in the United States. quickly, such infections spread. Health experts have Annual influenza outbreaks could kill entire fami- used this knowledge to develop mechanisms and lies, even communities, within weeks. In cities, systems to detect and report outbreaks that have infections caused the deaths of nearly a third of pandemic potential. Such efforts could not entirely infants before their first birthdays. prevent, though did help contain, influenza pan- With clean water standards came assurances demics in 1957 (the Asian flu) and 1968 (the Hong that bathing would no longer be the source of ill- Kong flu). They did, however, allow early detection ness but rather could be the guardian of health. and containment of small outbreaks of avian Public officials began to extol the virtues of fre- influenza in 2000 and 2004, and of the deadly SEVERE quent HAND WASHING and daily, or at least weekly, ACUTE RESPIRATORY SYNDROME (SARS). bathing. Between 1920 and 1937 illnesses and Motor vehicle safety A uniquely modern-day deaths from waterborne infections such as cholera public health issue is motor vehicle safety. Coming and typhoid fever plummeted, and by 1950 were into its own in the early 1900s, the automobile nearly nonexistent. Health officials also encour- wasted little time acquiring notoriety. By the time aged opening windows and getting fresh air, Henry Ford set the standard for the “everyman” measures that helped dilute the concentration of car, MOTOR VEHICLE ACCIDENTS had already claimed airborne pathogens such as viruses and BACTERIA more than 40,000 lives. By the 1960s, motor vehi- and reduce opportunities for infection to occur. In cle accidents accounted for more than 40,000 1944 the US Congress passed the Public Health deaths each year. Measures such as structural Service Act that established a consistent frame- integrity requirements, seat belts, and airbags work for public health laws, standards, and proce- have held motor vehicle deaths steady near that dures throughout the United States. level since 1998. Life expectancy A key measure of public health and the effectiveness of disease-prevention efforts Individual Health Factors is LIFE EXPECTANCY. A child born in 1900 could The recognition that PERSONAL HYGIENE—frequent expect to live to age 47. A child born in 1950, the hand washing and daily or at least weekly dawn of the golden era of preventive health care, bathing—could prevent the passing of disease could expect to live nearly half again as long, to from one person to another was a milestone in Preventive Medicine 3 preventive medicine. Until the early 20th century ease. Recommendations for individual preventive even doctors did not often wash their hands, not health measures emphasize nutritious eating habits even between seeing patients. This was largely a and daily exercise, urge SMOKING CESSATION, pro- function of ignorance. Until Lister, Koch, Pasteur, mote IMMUNIZATION, and encourage routine health and others demonstrated the existence of bacteria screenings for early detection and treatment of dis- and their causal relationship to infection, doctors ease. Health experts believe lifestyle modifica- and others simply did not know their hands car- tions—reduction of personal health risks—could ried the agents of disease. Health experts today eliminate as much as 90 percent of acquired heart believe that frequent hand washing could prevent disease as well as 95 percent of type 2 diabetes (a 90 percent or more of the infections that occur. leading cause of heart disease).

THE US CENTERS FOR DISEASE CONTROL AND KEY PERSONAL HEALTH FACTORS PREVENTION’S (CDC’S) 10 MOST SIGNIFICANT PUBLIC ALCOHOL use cigarette smoking HEALTH ACHIEVEMENTS OF THE 20TH CENTURY EATING HABITS occupational and recreational control of infectious diseases physical inactivity safety decline in deaths from heart disease and STROKE safer sex practices seat belt and helmet use FAMILY PLANNING substance abuse FLUORIDATION of drinking water healthier mothers and babies Contemporary Issues and Challenges motor-vehicle safety Preventive medicine specialists acknowledge the recognition of TOBACCO use as a health hazard many challenges of controlling or eliminating the safer and healthier foods factors that result in the health conditions that are safer workplaces most significant at present. Despite the truly phe- vaccination nomenal strides in health care that have occurred Source: CDC, MMRW Weekly, April 2,1999, 48(12):241–243. in the past 50 years, the emphasis within the American health-care structure remains on treat- Health discoveries in the 1950s and 1960s began ing disease. Factors that influence the success of to connect lifestyle habits with health and disease. prevention measures include cultural and genera- The landmark surgeon general’s report of 1964 tional perceptions, literacy and non-English- established the scientific correlation between ciga- speaking populations, aging of the US population, rette smoking and LUNG disease, notably lung CAN- access to care and mechanisms of care delivery, CER. Research explored the roles of nutrition and and disparities among population groups. exercise in preventing disease and even in the early Cultural and generational perceptions Percep- 1960s issued recommendations for daily “calisthen- tions about health screening, preventive care, and ics” to maintain the physical health of the body. even treatment for diagnosed health conditions Fast food (available in restaurants and from grocery differ among cultures and age groups. Older gen- stores) changed EATING HABITS and body weight, and erations may hold to beliefs that one goes to the health experts noted alarming rises in CARDIOVASCU- doctor only when ill or injured, stemming from LAR DISEASE (CVD) and type 2 DIABETES. limited access and affordability that typified health In 1900 heart disease was the fourth leading care before the emergence of health insurance. cause of death in the United States; by 1977 it had Ethnic groups may be suspicious of Western medi- become, and today remains, number one. Though cine and its intrusive nature or find conventional infections such as HIV/AIDS and HEPATITIS remain sig- medical practices at odds with spiritual or religious nificant threats to personal and public health, the beliefs. CULTURAL AND ETHNIC HEALTH-CARE PERSPEC- greatest challenges are now those that are nearly TIVES and GENERATIONAL HEALTH-CARE PERSPECTIVES exclusively within the realm of individual control. greatly influence compliance with public health Health promotion emphasizes community-based as recommendations, affecting groups that are partic- well as individual preventive efforts that target ularly vulnerable to health conditions, such as car- modifiable risk factors for injury, illness, and dis- diovascular disease or infections such as hepatitis 4 Preventive Medicine and tuberculosis, that current preventive meas- TED DISEASES (STDS), tuberculosis, hepatitis, and ures target. HIV/AIDS, all of which have significant public Literacy A key platform of public health edu- health ramifications. cation efforts is the presentation of information through written materials such as posters, hand- Breakthrough Research and Treatment Advances out informational sheets, brochures, and display At the start of the 20th century doctors marveled at placards. Some studies suggest that up to two the notion that living organisms so small only the thirds of English-speaking individuals lack the magnification of a microscope revealed their exis- functional literacy level to understand the content tence caused the many diseases that ravaged entire of these materials, complete health and risk populations. Perhaps the most profound break- assessment tools such as surveys and question- through in preventive medicine at the start of the naires, or follow written care instructions after 21st century is the mapping of the HUMAN GENOME. procedures such as surgery. In regions where Within reach, and in various stages of research and there are high concentrations of non-English- development, are “smart” drugs that target specific speaking populations, health education materials substances in the body and pharmacogenomic and basic health questionnaires are often available products that will “turn off” predisposing genetic in the dominant languages of such populations. factors for diseases such as HYPERTENSION (high However, most people who do not understand BLOOD PRESSURE), diabetes, and certain cancers. GENE materials the doctor gives them will not say so. THERAPY holds the promise of manipulations that Aging of the US population In 1900, less than may end diseases such as CYSTIC FIBROSIS. 4 percent of the American population—3 million No longer the venue of science fiction is the people—was over the age of 65. In 2000, 35 mil- field of molecular medicine, in which doctors can lion Americans, nearly 13 percent of the popula- redirect cell function. In 2001, after 10 years of tion, were age 65 and older, a 10-fold increase intensive research, a multidisciplinary team of sci- over the span of a century. By 2030 the US entists finished decoding the human genome. The Bureau of the Census projects that 30 percent of unprecedented achievement revealed startling and the population—70 million people—will be over revolutionary insights into the functions of the age 65. Given the rise in the frequency of health human body. The offshoot Microbial Genome Pro- conditions such as cancer, cardiovascular disease, gram, initiated in 1994, continues to unravel the and diabetes as well as the conditions relatively genetic encoding of the organisms that function at specific to the older population such as the most foundational level of organic existence. ALZHEIMER’S DISEASE and PARKINSON’S DISEASE, the In the space of a century, medicine has come from potential demand for health-care services may identifying the existence of the MICROBE to under- quadruple. Efforts to reduce the likelihood for pre- standing the most intimate details of its functions. ventable health conditions takes on increasing sig- Yet even as technology ushers health care into nificance within this scenario. the 21st century and beyond, the challenges of the Access to care and mechanisms of delivery previous century linger. Infectious illnesses, Though 85 percent of Americans have private or though different from those that plagued earlier public health insurance, 15 percent do not. In a generations, remain at the forefront of preventive delivery model predicated on insurance as primary medicine. The first Nobel Prize in Medicine or payer, insurance coverage determines access to Physiology was awarded to Emil von Behring in care. People who do not have health insurance 1901 for discovering the cause of one of the time’s have difficulty receiving health-care services and most deadly diseases, diphtheria. The 1997 award often are then more seriously ill when they do went to Stanley Prusiner for his discovery of receive care. Health experts worry that lack of another new pathogen, the infectious PRION. The access to appropriate health-care services, includ- most rampant infection in the world, HIV/AIDS, ing preventive measures such as immunization, remains incurable. Preventive medicine is on a increases the risk for outbreaks of infectious dis- new, yet familiar, path as the current millennium eases. Of particular concern are SEXUALLY TRANSMIT- moves forward. A accidental injuries Accidental injuries, also motor vehicle accidents. The three most signifi- called unintentional injuries, claim more than cant factors in motor vehicle accident injuries and 100,000 lives each year and are the fifth leading deaths are: cause of death in the United States. Accidental injuries account for nearly half of childhood • Improper restraints—nearly three fourths of deaths. Accidental injuries further account for those who die in motor vehicle accidents are not more than 90 million health-care provider (ambu- wearing seat belts or secured in child seats and latory medical care) visits annually, 10 million of are thrown from the vehicle in the accident. which are for injuries to children. Many accidental •ALCOHOL use—alcohol use is involved in 40 per- injuries are preventable. cent of fatalities and 7 percent of accidents overall. KEY PUBLIC HEALTH MEASURES • Excessive speed—speeding contributes to a TO REDUCE ACCIDENTAL INJURIES third of all motor vehicle accidents, though is a boating safety regulations building occupancy disproportionate factor among male drivers building sprinkler systems regulations between the ages of 16 and 20. carbon monoxide detectors child-resistant container laws emergency exit requirements fire codes Up to a third of motor vehicle accidents involve fireworks restrictions flammability standards combinations of these factors, greatly increasing playground safety standards product labeling requirements the likelihood of injury or death. seat belt, child restraint, smoke detectors Poisoning Accidental poisoning accounts for and helmet laws structural building codes 14,500 deaths and 500,000 injuries that require traffic speed limits vehicle safety standards medical attention each year. More than 60 percent of poisonings are among children under the age of Major Causes of Accidental Injuries 14. Children under the age of 4 account for two There are numerous causes for accidental injuries. thirds of poisonings in children. Poisoning from MOTOR VEHICLE ACCIDENTS lead them, accounting for common OVER-THE-COUNTER (OTC) DRUGS such as 40 percent of those deaths. Poisoning and falls acetaminophen (Tylenol), aspirin, and iron sup- each account for 15 percent. Other common plements can occur with as few as six or eight causes of accidental injuries include choking, fires, tablets, depending on the body weight, age, and recreational activities, and fireworks. health status of the person. Other common Motor vehicle accidents Motor vehicle accidents sources of poisoning among children are prescrip- are the leading cause of death for those between tion medications that adults, particularly grand- the ages of 2 and 33, resulting in more than parents and older caregivers, are taking. Chronic 40,000 deaths each year. Motor vehicle accidents lead poisoning occurs in children exposed to high also account for nearly 3 million injuries for levels of lead such as are present in leaded paints which people seek medical care each year. People applied before 1978. between ages 15 and 25 years and over age 74 Falls More than 14,200 people lose their lives years are at highest risk for injury or death in in falls each year, nearly two thirds of whom are 5 6 Preventive Medicine age 65 and older. About 7.5 million people require to concentrate in the weeks around the Fourth of medical attention for accidental injuries received July and New Year’s Day celebrations. Children in falls, Falls account for nearly a third of medical are at greatest risk for injuries due to fireworks, visits for accidental injury and are most frequent two thirds of which are burns. Cuts to the face, among those under age 14 (2.3 million) and over fingers, and hands, as well as traumatic AMPUTA- age 60 (1.8 million). Child walkers (wheeled TION of fingers and vision-threatening EYE injuries, chairs prewalking children can push around with occur most commonly. their feet) and stairs account for the greatest num- ber of falls among young children. Among older Health Consequences of Accidental Injuries adults, stairs, irregular surfaces, and items such as Though many people fully recover from the throw rugs present the most common falling haz- injuries they receive, some experience residual ards, particularly when lighting is poor as when consequences that may include extended or life- getting up at night to go to the bathroom. Medica- long disability. Among the most significant of such tion side effects such as drowsiness and balance consequences are disturbances often are contributing factors to falls among older adults. • TRAUMATIC BRAIN INJURY (TBI) Choking Choking is a significant risk among • SPINAL CORD INJURY the very young, the very old, and those who have • loss of limbs, fingers, and toes temporary or long-term SWALLOWING DISORDERS. Choking accounts for 4,200 deaths each year as • extensive scarring and disfigurement well as nearly 600,000 medical care visits. Two • VISION IMPAIRMENT thirds of choking episodes involve food. Balloons, coins, and candy are also choking hazards for Even short-term recovery, such as from frac- children. tures, burns, and lacerations, disrupts regular Fires Nearly 4,000 people lose their lives in activities such as school and work. residential fires each year, most of whom die from inhaling toxic gases and smoke (ASPHYXIATION) Preventive Measures rather than BURNS. Health-care providers treat Many, if not most, accidental injuries are prevent- another 500,000 people a year for burns received able through measures that require little extra in residential fires, about half of which are serious effort. Often people are unaware of the risks of enough to result in lifelong disability. their behaviors or believe their participation is not Recreational activities Recreational activities enough to expose them to such risks; for example, result in 5 million injuries that require medical driving only a few blocks to the store without attention each year. Water activities are the most wearing a seat belt or turning attention away from lethal, accounting for 4,000 deaths annually, with a child in a swimming pool to answer the tele- 25 percent of them among children. Basketball, phone. Overall, however, 90 percent of unin- football, and baseball collectively account for the tended injuries occur in or within two miles of highest number of injuries resulting from partici- home. pation in structured athletic activities, nearly 1 Key preventive measures among children, for million per year. Bicycling accidents account for whom accidental injuries carry high risk of serious about 500,000 injuries and 800 deaths annually. disability or death, include requiring use of appro- Each year playground injuries send more than priate safety gear and supervision when participat- 200,000 children for medical care and over 2 mil- ing in recreational activities. Health experts lion adults require medical attention for injuries estimate that proper helmet use could prevent 80 related to overexertion. percent of the 800 deaths and thousands of seri- Fireworks Though fireworks are illegal in most ous head injuries that result from bicycle acci- federal, state, and municipal jurisdictions, fire- dents, most of which do not involve collisions works account for more than 9,000 injuries that with motor vehicles, among children and adults require medical attention each year. Injuries tend alike. Properly worn helmets reduce the risk of antibiotic prophylaxis 7 head injury by 80 percent when using skate- and women in LABOR who are group B-strep posi- boards, roller skates, and inline skates as well as tive or with prolonged rupture of membranes. for downhill skiing and horseback riding. Bacterial endocarditis is a serious infection that Taking small bites and chewing food thor- can result in permanent damage to the heart, oughly before swallowing are important measures especially the heart valves, or in death. The heart to prevent choking in children and adults. Many valves are particularly vulnerable to bacteria cul- older adults use “scheduled DOSE” medication con- tures that establish themselves in their tissues. tainers that may not be child resistant. A signifi- This risk increases when there are abnormalities of cant portion of poisonings among children occurs blood flow through the heart that can allow blood when children get into their grandparents’ med- to slow or stagnate in the heart’s chambers, or ications. Many medications have coatings that when there is damage to the valves that prevents make them taste sweet, giving children the normal movement. Invasive procedures, particu- impression that they are candy. larly in the MOUTH (such as tooth extraction or root canal) and gastrointestinal tract, which are KEY PERSONAL MEASURES rich in natural BACTERIA, provide opportunity for FOR PREVENTING ACCIDENTAL INJURIES bacteria to enter the bloodstream and travel to the • wear seat belts and place children under 60 pounds in heart. appropriate child safety seats in the back seat The typical regimen is a single large dose of an • wear a helmet when riding a bicycle or horse, downhill ski- antibiotic one hour before the procedure, usually ing, and wheeled skating, and other appropriate safety gear taken by mouth. The recommended antibiotic is for sports and athletic activities amoxicillin or cephalexin, azithromycin, or clar- • store medications in their original labeled containers, with ithromycin for people who are allergic to peni- childproof lids or caps, and in locked cabinets or drawers cillin. People who are already taking prophylactic • install handrails and lighting for stairways and hallways, and antibiotics for other purposes should let their doc- use child gates or child locks to block access to stairs, tors or dentists know; the health-care practitioner kitchens, bathrooms, garages, and other hazardous areas will likely choose a different antibiotic for specific • install handrails in showers and baths, especially for the prophylaxis to appropriately target the potential elderly classification of bacteria. • install smoke detectors and put in fresh batteries every six months ANTIBIOTIC PROPHYLAXIS ADVISED • install car horns or buzzers that operate while the vehicle is When Any of These Conditions Exist in reverse cardiopulmonary shunt cyanotic CONGENITAL HEART DISEASE HEART TRANSPLANTATION hypertrophic CARDIOMYOPATHY See also ATHLETIC INJURIES; DOMESTIC VIOLENCE; mitral valve prolapse previous bacterial ENDOCARDITIS FRACTURE; HEAVY-METAL POISONING; HEIMLICH MANEU- with regurgitation prosthetic heart valve VER; HIP FRACTURE IN OLDER ADULTS; NOISE EXPOSURE RHEUMATIC HEART DISEASE uncorrected congenital heart AND HEARING; OCCUPATIONAL HEALTH AND SAFETY; POI- malformations SON PREVENTION; VIOLENCE. Before Any of These Procedures antibiotic prophylaxis A DOSE or brief course of CARDIAC CATHETERIZATION CYSTOSCOPY ANTIBIOTIC MEDICATIONS before invasive dental, sur- gastrointestinal ENDOSCOPY periodontal surgery gical, or diagnostic procedures for people who placement of bands for prophylactic professional dental have had certain HEART operations or who have braces cleaning certain heart conditions to help prevent bacterial root canal surgery (laparoscopic or open) ENDOCARDITIS (INFLAMMATION and INFECTION of the tissue biopsy tooth extraction heart). Doctors may, though do not always, sug- gest antibiotic prophylaxis for people who have Though numerous studies suggest the value of other heart conditions as well as certain IMMUNE antibiotic prophylaxis, none definitively supports DISORDERS, HIV/AIDS, type 1 DIABETES, active CANCER, or refutes it, giving rise to some disagreement 8 Preventive Medicine among health-care providers as to whether it truly 1. Encourage people never to start smoking. lowers the risk for bacterial endocarditis. However, 2. Encourage people who do smoke to stop, no the American Heart Association, the American matter how long they have been smoking. Dental Association, the Infectious Diseases Society of America, the American Academy of Pediatrics, These efforts emphasize coordinated educa- and the American Society for Gastrointestinal tional approaches among schools, youth organiza- Endoscopy jointly recommend antibiotic prophy- tions, community organizations, sports and laxis in specific circumstances. athletic organizations, and health-care providers. See also IMMUNODEFICIENCY; VALVULAR HEART DIS- As well, a number of class-action lawsuits against EASE. TOBACCO companies have forced payments from them to fund health care for smoking-related antismoking efforts The US health community chronic illnesses and antismoking efforts. General has targeted cigarette smoking since the landmark practice guidelines for physicians include screen- 1964 surgeon general’s report, Smoking and Health: ing for tobacco use and recommendation of SMOK- Report of the Advisory Committee to the Surgeon Gen- ING CESSATION methods for people who do smoke. eral of the Public Health Service, formally identified the connections between smoking and health con- KEY ANTISMOKING EFFORTS ditions such as LUNG CANCER, laryngeal CANCER, and • intensive education of youth through the schools, advertis- chronic BRONCHITIS. A single sentence from the ing, community programs, celebrity advocates, and other 387-page document summarized what was to targeted approaches become a major preventive health emphasis in the • effective and accessible SMOKING CESSATION methods United States for the ensuing decades: “Cigarette • strong warning labels on cigarette packages smoking is a health hazard of sufficient impor- • stringent enforcement of age-restricted access to TOBACCO tance in the United States to warrant appropriate products remedial action.” • prohibition of smoking in the workplace, public buildings At the time of the 1964 surgeon general’s and venues, and other indoor locations report, 70 million Americans were smokers. The US Centers for Disease Control and Prevention The 1964 report that first linked cigarettes and (CDC) reports the number of current smokers cancer and subsequent surgeon general’s reports remains fairly stable at about 46.2 million, 8.6 on smoking and health are available on the CDC’s million of them becoming ill as a result each year. Web site (www.cdc.gov/tobacco/sgr/index.htm). Health experts project that more than half of peo- See also CANCER PREVENTION; LIFESTYLE AND ple who continue to smoke, about 25 million, will HEALTH; SMOKING AND CANCER; SMOKING AND CARDIO- die of smoking-related diseases. Antismoking VASCULAR DISEASE; SMOKING AND HEALTH; TOBACCO USE efforts have a two-prong focus: OTHER THAN SMOKING. B birth defects More than 150,000 infants born birth defects. The US Food and Drug Administra- each year in the United States have structural or tion (FDA), which regulates drug approval and functional abnormalities present at birth, ranging use in the United States, assigns pregnancy cate- from mild to severely debilitating or fatal. Sub- gories to medications to help doctors and women stances and circumstances that can cause birth assess the risks of using the medications during defects are teratogenic. Some birth defects, pregnancy. These categories are notably FETAL ALCOHOL SYNDROME (FAS) and those that occur as a SIDE EFFECT of medications, are • pregnancy category A: medications for which entirely preventable. GENE mutations, some of numerous clinical studies have shown no which are hereditary mutations and many of adverse effects in pregnancy which are spontaneous or isolated mutations, • pregnancy category B: medications for which cause many birth defects. The risk for the genetic animal studies have shown no adverse effects condition DOWN SYNDROME (trisomy 21), a chromo- or for which there are limited studies somal disorder, rises with the mother’s age, the • pregnancy category C: medications for which only birth defect doctors know for certain does so. there are no studies to indicate either safety or Many other birth defects are not preventable, hazard during pregnancy however, and may not be detectable before birth. The risk for many other birth defects correlates • pregnancy category D: medications for which to exposures during PREGNANCY, such as to the viral clinical studies demonstrate risk to the develop- infections RUBELLA (German measles), CYTOMEGA- ing fetus, although the benefits to the mother LOVIRUS (CMV), and CHICKENPOX, and to the parasitic of the medication may outweigh the risks to INFECTION TOXOPLASMOSIS. These infections can the fetus cause mild to significant birth defects, ranging • pregnancy category X: medications for which from congenital CATARACT and HEARING LOSS to clinical studies demonstrate clear evidence of HEART malformations. Avoiding these exposures damage to the developing fetus prevents any consequential damage to the devel- oping FETUS. Doctors generally consider pregnancy category A and B medications safe for women to use during Teratogenic Medications pregnancy, though approach the use of pregnancy Doctors widely prescribed the DRUG thalidomide in category C medications with caution. Women who the 1950s and early 1960s as a treatment for are pregnant or planning pregnancy should thor- MORNING SICKNESS until they discovered the high oughly discuss benefits and risks with their doc- incidence of limb deformities associated with its tors before taking or continuing to take category D use. Thalidomide marked a turning point in public medications and should never take pregnancy cat- awareness about the teratogenic hazards of med- egory X medications. Pregnant women should ications as well as in research efforts to identify check with their doctors or pharmacists about any those hazards. Numerous medications can cause medications they are taking when they become

9 10 Preventive Medicine

COMMON BIRTH DEFECTS Birth Defect Health Risk to Infant Preventive Measures cleft defects (craniofacial negligible with reconstructive surgery possibly folic acid supplementation clefts) difficulty nursing, eating, and with speech GENE mutations have been identified when uncorrected

FETAL ALCOHOL SYNDROME (FAS) mild to moderate physical deformities, abstinence from ALCOHOL during PREGNANCY mental retardation, and BEHAVIORAL DISORDERS is fully preventive genitourinary defects negligible with reconstructive surgery none known EPISPADIAS absence of both kidneys is usually fatal gene mutations have been identified HYPOSPADIAS KIDNEY deformities

INFECTION mild to severe deformities, depending on vaccination for measles, rubella, and CHICKENPOX gestational age at time of infection chickenpox prior to pregnancy CYTOMEGALOVIRUS (CMV) blindness avoid contact with cat feces (such as through MEASLES cleaning litter boxes or handling dirt RUBELLA outdoors) and with uncooked meat to TOXOPLASMOSIS prevent toxoplasmosis HERPES frequent HAND WASHING to reduce risk for infectious diseases in general major HEART defects significant, with high risk for death none known hypoplastic left heart lifelong complications remain even with comprehensive PRENATAL CARE for early syndrome (HLHS) successful surgery detection and treatment planning; infant will tetralogy of Fallot these defects are the leading reason for heart require emergency treatment at birth transposition of the great transplantation in children gene mutations have been identified arteries (TPA) minor heart defects negligible with appropriate treatment none known ATRIAL SEPTAL DEFECT (ASD) (usually surgical repair) comprehensive prenatal care for early PATENT DUCTUS ARTERIOSUS detection and treatment planning (PDA) gene mutations have been identified VENTRICULAR SEPTAL DEFECT (VSD)

NEURAL TUBE DEFECTS significant folic acid supplementation before CONCEPTION anencephaly anencephaly is always fatal through the first 28 days of pregnancy cuts SPINA BIFIDA spina bifida often causes deformity and risk in half lower body PARALYSIS, including loss of bowel many health experts recommend all women and BLADDER function of childbearing age take folic acid supplements (400 micrograms per day) gene mutations have been identified birth defects 11

COMMON TERATOGENIC MEDICATIONS Medication Taken to Treat Kinds of Birth Defects Pregnancy Category X Medications antimetabolitic CHEMOTHERAPY CANCER craniofacial anomalies, anencephaly, drugs (aminopterin, cytarabine, absence of kidneys, HEART malformations methotrexate, methyl aminopterin) risk highest in first trimester danazol (Danocrine) ENDOMETRIOSIS, FIBROCYSTIC BREAST PSEUDOHERMAPHRADITISM DISEASE, hereditary ANGIOEDEMA

finasteride (Propecia, Proscar) male pattern baldness (Propecia), malformation of male GENITALIA BENIGN PROSTATIC HYPERTROPHY (BPH) (Proscar) pregnant women are at risk if they handle the pills

flurazepam (Dalmane) SLEEP DISORDERS isolated cleft palate lovastatin (Mevacor) HYPERLIPIDEMIA SPINA BIFIDA retinoic acid, isotretinoin severe ACNE craniofacial anomalies, heart malformations, (Accutane) limb deformities, LIVER malformations highest risk in early first trimester temazepam (Restoril) sleep disorders isolated cleft palate triazolam (Halcion) sleep disorders isolated cleft palate thalidomide (Thalomid, Synovir) HANSEN’S DISEASE (leprosy), severely shortened or missing long bones in AIDS-related wasting disease the arms and legs (cachexia) warfarin (Coumadin) blood clots (preventive) constellation of birth defects commonly referred to as fetal warfarin syndrome multiple skeletal deformities and malformations occur with exposure in early first trimester CENTRAL NERVOUS SYSTEM damage occurs with exposure in second and third trimesters

Pregnancy Category D Medications angiotensin-converting enzyme HYPERTENSION KIDNEY deformities or absence of kidneys, limb (ACE) inhibitor medications contractures, patent ductus arteriosus (PDA) (benazepril, captopril, enalapril, risk highest in second and third trimesters fosinopril, lisinopril, moexipril, ramipril, trandolapril) 12 Preventive Medicine

Medication Taken to Treat Kinds of Birth Defects angiotensin II receptor antagonist hypertension heart malformations, kidney deformities or medications (losartan, valsartan, absence of kidneys, widespread organ candesartan, irbesartan) damage risk highest in third trimester cimetidine (Tagamet) GASTROESOPHAGEAL REFLUX DISORDER NEURAL TUBE DEFECTS (GERD), PEPTIC ULCER DISEASE phenytoin (Dilantin) SEIZURE DISORDERS constellation of birth defects commonly referred to as fetal phenytoin syndrome craniofacial anomalies, deformities of the hands and feet, rib deformities sulfasalazine (Azulfidine) INFLAMMATORY BOWEL DISEASE (IBD), neural tube defects especially ulcerative COLITIS valproic acid (Depakene) seizure disorders craniofacial anomalies, spinal deformities

pregnant and before taking any new medications KEY MEASURES FOR PREVENTING BIRTH DEFECTS during pregnancy. The risk for teratogenic effects • folic acid supplementation for all women of childbearing may increase when a woman takes multiple med- age, whether or not they are pregnant or planning PREG- ications, even when those medications are preg- NANCY nancy category A and B classifications. • comprehensive PRENATAL CARE during pregnancy • no alcohol consumption during pregnancy or when Prenatal Care attempting to conceive PRENATAL CARE lowers the risk for many birth • vaccination before pregnancy for RUBELLA, CHICKENPOX, defects. Folic acid (folate) supplementation signifi- MEASLES cantly reduces the risk for NEURAL TUBE DEFECTS • GENETIC COUNSELING when known hereditary conditions exist such as SPINA BIFIDA and also improves blood GLU- in either parent or a previous child was born with birth COSE (sugar) control in women who have diabetes. defects Doctors recommend folic acid supplementation beginning before CONCEPTION when possible, and See also ABORTION; CEREBRAL PALSY; CHROMOSOMAL especially for women who are or have been taking DISORDERS; CLEFT PALATE/CLEFT PALATE AND LIP; CON- oral contraceptives (birth control pills), which GENITAL ANOMALY; GENETIC DISORDERS; INHERITANCE lower folic acid even further. Maternal blood tests PATTERNS. for rhesus (Rh) factor and ALPHA FETOPROTEIN (AFP), ULTRASOUND, and in utero diagnostic procedures such as CHORIONIC VILLI SAMPLING (cvs) and AMNIO- building-related illness A health condition that CENTESIS can detect many birth defects before birth, arises as the result of problems within a structure, allowing the mother and her health-care provider such as an office, school, or home. The US Envi- to make decisions and appropriate preparations. ronmental Protection Agency (EPA) defines a Other prevention efforts target educating women building-related illness (also called a BRI) as one of childbearing age about the benefits of folic acid that supplementation and prenatal care, as well as the risks of behaviors such as alcohol consumption • causes clinically observable symptoms and during pregnancy. signs, such as COUGH and FEVER, that extend building-related illness 13

beyond the length of time a person spends in • BRONCHITIS, ASTHMA, chronic LARYNGITIS, pneu- the building monia, CHRONIC OBSTRUCTIVE PULMONARY DISEASE • doctors can diagnose as a specific condition (COPD), and cancers resulting from exposure to ENVIRONMENTAL CIGARETTE SMOKE or industrial • requires correction of an identifiable problem chemicals within the building Doctors diagnose and treat building-related ill- Building-related illnesses include nesses as they would similar illnesses arising from •LEGIONNAIRES’ DISEASE, a type of PNEUMONIA that other causes. Because exposure and illness are results from bacterial contamination of building often chronic, recovery may take extended time. heating and air-conditioning systems Contemporary building codes and practices help prevent many of the circumstances that cause • upper respiratory illnesses due to toxic molds building-related illnesses, though INDOOR AIR QUAL- and fungi ITY remains a significant concern. • asbestos-related lung disease See also ASBESTOSIS; ASPERGILLOSIS; LUNGS; RADON • radon-induced LUNG CANCER EXPOSURE; SICK BUILDING SYNDROME. C

cancer prevention CANCER claims more than INFECTION, such as LIVER CANCER that results from 500,000 lives each year in the United States, and chronic HEPATITIS. Avoiding hepatitis through vacci- nearly nine million Americans are cancer sur- nation and appropriate preventive practices elimi- vivors. Yet all cancers related to TOBACCO use and nates the cancers it might otherwise cause. excessive ALCOHOL consumption are preventable, Other cancer prevention efforts target early and cancer experts believe lifestyle changes could detection of precancerous and cancerous condi- prevent a third or more of most other cancers. tions through screening methods. Early detection The first correlation between a controllable allows the highest success for treatment. Nearly all external factor and the development of cancer CERVICAL CANCER results from infection with HUMAN occurred more than a century ago with the obser- PAPILLOMAVIRUS (HPV), which is transmitted sexu- vance that cigarette smokers died younger than ally, and nearly all COLORECTAL CANCER arises from nonsmokers. Researchers have since linked ciga- intestinal polyps. Screenings that detect precan- rette smoking to nearly a dozen types of cancer, cerous conditions, such as intestinal polyps notably lung, laryngeal, esophageal, STOMACH, pan- (COLONOSCOPY) and cervical DYSPLASIA (PAP TEST), creatic, colorectal, prostate, and BREAST cancers as permit doctors to intervene before the circum- well as myeloid LEUKEMIA. Over the past 40 years stance evolves into one of cancer. scientists have established numerous connections Some health experts advocate taking supple- between other external factors and different types ments of antioxidants (such as vitamin C and vita- of cancer. Many cancer prevention efforts today min E), and in particular COENZYME Q10, to boost the target those connections, most of which are body’s ability to resist cancerous growth. Clinical lifestyle factors. Lifestyle factors associated with an research studies of coenzyme Q10 suggest various increased risk for many types of cancer include health benefits for this potent antioxidant, though to date those investigating the cancer-fighting capabili- • tobacco use (particularly cigarette smoking) ties of other antioxidants have failed to demonstrate • no regular physical exercise such effect. Consuming substances that decrease inflammatory markers, such as fish oils and aged • EATING HABITS that favor high-fat, low-fiber, and garlic, may also have preventive benefit. low fruit and vegetable consumption See also CANCER RISK FACTORS; CERVICAL INTRAEPI- • OBESITY THELIAL NEOPLASIA (CIN); LIFESTYLE AND HEALTH; SCREEN- • excessive alcohol consumption ING FOR CANCER.

Though the links between cancer and some cardiovascular disease prevention CARDIOVASCU- lifestyle factors are less than finite, health experts LAR DISEASE (CVD) is the leading cause of death and believe lifestyle modifications to minimize the disability among Americans. It accounts for nearly roles of these factors may play in causing cancer a million deaths each year and disables as many as could reduce the development of new cancers by 20 million people, limiting their capabilities for about a third and are beneficial for health overall. work and recreational activities. More than 60 Some cancers occur as a consequence of chronic million Americans live with some form of CVD. 14 cardiovascular disease prevention 15

SCREENING FOR EARLY DETECTION OF CANCER Type of Cancer Routine Screening* BREAST CANCER monthly BREAST SELF-EXAMINATION (BSE) annual breast examination from health-care provider annual MAMMOGRAM for women beginning at age 40 years

CERVICAL CANCER PAP TEST every one to three years beginning with the start of sexual activity or at age 18 colorectal CANCER annual FECAL OCCULT BLOOD TEST (FOBT) beginning at age 50 in combination with one of the following: • flexible sigmoidoscopy every five years OR • double-contrast BARIUM ENEMA every five years OR • COLONOSCOPY every 10 years oral cancer (lips and structures of the MOUTH) annual dental examination

OVARIAN CANCER annual pelvic examination

PROSTATE CANCER annual DIGITAL RECTAL EXAMINATION (DRE) to palpate the PROSTATE GLAND for growths beginning at age 45 annual PROSTATE-SPECIFIC ANTIGEN (PSA) blood test beginning at age 50

SKIN CANCER regular self-examination of all SKIN surfaces skin examination by dermatologist every three to five years after age 40

TESTICULAR CANCER monthly TESTICULAR SELF-EXAMINATION physician examination with every routine physical for men between the ages of 15 and 35 *For people who have no greater than normal risk for developing cancer. Those who have increased risk because of personal or family health history should follow the recommendations of their physicians.

Yet health experts believe that nearly 90 percent affect every person to some degree. Even in the of acquired CVD is preventable. Though people presence of these risks, however, cardiovascular commonly perceive CVD, also called HEART disease, disease remains primarily the evolution of lifestyle as a condition affecting older adults, its genesis is and behavior. These are modifiable (mutable) risk often in ADOLESCENCE. Some research studies have factors; it is possible to change them and thus the found early-stage ATHEROSCLEROSIS and CORONARY influences they exert on the development of car- ARTERY DISEASE (CAD) in teenagers whose lifestyles diovascular disease. Cigarette smoking, OBESITY, are sedentary and feature EATING HABITS high in fast lack of regular physical exercise, and eating habits foods. are the leading factors that result in acquired Age and heredity are primary factors in the (noncongenital) heart disease. Accordingly, per- development of cardiovascular disease. It is not, at sonal prevention efforts target these habits. Key present, possible to do much to change their among such efforts are effects on the cardiovascular system. Doctors con- sider them fixed (immutable) risk factors that • SMOKING CESSATION programs 16 Preventive Medicine

FORMS OF CARDIOVASCULAR DISEASE replace arteries supplying the heart with blood

ANEURYSM ANGINA PECTORIS that are clogged with vascular debris (arterial ARRHYTHMIA ATHEROSCLEROSIS plaque). BUNDLE BRANCH BLOCK CARDIOMYOPATHY Prevention guidelines established in 2004 take cerebral vascular disease CONGENITAL HEART DISEASE the preventive role of medications a step further, (STROKE) CORONARY ARTERY DISEASE (CAD) recommending that most people who have heart ENDOCARDITIS HEART ATTACK attacks take a “statin” medication afterward to HEART FAILURE HYPERLIPIDEMIA prevent subsequent heart attacks. Statins belong HYPERTENSION INTERMITTENT CLAUDICATION to the HMG-CoA reductase inhibitor family of ISCHEMIC HEART DISEASE (IHD) LONG QT SYNDROME drugs that came into widespread use in the 1990s MYOCARDITIS (LQTS) as lipid-lowering medications. Extensive longitudi- PERICARDITIS PERIPHERAL VASCULAR DISEASE nal studies (studies over time involving varied primary PULMONARY (PVD) populations) conducted in several countries, HYPERTENSION RAYNAUD’S SYNDROME including the United States, demonstrated the fur- RHEUMATIC HEART DISEASE SICK SINUS SYNDROME ther ability of statins to significantly reduce the VALVULAR HEART DISEASE WOLFF-PARKINSON-WHITE risk for heart attack in people who have already SYNDROME experienced one or more heart attacks, even when blood cholesterol levels are within heart- healthy ranges. • WEIGHT LOSS AND WEIGHT MANAGEMENT programs Because many people do not know they have • nutrition and dietary education that empha- cardiovascular disease until they have heart sizes eating habits high in fruits, vegetables, and attacks or strokes, statin therapy becomes a signifi- whole grain products with fewer highly cant preventive measure for future heart condi- processed and fried foods tions. However, statins deplete COENZYME Q10, an important antioxidant that has powerful anti- • encouraging daily physical exercise through inflammatory actions. Taking a coenzyme Q10 education and activities organized through supplement while on statin therapy helps restore schools, workplaces, and community organiza- this vital substance. Many people also benefit from tions ASPIRIN THERAPY, which provides a mild anticoagu- • cholesterol screening with lifestyle modifica- lant effect to reduce the risk for blood clots. tions and lipid-lowering medications, as appro- priate, to maintain healthy levels, and LEARN THE WARNING SIGNS OF aggressive therapeutic interventions for people HEART ATTACK AND HOW TO RESPOND who have high blood cholesterol Health experts recommend that all adults learn • BLOOD PRESSURE checks to detect and treat HYPER- the warning signs of HEART ATTACK and become TENSION trained in CARDIOPULMONARY RESUSCITATION (CPR). • DIABETES screening programs, as CVD is a lead- Schools, fire departments, community organiza- ing complication of diabetes and many of the tions, and health agencies typically offer CPR same lifestyle factors contribute to both health classes for minimal or no fee. problems Though some studies suggest consumption of Medical interventions can further reduce the red wine lowers the risk for heart disease, most effects of lifestyle factors to lower the risk for car- doctors recommend minimizing ALCOHOL consump- diovascular disease. These interventions may tion overall because of other health risks (such as include lipid-lowering medications to reduce CHO- LIVER disease). Foods that are high in the B vita- LESTEROL BLOOD LEVELS, antihypertensive medica- mins, vitamin C, and vitamin E contain natural tions to lower blood pressure, anti-arrhythmia antioxidants that help counter the destructive con- medications to regulate the beating of the heart, sequences of accumulated metabolic waste (oxi- and CORONARY ARTERY BYPASS GRAFT (CABG)to dants). Many doctors recommend the nutritional community sanitation 17 supplement coenzyme Q10, which several studies are combination products, such as MMR (MEASLES, have shown can improve the ability of cells to resist MUMPS, RUBELLA) and DTP (diphtheria, tetanus, damage and to repair themselves. Cardiovascular pertussis). Some vaccinations confer lifelong disease prevention is a comprehensive process that IMMUNITY (protection from INFECTION) while others encompasses numerous facets of lifestyle and phys- require periodic booster vaccines. iology. The more risk factors an individual can con- There is some concern that the mercury in trol, the greater the preventive benefit. thimerosal, used to preserve some vaccines, exposes young children to levels of mercury that KEY MEASURES FOR PREVENTING far exceed established guidelines. In 1999 a num- CARDIOVASCULAR DISEASE ber of US health agencies joined forces to urge • Do not smoke. development of thimerosal-free vaccines, which • Get 30 to 45 minutes of exercise daily. are now available for most vaccines recommended • Eat appropriate portion sizes. for children age 6 years and younger. Efforts con- • Eat more fruits, vegetables, and whole grains and fewer tinue to reduce or eliminate thimerosal in all vac- processed and fried foods. cines. Parents should ask for their children to • Get regular BLOOD PRESSURE and blood cholesterol level receive thimerosal-free vaccines. When this is not checks. possible, parents should ask for children to receive single-agent rather than combination vaccinations See also AGING, CARDIOVASCULAR CHANGES THAT to reduce mercury exposure as much as possible. OCCUR WITH; ANTIOXIDANT; DIET AND CARDIOVASCULAR For nearly all children the benefits of vaccination HEALTH; LIFESTYLE AND HEALTH; MEDICATIONS TO TREAT far outweigh the potential risks associated with CARDIOVASCULAR DISEASE; NUTRITIONAL NEEDS; PHYSICAL mercury exposure. EXERCISE AND CARDIOVASCULAR HEALTH; RISK FACTORS Children who do acquire the infectious disease FOR CARDIOVASCULAR DISEASE. rather than receive the vaccination also develop immunity, though the course of the disease can childhood diseases Until the advent of vaccines include serious complications and exposes count- in the middle of the 20th century, infectious child- less other people to infection as well. Measles can hood diseases such as DIPHTHERIA and PERTUSSIS cause severe HEARING LOSS, mumps can result in (whooping cough) were the leading cause of male sterility, and HEPATITIS can cause LIVER failure. death among children under age 18. Vaccinations Rubella and chickenpox (also called varicella) can have virtually eliminated some communicable dis- cause BIRTH DEFECTS in unborn children whose eases such as SMALLPOX (for which doctors no mothers get the disease in PREGNANCY. longer routinely administer vaccinations) and See also HEAVY METAL POISONING; PREVENTIVE POLIOMYELITIS. HEALTH CARE AND IMMUNIZATIONS.

ROUTINE CHILDHOOD VACCINATIONS community sanitation Some of the most far- CHICKENPOX DIPHTHERIA reaching improvements in public health have Haemophilus influenzae hepatitis A arisen not from laboratory experiments or techno- type b (Hib) pneumonia hepatitis B logical discoveries but rather from the mundane INFLUENZA (the flu) MEASLES aspects of everyday life. Community health DRINK- MUMPS PERTUSSIS (whooping ING WATER STANDARDS, sewage treatment and dis- pneumococcal pneumonia cough) posal, and garbage collection and disposal POLIOMYELITIS RUBELLA (German measles) influence health and LIFE EXPECTANCY as much as tetanus any medical intervention. Ancient Rome provides the earliest archaeolog- Because of vaccination programs, most Ameri- ical evidence of the understanding of these corre- cans born after 1970 have not experienced the lations. The city’s design featured elaborate infectious childhood diseases that caused illness networks of aqueducts (water conduits), public for their parents as children. Some vaccinations toilets and baths, and sewage drainage systems. 18 Preventive Medicine

These infrastructures established and maintained BORNE ILLNESSES. In such times and circumstances separation among living areas, clean water, and personal bathing was more likely to spread disease waste management. Though perhaps imple- than result in cleanliness. mented as much as for aesthetic purposes as for By the start of the 20th century most industri- health reasons, the health benefits of such separa- alized countries incorporated public sanitation tions were clear to ancient Romans who wrote practices to separate sewage from drinking water about them, such as Marcus Vitruvius Pollio supplies and to promote community as well as (90–20 B.C.E.) who wrote extensively about personal hygiene. Throughout the United States Roman architecture and engineering. today strict regulations govern community sanita- Not until the 19th century and its many discov- tion, establishing processes for disposing of eries in microbiology did physicians finally con- garbage and sewage as well as for maintaining the nect community sanitation, PERSONAL HYGIENE, and purity of drinking water and controlling living public health. In the millennia between, unsani- conditions. However, inadequate sanitation tary and crowded living conditions fostered rav- remains a key cause of disease and death in devel- aging epidemics of CHOLERA (from contaminated oping parts of the world that lack appropriate water); bubonic plague (from flea-infested rats); mechanisms for community and personal hygiene. yellow FEVER (from mosquitoes); and infectious See also HAND WASHING; HEALTH EDUCATION; HEALTH diseases such as TUBERCULOSIS, SMALLPOX, and FOOD- RISK FACTORS; WATERBORNE ILLNESSES. D

diabetes prevention DIABETES is emerging as one ment. In particular, exercise improves cell sensitiv- of the most significant health concerns facing the ity to insulin. Numerous clinical studies have United States in the 21st century. Approximately shown that 30 minutes a day of moderate physical 18 million Americans have diabetes and 16 mil- activity such as walking, coupled with weight loss lion have prediabetes, a condition of INSULIN RESIST- of 5 to 10 percent, improves insulin resistance ANCE that has a high risk for progressing to more effectively than do antidiabetes medication. diabetes. Prevention efforts target type 2 diabetes, Diabetes is a leading cause of CARDIOVASCULAR DIS- which primarily appears in adults as a manifesta- EASE (CVD), KIDNEY disease, blindness, PERIPHERAL tion of converging lifestyle factors. About 95 per- VASCULAR DISEASE (PVD), and limb AMPUTATION. cent of diabetes in the United States is type 2, which many researchers and doctors believe KEY MEASURES FOR PREVENTING DIABETES appropriate preventive measures that focus on • 30 to 45 minutes of physical exercise daily EATING HABITS and physical exercise can eliminate. • weight loss if necessary to achieve a BODY MASS INDEX (BMI) Type 1 diabetes, which typically features sudden below 25 onset in childhood or ADOLESCENCE, is an autoim- • diet that features fruits, vegetables, and whole grain prod- mune disorder. Most researchers do not consider ucts with fewer processed and fried foods type 1 diabetes preventable through lifestyle mod- • annual blood GLUCOSE (sugar) test beginning at age 40 years ifications although lifestyle measures can signifi- (sooner in women who have had GESTATIONAL DIABETES) cantly influence insulin EFFICACY and the development of complications related to diabetes. See also AUTOIMMUNE DISORDERS; DIET AND CARDIO- The discovery of INSULIN replacement therapy in VASCULAR HEALTH; PHYSICAL EXERCISE AND CARDIOVAS- the early 20th century provided the first viable CULAR HEALTH. treatment for diabetes, which until that time had been a diagnosis of death. Nearly 100 years later drinking water standards Clean water is funda- insulin replacement therapy remains the only mental to health. In 1974 the US Congress passed treatment for type 1 diabetes. In the 1980s oral into legislation the Safe Drinking Water Act ANTIDIABETES MEDICATIONS became available to treat (SDWA), which the Environmental Protection type 2 diabetes. Many of these medications work Agency (EPA) administers and enforces. Amended by increasing cellular sensitivity to insulin. Most in 1986 and 1996, the SDWA regulates all public type 2 diabetes develops over years to decades and drinking water systems in the United States as manifests after age 40 years, though doctors are well as the sources for drinking water supplies. diagnosing the condition in an increasing number Regulations define the operational parameters for of adolescents. Doctors and researchers attribute maintaining safe drinking water systems. Though the increase in young-onset type 2 diabetes to the the SDWA does not apply to private wells that rise in OBESITY among younger people. serve fewer than 25 people, the US Food and Drug Diet and exercise are the major lifestyle factors Administration (FDA) encourages those who that contribute to type 2 diabetes. Improvements obtain their drinking water from private wells to in both can delay or prevent the disease’s develop- maintain similar clean water standards. 19 20 Preventive Medicine

HEALTH RISKS OF DRINKING WATER CONTAMINANTS Contaminant Potential Health Risks disinfectants and disinfectant by-products localized irritation, CANCER, neurologic, LIVER, KIDNEY chlorine, chloramine, chlorite EYE/NOSE irritation, ANEMIA bromate, haloacetic acid increased cancer risk trihalomethane increased cancer risk, liver disease, kidney disease, NERVOUS SYSTEM dysfunction metals and minerals neurologic, SKIN, kidney, liver, thyroid, circulatory asbestos INTESTINAL POLYP arsenic skin and circulatory problems, increased cancer risk copper liver and kidney damage cyanide nervous system damage, thyroid dysfunction lead developmental delays, kidney damage mercury kidney damage selenium circulatory damage, HAIR loss pathogenic microorganisms GASTROENTERITIS (NAUSEA, vomiting, DIARRHEA) Giardia lamblia (PARASITE) GIARDIASIS Cryptosporidium (parasite) CRYPTOSPORIDIOSIS Fecal coliform (BACTERIA) generalized gastroenteritis Escherichia coli (bacteria) E. coli gastroenteritis legionella LEGIONNAIRES’ DISEASE (PNEUMONIA) organic chemicals fertilizers, herbicides, industrial chemical altrazine, carbofuran, 1,2-dibromo-3-chloropropane reproductive dysfunction (DBCP), dioxin, ethylene dibromide, methoxychlor increased cancer risk dichloromethane, dichloropropane, heptachlor, liver dysfunction hexachlorobenzene, pentachlorophenol, anemia and other blood disorders tetrachloroethylene, trichloroethylene, vinyl chloride immune dysfunction, neurologic disturbances, increased cancer alachlor, carbon tetrachloride, chlordane, chlorobenzene, risk, reproductive dysfunction dichloroethylene, endrin, ethylbenzene, lindane neurologic disturbances benzene, simazine, styrene polychlorinated biphenyls (PCBs)

acrylamide, toluene, xylene radionuclides increased cancer risk radium 226/228, uranium increase in overall lifetime risk for developing cancer viruses gastroenteritis enteroviruses, noroviruses, rotavirus nausea, vomiting, cramping, diarrhea

Drinking water supplies contain numerous nat- ing water supplies or at levels not expected to ural and manmade substances that are harmful to cause health problems in people with a healthy health. Under the SDWA, the FDA researches the IMMUNE SYSTEM. These standards may be inade- effects of such contaminants and establishes stan- quate to protect people who are IMMUNOCOMPRO- dards that keep contaminants either out of drink- MISED, such as people who have HIV/AIDS. Local drinking water standards 21 health departments can provide information about • enteric viruses (viruses that cause gastrointesti- contaminant levels in specific water supplies as nal INFECTION) well as recommendations for further purifying • disinfectants and disinfectant by-products drinking water. Because it is not always possible to • organic and nonorganic chemicals (metals, prevent contaminants from entering drinking minerals, and industrial chemicals) water sources, water systems typically filter and • radionuclides (radioactive particles) treat (such as by chlorination) drinking water sup- plies to reduce contaminants to nonpathogenic Because scientific knowledge continuously levels. evolves, detecting and eliminating drinking water FDA regulations currently address approxi- contaminants is a dynamic process. Generally, mately 80 contaminants capable of causing acute state and local water jurisdictions develop the pro- (immediate and short term) or chronic (cumula- cedures they follow to comply with FDA safe tive with exposure over time) health conditions. drinking water standards, with input from local Among them are health authorities as well as the general public. See also COMMUNITY SANITATION; ENVIRONMENTAL • microorganisms such as BACTERIA (notably fecal HAZARD EXPOSURE; FLUORIDATION; WATERBORNE ILL- coliform and Escherichia coli) and parasites NESSES. E–F

environmental hazard exposure Numerous sub- ing due to water contamination, not only because stances in the environment create risk for a vari- of their smaller size but also because their bodies ety of health problems and conditions. They are still developing and cannot yet efficiently clear include pesticides, herbicides, industrial pollu- toxins. People who are IMMUNOCOMPROMISED are tants, minerals and metals, molds and fungi, BAC- highly vulnerable to INFECTION resulting from food- TERIA, viruses, radiation, sewage, garbage, borne or waterborne viruses and bacteria, whereas biological waste, and electromagnetic fields. These infection fails to gain a stronghold in people substances may be naturally occurring or the con- whose immune systems are healthy. sequence of human actions, such as manufactur- Federal, state, and local agencies oversee ing and agricultural processes. They may cause a administration and enforcement of environmental wide spectrum of health conditions ranging from health laws, regulations, and standards in the hypersensitivity reactions to CANCER. United States. Key among them are the US Cen- ters for Disease Control and Prevention (CDC), the National Center for Environmental Health, the HEALTH CONDITIONS THAT MAY ARISE US Department of Agriculture (USDA), and the FROM ENVIRONMENTAL HAZARD EXPOSURE US Environmental Protection Agency (EPA). Col- ALLERGIC RHINITIS ALZHEIMER DISEASE lectively, these agencies operate programs to pre- ASTHMA AUTISM vent, detect, mitigate, and remedy health brain cancer chronic BRONCHITIS conditions arising from exposure to environmen- CHRONIC OBSTRUCTIVE PULMONARY DERMATITIS tal hazards. DISEASE (COPD) EMPHYSEMA See also BUILDING-RELATED ILLNESS; DRINKING FIBROMYALGIA GASTROENTERITIS WATER STANDARDS; FOODBORNE ILLNESSES; INDOOR AIR HEARING LOSS HEAVY-METAL POISONING QUALITY; RADIATION EXPOSURE; SICK BUILDING SYN- INFECTION LIVER CANCER DROME; WATERBORNE ILLNESSES. LUNG CANCER MALIGNANT MELANOMA METHEMOGLOBINEMIA MULTIPLE SCLEROSIS environmental cigarette smoke People who do PNEUMONIA poisoning not smoke but who live or work among people thyroid disease who smoke in their presence are at risk for the same health conditions that affect smokers, Often, environmental hazards may not directly including LUNG CANCER, CHRONIC OBSTRUCTIVE PUL- cause disease but rather become added risk factors MONARY DISEASE (COPD), EMPHYSEMA, CARDIOVASCULAR that, in aggregate with other factors or circum- DISEASE (CVD), and chronic BRONCHITIS. Children stances relevant to certain individuals or popula- who regularly breathe cigarette smoke from tion groups, increase the likelihood of disease. For smokers in the home, also called secondhand example, environmental chemicals may present smoke or passive smoking, have a much higher little risk to the public overall yet confer signifi- rate of chronic OTITIS media (middle EAR INFECTION), cant risk on pregnant women. Young children are ASTHMA, allergies, and chronic bronchitis. Most more likely than adults to experience lead poison- schools, workplaces, government offices, and 22 ergonomics 23 indoor public facilities ban cigarette smoking as a in health is to prevent injuries, particularly mus- means to reduce exposure to environmental ciga- culoskeletal injuries that result from repetitive rette smoke. Some municipalities in the United motions, by identifying interactions that present a States have banned all indoor smoking in loca- risk for injury and implementing interventions to tions open to the public. mitigate the risk. Ergonomic interventions may be One measure of cigarette smoke exposure is the as simple as rearranging the work area to put blood cotinine level. The body produces cotinine commonly used items within easy reach or may when it breaks down (metabolizes) NICOTINE, the require specialized devices and equipment such as active chemical ingredient of TOBACCO. Researchers telephone headsets, curved handles on tools, believe that while cotinine itself presents no nonglare screens for computers, and implements health risk, it provides an accurate measure of designed specifically for left-handed use. exposure to other chemicals, many of which are Ergonomics also evaluates the movements and carcinogenic (cancer-causing), that are present in actions of commonly performed tasks to minimize cigarette smoke. Cotinine is among the chemical the risk of overuse to recommend improved meth- federal agencies monitor to assess the health risks ods and techniques. Many job tasks have evolved of ENVIRONMENTAL HAZARD EXPOSURE. without formalized attention to the movements See also ANTISMOKING EFFORTS; INDOOR AIR QUAL- they require, with the consequence that employ- ITY; LIFESTYLE AND HEALTH; RADON EXPOSURE; SMOKING ees develop habits for performing the tasks that AND CANCER; SMOKING AND CARDIOVASCULAR DISEASE; may not be ergonomically sound. Actions that SMOKING AND HEALTH. cause continual reaching across the body, for example, create repetitive stress for the shoulders, ergonomics The interactions between people back, and neck. Changing the pattern of move- and their physical environments can support or ment to use the other hand or rearranging the challenge health. The primary role of ergonomics work area to eliminate cross-reaching can signifi-

ERGONOMICS-RELATED HEALTH CONDITIONS Health Condition Common Tasks Remedies CARPAL TUNNEL SYNDROME typing, keyboarding, production line, proper technique, ergonomically designed retail scanner keyboard, frequent movement to stretch fingers and rotate wrists

EYE STRAIN computer work, watching security eyeglasses to accommodate midrange vision, monitors, reading, inadequate or frequent looking away from task to change inappropriate lighting focal distance, proper lighting

HEADACHE noise exposure, bright lights improved ventilation and airflow low BACK PAIN twisting, bending, lifting, extensive frequent stretching and position changes, walking, prolonged standing proper lift and carry techniques, supportive shoes, shock-absorbent flooring neck PAIN holding telephone between chin and headset, correct height and distance shoulder, looking at computer or video placement for monitor, rearrange workspace monitor, frequently turning head to minimize turning

ROTATOR CUFF IMPINGEMENT reaching, production line, throwing reorganize work area to minimize turning, SYNDROME frequent stretching and resting 24 Preventive Medicine cantly reduce this stress and its corresponding settings such as cruise ships or restaurants, most injuries. An improved method might be as simple foodborne illness occurs as a result of contamina- as using a footstool or sliding ladder instead of tion in home-prepared foods. reaching for items on shelves, or could require Summertime picnics, holiday parties, and other retraining employees in proper use of equipment events where people entertain large groups in and machinery. their homes or other private venues are common Ergonomic factors account for about 4 million sources of “food poisoning.” Nearly always, these injuries among Americans each year, about half of events can be traced to improper food preparation, which are serious enough to require medical care handling, serving, and storage. Using the same or limit participation in daily activities. Ergonomic surfaces and implements to prepare meat or poul- injuries further account for a third of lost work try and then vegetables and fruits allows cross- time. Most of these injuries are musculoskeletal. contamination of BACTERIA that may be present on The US Occupational Health and Safety Agency countertops and cutting boards, in the air, or on (OSHA) develops and administers guidelines for foods. ergonomic standards and improvements in the Proper cooking kills the bacteria in the meat or workplace. Though implemented changes to poultry, but raw vegetables and fruits can carry improve the ergonomics of job tasks can prevent bacteria and the potential for illness to those who future injuries, people who have already experi- eat them. The tendency to leave food out so peo- enced ergonomic-related injuries may have long- ple may help themselves or while other festivities term or permanent health consequences. take place can allow bacteria to flourish. Salads See also ACCIDENTAL INJURIES; OCCUPATIONAL made with mayonnaise, cooked turkey, and pies HEALTH AND SAFETY; REPETITIVE MOTION INJURIES. left out too long at warm temperatures are com- monly to blame for foodborne illness. More often food safety FOODBORNE ILLNESSES sicken 76 mil- than not, contaminated foods look and taste fine. lion Americans each year, 5,000 of whom die as a result. Public health efforts target food safety on a KEY INDIVIDUAL MEASURES community as well as an individual level. At the FOR PREVENTING FOODBORNE ILLNESSES public safety level, the US Department of Agricul- • Wash hands frequently with soap and warm water, espe- ture (USDA) and the US Food and Drug Adminis- cially before and after preparing food. tration (FDA) oversee numerous programs that • Use separate surfaces for preparing meats and other foods. regulate food safety in the United States. These • Thoroughly cook meats. programs cover the gamut of food production and • Keep hot foods heated and cold foods chilled when serving include pesticide and herbicide use, animal feed them buffet-style. and use of supplements, food additives, product • Promptly refrigerate leftovers and throw away most leftovers packaging and labeling, and safe food handling after five days. practices among wholesalers and retailers (includ- ing grocery stores and restaurants). These agencies See also HAND WASHING; WATERBORNE ILLNESSES. inspect production facilities and test produce, grains, dairy products, meats, and other foods for fluoridation Fluoride is a naturally occurring biological and chemical contaminants. element that enhances a tooth’s ability to retain The US Centers for Disease Control and Pre- hardening minerals such as calcium. US federal vention (CDC) monitors foodborne illness out- regulations began requiring communities to add breaks, in coordination with state and local health fluoride to their water supplies, when naturally departments. These agencies investigate illnesses occurring levels of fluoride fall below 0.7 parts per and recommend corrective procedures to prevent million (ppm), in 1945 as a means of reducing future outbreaks. They also provide education and DENTAL CARIES (cavities). Fluoride offers the great- training for people who work in food services est protection when it is in the bloodstream as the industries. Though the public tends to fear out- TEETH are forming, so it becomes part of the breaks of foodborne illnesses that originate from enamel. Even after the teeth have fully developed, fluoridation 25

fluoride continues to interact with the enamel tions of those concerns have failed to produce through its presence in the saliva. Dentists also conclusive evidence to validate them, when fluo- may apply topical fluoride to the surfaces of the ride levels are within the established therapeutic teeth for added protection. ranges. Excessive fluoride consumption can cause The American Dental Association and numer- dental fluoridosis, in which dark stains appear on ous other health organizations advocate fluorida- the teeth. Though harmless, the tooth stains are tion, though some groups question the safety of permanent. Children should use fluoridated the practice. In the decades since fluoridation toothpaste in small amounts and with close became public policy, numerous claims about parental supervision. adverse health effects have surfaced. Investiga- See also ORAL HYGIENE. H hand washing Frequent hand washing with mission spreads many gastrointestinal infections. soap and warm water is one of the most effective Some studies suggest that many people wash their means of preventing the spread of infectious dis- hands only when they believe someone is observ- eases. Hand contact is a primary method of trans- ing them. Though hand washing sounds like a mitting bacterial and viral infections. Hand simple solution to a complex problem, health washing kills or removes most pathogenic agents. experts project it could significantly reduce infec- To wash the hands: tious diseases. See also BACTERIA; ENTERITIS; FOODBORNE ILL- • Turn on tap to dispense water that is warm but NESSES; GASTROENTERITIS; PERSONAL HYGIENE; TRANS- not too hot to hold the hands under its flow. MISSION MODES; VIRUS. • Get hands wet. health education Health experts consider • Apply soap, preferably liquid soap from a dis- instruction about health and disease to be a fun- penser. damental dimension of preventive medicine. • Work the soap into a lather that covers all sur- Health education formalizes such instruction faces of the hands, taking a full minute. within structured settings such as schools, work- • Rinse hands under running water. shops, and classes. At its most basic level, health education the form of the fundamental instruction • If it is not possible to turn off the water without children receive in school about the functions of touching the faucet handles, leave the water the human body. All states in the United States temporarily running. have governmentally mandated health education • Dry hands thoroughly using disposable towels requirements, typically for kindergarten (K) or a heated air dispenser. through grade 8 or grades K through 12. Other • Use a paper towel to cover the faucet handle, health education curricula may target college-level then turn off the water. students. Some health education programs focus on the needs of specific populations, such as child- WHEN TO WASH THE HANDS birth education classes for pregnant women and after changing a diaper after cleaning dirty dishes their partners or DIABETES education classes for after handling raw meat after holding an infant people who have diabetes. Businesses may offer or poultry after petting or handling health education programs for their employees after sneezing or coughing animals and their families with the dual goals of improving into the hand after sneezing, coughing, or personal health and reducing time lost to illness or after using the bathroom BLOWING THE NOSE injury. before eating before holding an infant See also LIFESTYLE AND HEALTH. before preparing food before serving food health insurance Health insurance is the finan- It is particularly important to wash the hands cial platform for health care in the United States. after going to the bathroom. Fecal-to-oral trans- As such, it plays a significant role in access to 26 health risk factors 27 health-care services and in health-care treatment other care, though the need far exceeds available decisions. In 2004, about 250 million Americans services. had health insurance, just over two thirds through The intertwining of health insurance and private coverage and the remainder through pub- health services that can be an advantage for peo- lic programs such as Medicaid and state low-cost ple who have health insurance becomes a barrier health plans. for the 42 million Americans who do not. They Nearly all health insurance plans require partic- frequently go without medical care for conditions ipants to pay a portion of their medical expenses, that prompt treatment would remedy but that typically in the form of annual deductibles and without early intervention become serious and service co-payments. A deductible is payment at even life-threatening. Preemptive treatment, such the front end, for example, the first $2,500.00 of as medications to lower blood cholesterol levels or medical costs each year. A co-payment shares the control BLOOD PRESSURE, as well as preventive cost of each health-care service between the per- health measures such as ROUTINE PHYSICAL EXAMINA- son and the insurer, either as a dollar amount or a TION, often are out of reach. Many health experts percentage of the charge. Most plans have a cap and public health policy planners view the lack of on out-of-pocket medical expenses, after which health insurance as one of the most significant the insurer pays the full amount for covered serv- challenges facing the health of Americans and the ices. Nonetheless, people who experience serious stability of the US health-care system. illnesses or injuries can accumulate significant See also HEALTH RISK FACTORS; HEALTHY PEOPLE additional medical expenses for services the insur- 2010; QUALITY OF LIFE. ance plan does not cover. As well, most people pay a portion or all of their health insurance pre- health risk factors The variables that create miums. increased vulnerability to illness and injury are Because the US health-care system intricately numerous and varied. Some health risks are fixed intertwines health-care services and health insur- (immutable), such as those related to heredity, ance, conflicts arise between care needs and insur- gender, and age. Many health risk factors are ance coverage. Doctors and hospitals coordinate modifiable (mutable) and correlate to lifestyle and with insurers to obtain approval for most non- habit. The combination of fixed and modifiable emergency treatments before engaging in them. risk factors helps one assess an individual’s overall Most insurers have lists of approved procedures likelihood of developing health conditions such as and medications to facilitate the administrative CARDIOVASCULAR DISEASE (CVD), DIABETES, LIVER dis- processes and issue payments directly to providers. ease, KIDNEY disease, COLORECTAL CANCER, LUNG CAN- Each state has laws and rules that regulate how CER, PROSTATE CANCER, CERVICAL CANCER, and BREAST these processes take place and establish proce- CANCER. Though researchers separate fixed and dures for handling disagreements with insurer modifiable risk factors from the perspective of decisions, and a state insurance commissioner health prevention opportunities, within the body oversees their enforcement. the effects of all health risk factors intertwine and Though 85 percent of the US population has affect each other in immeasurable ways. health insurance and thus access to health-care services, 15 percent does not—about 42 million Fixed (Immutable) Health Risk Factors people. Those who do not have health insurance Age and gender are the primary fixed risk factors have great difficulty receiving needed health-care for health. Other fixed health risk factors include services. The federal government mandates that personal and family health history (heredity). providers may not deny care to anyone for life- Though it is not possible to change fixed risk fac- threatening illness or injury and for a pregnant tors, it is possible to influence and somewhat miti- woman’s delivery of her child. All states have pro- gate them through lifestyle and by controlling grams to provide basic health-care services for modifiable risk factors. children and pregnant women. State and local Age The risk for many health conditions programs attempt to fill in the gaps in providing increases with age as body systems and structures 28 Preventive Medicine begin to deteriorate. Age further carries with it the may delay the condition’s development or further specter of lifestyle choices and their health conse- mitigate its the adverse effects. quences, often compounding health risk. With increasing age, for example, the body becomes less Modifiable (Mutable) Health Risk Factors efficient in its ability to use INSULIN. This increases Cigarette smoking, eating habits, and physical the risk for type 2 diabetes. Physical inactivity and activity are the primary modifiable risk factors for EATING HABITS may further challenge the body’s health. Other health risk factors include occupa- insulin efficiency, as well as contribute to OBESITY, tion, recreational activities, ALCOHOL use, substance an independent risk factor for diabetes. In combi- abuse, seat belt use, helmet use, and preventive nation, these circumstances significantly boost the health measures such as vaccination and safer sex likelihood of developing diabetes in older age. practices. Modifiable health risk factors may Cardiovascular function also becomes less efficient directly cause disease, such as cigarette smoking, with age, as blood vessels lose elasticity (often as a or contribute to the circumstances that allow result of ATHEROSCLEROSIS). health conditions to develop, as with diabetes. Gender Some health conditions, of course, Cigarette smoking Since the 1950s, research affect only men (prostate and testicular disorders) has linked cigarette smoking with a growing list of or only women (cervical, ovarian, and uterine dis- health conditions. There are no known health orders as well as PREGNANCY-related conditions). benefits of cigarette smoking. The leading health Other health conditions may predominantly affect consequences of smoking are cardiovascular dis- one over the other gender, such as breast cancer. ease and lung cancer. Smoking also causes or con- Popular perception erroneously holds that some tributes to dozens of other health conditions along health problems, such as cardiovascular disease the entire continuum of life: it influences CONCEP- and colorectal cancer, are primarily health risks for TION, pregnancy, childhood health (ENVIRONMENTAL men. Though men are more likely than women to CIGARETTE SMOKE), nutrition, chronic diseases, develop cardiovascular disease earlier in life, car- numerous cancers, and LIFE EXPECTANCY. diovascular disease is the leading cause of death Eating habits The advent of fast food and and disability among men and women alike. Doc- processed food in the 1960s forever changed eat- tors diagnose more women than men with colo- ing habits in the United States. Three decades later rectal cancer each year. two thirds of the American population was over- Health history PERSONAL HEALTH HISTORY signifi- weight, a significant general health risk. Most fast cantly influences future health circumstances and foods and processed foods combine low nutri- often integrates with lifestyle (modifiable risk fac- tional content and excessive portion sizes. tors). Some health conditions are purely of heredi- Fast-food meals often feature “deals” that offer tary origin, such as CYSTIC FIBROSIS, HEMOPHILIA,or more food for a small increase in price, giving the congenital heart malformations. Some acquired impression of value. Processed foods, such as conditions may result in residual health effects, quick-prepare meals and snack items, come in such as chronic OTITIS media (middle ear INFECTION) packaging often implies the product is a single that may have consequential HEARING LOSS. Other serving when instead the package contains two, conditions may reflect a genetic predisposition as three, or even four servings. When fast foods and well as lifestyle choices, such as DIABETES AND CAR- processed foods are the mainstay of a person’s eat- DIOVASCULAR DISEASE. ing habits, CALORIE consumption often is two to Advances in genetics and molecular medicine four times what it should be. are making it possible to determine whether a per- Fewer than 20 percent of Americans eat the son has a hereditary health condition. Though American Cancer Society’s recommended 9 to 12 such knowledge does not change the risk for daily servings of fruits and vegetables, yet more developing the condition, it does allow the person than a third exceed the American Heart Associa- and his or her doctor to establish a plan for man- tion’s guideline limiting dietary fat consumption to aging the condition. Making changes in lifestyle 30 percent of total calories. Most Americans need Healthy People 2010 29 to eat fewer processed and fried foods and more the health condition becomes a risk factor as well, fruits, vegetables, and whole grain products to changes that improve modifiable risk factors pro- meet the nutritional needs of their bodies. vide cumulative health benefits. For example, a Physical activity Despite the proliferation of person who has a heart attack may begin walking gyms, health clubs, and fitness centers over the every day as part of a cardiac rehabilitation pro- past few decades, fewer than 20 percent of Ameri- gram. The regular physical exercise improves car- can adults get the daily physical exercise their diovascular health, and over time the person loses bodies need to maintain cardiovascular health and 10 or 20 pounds. Blood pressure, blood GLUCOSE overall metabolic efficiency. Lack of regular physi- (sugar), and blood cholesterol levels also come cal activity may be more of a factor than eating down. habits for health maintenance as well as develop- Nearly everyone can benefit from doing as ment of health conditions. An adult needs a mini- much as is possible to reduce health risk factors. mum 30 minutes of sustained, moderately Seldom is it too late to make changes that improve intense, physical activity (such as walking) every health and QUALITY OF LIFE. day and one to two hours of sustained, moderate See also ACCIDENTAL INJURIES; CONGENITAL ANOM- to high intensity, exercise (such as swimming, ALY; DIET AND HEALTH; INHERITANCE PATTERNS; LIFESTYLE running, bicycling, or basketball) three or four AND HEALTH; EXERCISE AND HEALTH; RISK FACTORS FOR times a week to maintain optimal health. CARDIOVASCULAR DISEASE; SEXUAL HEALTH; SEXUALLY Obesity Obesity, a combination of factors with TRANSMITTED DISEASE (STD) PREVENTION; YOUTH HIGH- eating habits and physical activity at the hub, RISK BEHAVIOR. emerged in the 1990s as an independent health risk factor for numerous health conditions. Key Healthy People 2010 A program of health ini- among them are HYPERTENSION (high BLOOD PRES- tiatives that numerous US health agencies jointly SURE), HEART FAILURE, OBSTRUCTIVE SLEEP APNEA, type sponsor, the goals of which are to improve overall 2 diabetes, OSTEOARTHRITIS, infertility, and GALL- public health in key areas called leading health BLADDER DISEASE. The current clinical standard for indicators. The first Healthy People program, assessing health risk associated with body weight Healthy People 2000, evolved from the 1979 US is the BODY MASS INDEX (BMI), a mathematical calcu- surgeon general’s report of the same name. It lation that converts height-and-weight ratio to an established criteria for health monitoring and aggregate measure of body mass. Researchers improvement. Various federal and state health have been able to correlate such measures with organizations structured their objectives and pro- health conditions and know that lowering BMI, grams to dovetail with Healthy People 2000. which only occurs through weight loss, corre- Though Healthy People 2000 did not achieve all spondingly lowers health risk. of its goals, it resulted in measurable improve- ments in many areas of public health. Healthy Reducing Personal Health Risk People 2010 updates and expands the goals of its Health risk factors tend to converge in patterns of predecessor, with annual reports that identify increased susceptibility. A person who develops accomplishments and challenges. Healthy People diabetes, for example, acquires an increased risk 2010 draws data from existing sources and mecha- for cardiovascular disease, kidney disease, and nisms. cataracts. As well, the risks for these conditions Among the participating US federal agencies further increase with age, and family history may are the Agency for Healthcare Research and Qual- also play a role. The key to mitigating health risks ity (AHRQ), Centers for Disease Control and Pre- is sustained modifications in lifestyle habits that vention (CDC), US Food and Drug Administration allow a person to maintain optimal health. (FDA), Indian Health Service, National Institutes Sometimes these modifications are in response of Health (NIH), Office of Population Affairs, and to the emergence of health conditions such as car- President’s Council on Physical Fitness and Sports. diovascular disease, diabetes, or cancer. Though As well, more than 400 state and community 30 Preventive Medicine health organizations form the Healthy People mulated, and eventually most body systems return Consortium. to normal. Mercury The natural forms of mercury are liq- HEALTHY PEOPLE 2010 LEADING HEALTH INDICATORS uid or gas. It forms different chemicals when it access to health care environmental quality combines with other substances. Manufacturing IMMUNIZATION injury and VIOLENCE processes combine mercury with oxygen or chlo- mental health overweight and OBESITY rine to form inorganic combinations, called salts, physical activity responsible sexual behavior used in industrial applications such as caustic soda SUBSTANCE ABUSE TOBACCO use and batteries. Dentists use inorganic mercury compounds in fillings for TEETH. In nature mercury See also HEALTH RISK FACTORS; LIFESTYLE AND combines with carbon (methylmercury), usually HEALTH. in water, to form organic compounds. These organic mercury compounds accumulate in fish heavy-metal poisoning Toxicity due to metals and shellfish. such as lead, mercury, copper, and iron can have serious and even lethal health consequences, The liquid nature of mercury has given especially among children. Heavy metals occur rise to perceptions that it has mystical naturally in the environment. They are present in or supernatural abilities. Some spiritual soil and in plants that grow underground, and in and ritualistic practices use mercury, water. Heavy metals are also the by-products of also called quicksilver or azogue, in manufacturing processes. They can quickly accu- baths, burned in candles, and sprinkled mulate to hazardous levels when they leach into on surfaces. Like any other form of drinking water supplies or enter the food chain mercury, however, quicksilver is toxic. when farmers irrigate crops using contaminated Many people who handle, breathe, or water. Some metal pollutants are also present in ingest quicksilver suffer mercury poi- the air. Numerous environmental laws enacted soning. over the past 30 years have significantly reduced the presence of heavy metals as pollutants; and Excessive amounts of mercury in the body can various standards, such as those for drinking result in permanent damage to the BRAIN and kid- water, require monitoring of metal and mineral neys. Studies link two forms of mercury—mercury levels. The US Environmental Protection Agency chloride and methylmercury—with an increased (EPA) monitors and enforces these laws. risk for developing CANCER. Many people are con- Lead Federal regulations have banned lead in cerned about the health risks possibly associated paints, inks, and gasoline for several decades. with mercury dental fillings (also called dental Nonetheless lead poisoning continues to be a amalgam). The American Dental Association and problem, particularly among children, who are the US Food and Drug Administration (FDA), vulnerable to damage at much lower levels of among other health agencies, have issued position ingestion. Houses built before 1977 may still have statements supporting the continued use of mer- leaded paint on the walls and especially wood cury fillings because there are no conclusive stud- trim, which young children may peel off and eat. ies that correlate its use to mercury poisoning. Lead also can enter water supplies when the pipes However, most dentists offer alternative materials that carry it are made of lead. As the pipes deterio- for people who are concerned about mercury rate they release lead into the water they carry. fillings. Though many larger municipalities have replaced By far the most significant source of mercury old lead pipes, many smaller ones have not. The among Americans is seafood. In 2004 the FDA smaller body size of children makes them espe- issued a health advisory regarding mercury levels cially vulnerable to toxic accumulations of lead. in four kinds of fish: swordfish, king mackerel, When the body stops receiving fresh supplies of shark, and tilefish. These fish are at the top of the lead, it can slowly process the lead that has accu- food chain; they live for many years, subsisting on hepatitis prevention 31 a diet of other fish. Methylmercury levels in the highly toxic to the liver, resulting in hepatonecro- flesh of these kinds of fish are higher than in other sis (death of hepatocytes, the primary functional kinds of fish. The advisory recommends that preg- cells in the liver). nant women and women who are BREASTFEEDING See also DRINKING WATER STANDARDS; POISON PRE- avoid eating these kinds of fish. Salmon, cod, alba- VENTION. core tuna, pollock, haddock, ocean perch, tilapia, and fresh-water trout have the lowest levels of hepatitis prevention Although acute (sudden mercury. and limited) HEPATITIS infections are on the decline Thimerosal, a common preservative in vaccines in the United States, chronic hepatitis infections and some other biologic agents, contains mercury. (long-term) have reached epidemic proportions. Though pharmaceutical manufacturers are mov- Nearly a third of the US population has had hepa- ing away from its use, thimerosal remains a con- titis A INFECTION, an acute form of the disease that cern especially with childhood vaccinations. is sudden and limited. While the numbers of new Individuals should ask for thimerosal-free vaccines cases are dropping each year because of vaccina- and other biologic agents for themselves and for tion and education efforts, hepatitis A remains a their children. US health agencies have called for significant health threat because it can so easily be the complete eradication of thimerosal as a medic- transmitted from one person to another. Hepatitis inal preservative. A spreads via oral–fecal contamination as a conse- Copper Though copper occurs in nature, the quence of failing to wash the hands after using the most common source of human exposure to cop- bathroom. This spreads the VIRUS to items the per is through water supplies that travel through infected person touches. A significant source of copper pipes. Water that is highly acidic corrodes infection is contaminated uncooked foods such as the pipes, drawing copper into the water. Exces- salads. Hepatitis A outbreaks can sweep through sive copper accumulations in the body can cause schools, day care centers, cruise ships, prisons, and irreversible LIVER and KIDNEY damage. Copper also other environments in which large groups of peo- can accumulate in the brain, causing cognitive ple are in close contact. dysfunction. People who have WILSON’S DISEASE, a Another 7 percent of Americans have chronic hereditary disorder in which the body cannot forms of hepatitis, either hepatitis B or hepatitis C. metabolize copper, are especially vulnerable to The rate of infection for chronic hepatitis is high- copper in the food supply and the environment est among injectable DRUG users and homosexual because copper accumulates in their bodies. The men (because of bodily fluid contact). Health-care body needs only a very small amount of copper, and public safety workers are also at high risk for which it uses to make certain enzymes and to infection as a result of occupational exposures. facilitate iron METABOLISM for HEMOGLOBIN produc- However, hepatitis is so pervasive that anyone can tion. become infected without being aware they have Iron The body needs iron to produce hemoglo- been exposed. Some people can carry hepatitis bin, the protein in the blood that binds with oxy- without themselves being sick and usually do not gen. Iron deficiency is fairly common, and many know they are carriers. Yet they can spread the people take iron supplements. These supplements hepatitis virus to others. are the most frequent source for iron poisoning, Of the five most common hepatitis viruses, especially among young children. Excessive fecal–oral contact is the primary infectious route amounts of iron in the body slow the HEART RATE for two: hepatitis A and hepatitis E. These forms of and force of contractions, reducing the flow of hepatitis are generally acute (sudden and limited). blood. Other chemical changes that take place at Blood and body fluid contact, such as via sexual the molecular level affect the ability of cells intercourse and shared needles among injectable throughout the body to function. People who drug users, spread hepatitis B and hepatitis C. have the hereditary condition HEMOCHROMATOSIS Hepatitis D is a risk only for people infected with cannot properly metabolize iron, resulting in toxic hepatitis B, as it can replicate only by “hijacking” accumulations over years to decades. Iron is also the hepatitis B virus’s genetic material. 32 Preventive Medicine

Hepatitis C is particularly insidious because the States at about 40,000 a year. Advances in treat- infection can take 20 to 30 years to progress ment, however, have resulted in increasing num- enough to generate symptoms. A blood test can bers of people living with HIV. Though this marks detect antibodies after the virus has been in the an exciting milestone in the fight against body for about six weeks, however, and health HIV/AIDS, it also means the risk for INFECTION is experts recommend that people who are at risk for growing because more people are already infected. hepatitis C be tested. People at highest risk for As well, health experts worry that improved treat- having hepatitis C infection are those who may ment regimens that can forestall the transition have engaged in high-risk behaviors as long as 20 from an HIV-positive status to AIDS may encour- or 30 years ago. About 4 million Americans have age complacency about HIV protection. AIDS chronic hepatitis C infection, nearly 2 percent of remains ultimately fatal, and preventing infection the U.S. population, and epidemiologists believe remains the only cure. Though medical treatments they may reflect only about 30 to 40 percent of can delay the disease’s progression, there are as those who are actually infected. yet no treatments that can eradicate the virus. Hepatitis is a significant public health issue. Research continues to search for both a cure and a Acute hepatitis sickens thousands of people each VACCINE. year and can be particularly serious, even fatal, in Prevention efforts target two dimensions of children and in people who are IMMUNOCOMPRO- HIV/AIDS infection, halting the spread of infection MISED. Chronic hepatitis is the leading cause of and early diagnosis and treatment for those who LIVER FAILURE and leading reason for LIVER TRANS- become infected. Because of the long period of PLANTATION in the United States. A secondary pub- time during which a person can be infected and lic health concern is that a person who has had not know it, health experts view early diagnosis as hepatitis, or who has chronic hepatitis, cannot a preventive measure; because most people, once donate blood. This has the potential to severely diagnosed as HIV-positive, will take the recom- limit the availability of blood and blood products mended precautions to prevent spreading the for transfusion. virus to others. People who do not know they have HIV often do not feel the need to take signif- KEY MEASURES FOR PREVENTING HEPATITIS icant precautions. A special focus area is prevent- • Wash hands frequently with soap and warm water. ing perinatal infection, in which an HIV-positive • Do not share food, drinks, or eating utensils. woman passes the virus to her unborn child. • Receive the hepatitis A and hepatitis B vaccinations. • Do not use injectable drugs. Preventing New Infections • Use condoms during sexual intercourse, and limit sexual A person gets HIV/AIDS from close and regular partners. contact with the body fluids, such as BLOOD and • Use barrier precautions (masks and gloves) to protect SEMEN, of another person who already has the against INFECTION from occupational exposure. virus. Abstinence is the only certain way to pre- • Receive prophylactic treatment (immunoglobulin injection) vent infection via sexual activity with a partner. after suspected exposure. Barrier methods to prevent the body fluids of one person from contact with the mucous tissues of See also SEXUALLY TRANSMITTED DISEASE (STD) PRE- the other person during sex are the most effective VENTION. approaches to reduce the risk for transmitting HIV. Consistent use of latex condoms during sex (anal, HIV/AIDS prevention Researchers first detected vaginal, and oral intercourse) significantly reduces the human immunodeficiency VIRUS (HIV) that the risk of passing HIV from the infected partner causes acquired immunodeficiency syndrome to the noninfected partner. People who inject (AIDS) in the early 1980s. New HIV/AIDS infections drugs and share needles and paraphernalia can peaked about a decade later and have since slowly spread HIV through blood-to-blood contact. Breast but steadily declined to reach a point over the past milk can also transmit the virus from mother to decade of holding relatively steady in the United infant. The average length of time from infection HIV/AIDS prevention 33 to symptoms is about 10 years, during which time of disease for years, but symptoms progress and the person may not know he or she has HIV and will increasingly diminish QUALITY OF LIFE. can spread the infection to others. In 2004 the US Food and Drug Administration In 1994 HIV/AIDS experts issued a recommen- (FDA) approved the first rapid test to detect HIV-1 dation to test high-risk pregnant women for HIV antibodies in a fingerstick blood sample. HIV-1 is and to offer those with positive tests treatment the form of the virus that causes nearly all AIDS with zidovudine (AZT), which slows the rate at infections in the United States. More extensive and which the virus replicates. This allows the infant’s precise blood tests then confirm positive results. IMMUNE SYSTEM to develop sufficiently to produce The US Centers for Disease Control and Prevention resistance against HIV and stave off infection. The (CDC) and other health organizations recommend result was a two thirds reduction in the number of HIV testing become part of the ROUTINE MEDICAL infants born with HIV between 1994 and 1997. EXAMINATION to facilitate early diagnosis. Since then, HIV/AIDS programs have made a con- certed effort to extend HIV testing and AZT treat- KEY MEASURES FOR PREVENTING HIV/AIDS ment to all pregnant women with the hope that • sexual abstinence congenital HIV infections will decline even fur- • when sexually active, latex condom use during every act of ther. Many health-care providers believe HIV test- sexual intercourse unless in a longstanding monogamous ing should be among the routine screenings relationship in which both partners have tested negative for pregnant women undergo. HIV • avoiding injectable drugs Early Diagnosis and Prevention • regular testing for all people who are sexually active Nearly a million Americans live with HIV/AIDS • frequent testing for people who engage in high-risk sexual yet about 250,000 of them—one in four—do not behaviors (multiple sex partners, unprotected sex) or who know they do. The virus can exist in the body for use injectable drugs decades without progressing to the disease condi- • early intervention and monitoring for people who are HIV- tion of AIDS. During this time, however, the virus positive, to start treatment at the most opportune times and remains active and can spread to other people. By to encourage preventive behaviors the time symptoms begin to manifest, an impor- tant window of therapeutic opportunity has See also OCCUPATIONAL HEALTH AND SAFETY; SEXU- closed. Treatment can still contain the progression ALLY TRANSMITTED DISEASES (STDS). I indoor air quality The average American spends moist (humid), requiring humidification or dehu- 20 hours or more of each day in various indoor midification to make it more comfortable to environments such as work, school, and home. breathe. Humid air supports the growth of molds Because the air they breathe recirculates, it accu- and fungi, which can cause hypersensitivity mulates pollutants. Indoor air may contain two to response, ALLERGIC RHINITIS, chronic BRONCHITIS, and five times as much pollution as outdoor air. Health other upper respiratory tract conditions. Improp- experts believe this contributes to the rise over erly cleaned humidifiers also can become patho- recent decades in ASTHMA and other respiratory genic reservoirs, harboring and dispersing colonies diseases. Indoor air pollutants may be visible, of molds and bacteria. Central home heating sys- linger as odors, or remain undetected. The risk to tems have filters that homeowners or residents health does not necessarily correlate with the abil- must periodically change. ity to detect the pollutant; some of the most haz- The US Environmental Protection Agency ardous substances (such as carbon monoxide) (EPA) administers regulations and standards for have no smell or visible presence. indoor air quality, and recommends a three-prong approach: COMMON INDOOR AIR POLLUTANTS aerosol products animal dander 1. Control pollutants at their sources: This may include no smoking indoors and installing car- asbestos in older structures BACTERIA pets that do not contain VOCs, body fragrances CARBON DIOXIDE carbon monoxide cleaning solutions 2. Ventilate: Open windows and circulating fans dust dust mites move air containing pollutants outside and formaldehyde glues, paints, and solvents bring in fresh air. lead mercury 3. Clean the air: Air cleaners and filters use vari- molds, mildew, and fungi ozone ous methods to extract specific kinds of pollu- particulates pesticides tants from the air. The EPA cautions that air radon TOBACCO smoke cleaners cannot substitute for proper ventila- viruses volatile organic tion and source control as the primary mainte- compounds nance measures for clean air. Some air cleaners may add different pollutants to the air, such as Ventilation and outdoor air exchange are particulates or ozone. important for bringing fresh air into the building or home and releasing indoor pollutants so they See also BUILDING-RELATED ILLNESS; ENVIRONMENTAL can disperse. This helps reduce exposure to harm- CIGARETTE SMOKE; LEGIONNAIRES’ DISEASE; RADON ful substances and lower the risk of resulting EXPOSURE; SICK BUILDING SYNDROME. health conditions. Federal regulations establish ventilation and air exchange rates for commercial influenza prevention INFLUENZA, commonly buildings. Indoor air also may be too dry or too called the flu, is an upper respiratory INFECTION

34 influenza prevention 35 that causes epidemics (widespread outbreaks of influenza viruses that can also infect humans, disease) every year. In the United States each year health officials closely monitor avian influenza about 20 percent of the population becomes ill infections among birds. Avian influenza outbreaks with influenza (about 60 million people), and among domesticated birds in parts of Asia in the 30,000 to 40,000 people die as a result. Occasion- late 1990s and early 2000s caused alarm for the ally influenza occurs in a pandemic, in which peo- potential of a pandemic, though containment ple worldwide become ill. The most significant responses were effective in confining the out- influenza pandemic in modern times was the breaks. The ease with which people travel around Spanish influenza pandemic of 1918, which sick- the world creates considerable challenge for con- ened 40 percent of the world population and taining outbreaks. caused more than 20 million deaths. Other pan- demics occurred in 1957 (Asian influenza) and Influenza Vaccination 1968 (Hong Kong influenza). Outbreaks of Avian Vaccines provide immunity by stimulating the flu created concern among public health officials IMMUNE SYSTEM enough to produce antibodies to in the early 2000s but containment efforts pre- fight the virus at its next attempt to enter the vailed and limited the numbers of people who body but not enough to cause illness. The result- became ill. ing immunity is effective against only the specific strain of virus. Two kinds of influenza vaccines are Influenza Virus Strains: Moving Targets available in the United States: Viruses cause influenza. There are three types of influenza viruses: influenza A, influenza B, and • The conventional flu shot contains inactivated influenza C. Influenza A and B are responsible for (killed) influenza virus, which, when injected most cases of illness; influenza C infections are into the body, cause the immune system to generally mild and not so easily spread from one respond. The first killed-virus influenza VACCINE person to another as are A and B influenza became available in the United States in 1945. viruses. Every year the strains of the influenza Anyone older than six months of age can VIRUS responsible for causing illness are slightly dif- receive the flu shot. ferent from the strains that caused infection the • The live attenuated vaccine, which comes in previous year (epidemiologists call this “drift”). the form of a nasal spray, contains live but These changes help the virus survive. Having an weakened influenza virus genetically altered so influenza infection confers IMMUNITY against the it cannot cause illness (it is unable to survive at strain of virus that caused it. Because the strains body temperature). The weakened virus enters vary each year, however, this immunity has value the bloodstream via the mucous membranes of only for the duration of the flu season in which the nasal passages. Like the inactivated the virus strain is active (though a small amount influenza injected vaccine, the live attenuated of resistance may carry over to similar strains). vaccine activates an immune system response Epidemiologists and researchers attempt to predict to produce antibodies. The live attenuated which strains will emerge each year, and base influenza vaccine became available in the annual influenza vaccines on those strains. United States in 2003. Only people between the Occasionally the influenza virus makes a dra- ages of 5 and 49 who are healthy can receive matic alteration, a phenomenon epidemiologists the live attenuated virus. call “shift.” These are the influenza viruses capable of causing pandemic, or worldwide, infection Health experts recommend getting the because no immunity exists against them. Health influenza vaccine in October or November, as the organizations around the world have monitoring flu season in the United States typically runs systems in place to detect these viruses and December to March each year. Though everyone respond before pandemic infection develops. can benefit from vaccination, certain groups of Because bird populations serve as reservoirs for people are at high risk for infection. They include 36 Preventive Medicine

• children between the ages of six months and 2 Antiviral Medications years as well as their household members Because influenza is a viral infection, most treat- • people age 50 and older ment measures are supportive and target symp- toms. From a prevention standpoint, ANTIVIRAL • people who live in extended-care facilities and MEDICATIONS that can reduce the severity of symp- other group settings toms can also reduce the spread of influenza infec- • people who work in health-care and public tion. A doctor must prescribe an antiviral safety positions medication within 48 hours of the onset of symp- • people over age six months who have chronic toms; the more quickly after exposure, the more health conditions effective the medication. Antiviral medications available in the United States include amantadine Occasionally there are shortages of vaccine, as (Symmetrel), rimantadine (Flumadine), zanamivir occurred in 2004, which is a significant public (Relenza), and oseltamivir (Tamiflu). health issue. When this occurs, public health Frequent HAND WASHING and sneezing or cough- agencies such as the US Centers for Disease Con- ing into a tissue or the sleeve rather than the trol and Prevention (CDC) and the US Depart- hands are among the most effective measures for ment of Health and Human Services (HHS) issue preventing the spread of the influenza virus from revised guidelines to protect those who are most person to person. vulnerable to complications. See also INCUBATION PERIOD; TRANSMISSION MODES. L life expectancy A statistical calculation repre- lifestyle and health Many aspects of lifestyle senting how many years a person might expect to influence health. Among the most significant are live. Simple life expectancy calculates projected years of life from birth. Age-adjusted life • cigarette smoking and other tobacco use expectancy projects how many more years a per- • diet and nutrition son of a certain age might expect to live. It is • physical activity and exercise important to remember that such calculations are • occupational health risks projections, not factual assertions of how long an individual will live. Any individual may live • WEIGHT LOSS AND WEIGHT MANAGEMENT and OBESITY longer or less than his or her life expectancy as a • seat belt and helmet use result of numerous variables. • SAFER SEX PRACTICES Life expectancy at birth has steadily increased in the United States, climbing by 60 percent over- The correlations between lifestyle behaviors all between 1900 and 2000. A child born in 1900 and health conditions are both direct and indirect could expect to live about 48 years, whereas a and often intertwined. Numerous research studies child born in 2000 could expect to live about 77 show conclusively, for example, that cigarette years. Though life expectancy for men remains smoking is a direct cause of CARDIOVASCULAR DISEASE less than that for women, the gap is slowly clos- (CVD), LUNG CANCER, CHRONIC OBSTRUCTIVE PULMONARY ing. Some health experts believe discoveries in DISEASE (COPD), laryngeal CANCER, and STOMACH CAN- genetics and molecular medicine in the early years CER and a contributing cause to numerous other of the 21st century have the potential to extend cancers and diseases. Scientists and researchers life expectancy 15 to 25 percent within the next know, too, that OBESITY is a clear factor in health decade. conditions such as cardiovascular disease and DIA- Increases in life expectancy have historically BETES. Furthermore, diabetes is one of the leading reflected improvements in numerous areas of causes (along with cigarette smoking and obesity) public health, ranging from sanitation to vaccina- of cardiovascular diseases such as HYPERTENSION tions. Current increases reflect health and health- (high BLOOD PRESSURE), PERIPHERAL VASCULAR DISEASE care improvements primarily in areas such as (PVD), and CORONARY ARTERY DISEASE (CAD). pharmaceuticals, diagnostic procedures that allow Researchers also know that diet and nutrition early detection of potentially fatal health condi- are key factors in healthy body function as well as tions, and therapeutic technologies. Individual in disease states. Some diseases result directly variables such as family and PERSONAL HEALTH HIS- from nutritional deficiencies, such as pernicious TORY also influence life expectancy, as do behav- ANEMIA (vitamin B12 deficiency, which can occur iors that affect health such as cigarette smoking. from dietary insufficiency or due to MALABSORPTION Numerous government agencies publish life disorders, PEPTIC ULCER DISEASE, or GASTRECTOMY). expectancy data, updated annually. Researchers continue to investigate the ways in See also HEALTH RISK FACTORS; LIFESTYLE AND which nutritional and dietary factors contribute HEALTH; IMMUNIZATION; YOUTH HIGH-RISK BEHAVIORS. indirectly to health conditions, particularly with 37 38 Preventive Medicine respect to the disease-fighting potential of antioxi- results in overall improved metabolic efficiency. In dants. Cancer researchers have made connections a sense, regular physical activity seems for the between the body’s ability to fight off cancer and body like a tune-up is for a car—it keeps it run- dietary habits such as eating 9 to 12 servings a day ning as smoothly as possible. Health experts urge of fruits and vegetables. people to get a minimum of 30 minutes of physi- Health conditions may also affect EATING HABITS, cal exercise, such as walking, every day. with further consequence for health and well- The correlations between lifestyle and health being. People who have LACTOSE INTOLERANCE, for take on particular relevance in the context of the example, cannot consume dairy products, the aging of the American population. As people are most common source of calcium and vitamin D. It living longer, QUALITY OF LIFE becomes an increas- is important for them to obtain these nutrients ingly significant focus. Advances in medical tech- through other foods and through supplements. nology now allow routine treatments for Some medications may require dietary restric- conditions that only a few decades ago were tions. For example, people who take monoamine deadly. Thrombolytic medications can halt and oxidase inhibitor (MAOI) medications, prescribed even reverse HEART ATTACK and STROKE due to blood to treat DEPRESSION and occasionally to treat clots. ORGAN TRANSPLANTATION extends the promise PARKINSON’S DISEASE, cannot eat foods such as of normal life to thousands of Americans. Pros- cheeses and smoked meats that contain the amino thetic joints restore movement when arthritis or acid tyramine. Health conditions may also limit injury destroys joints and bones. Yet within the what a person can eat; for example, a person who framework of these advances remains the reality has CELIAC DISEASE (sprue) cannot eat foods that that individual health is an individual responsibil- contain gluten. ity. Medical science can fix quite a lot but the way Physical inactivity has come under intense in which a person chooses to protect the functions scrutiny from health experts in recent years as and structures of his or her body plays a signifi- more evidence emerges to connect physical activ- cant role in health. ity with health and sedentary habits with disease. See also COENZYME Q10; OBESITY, HEALTH CONSE- Though scientists do not fully understand the QUENCES OF; OCCUPATIONAL HEALTH AND SAFETY; SEXU- myriad ways in which exercise affects cell activity, ALLY TRANSMITTED DISEASE (STD) PREVENTION; SMOKING they know that it increases INSULIN sensitivity and AND HEALTH. N–P

neural tube defects BIRTH DEFECTS in which the most neural tube defects before birth, allowing neural tube, the precursor to the SPINAL CORD and women and their doctors to make decisions about BRAIN, fails to develop properly. The neural tube the course of the pregnancy and care needs fol- develops in the first few weeks of gestational life lowing birth. Doctors often recommend terminat- and may be complete by the time a woman knows ing the pregnancy when the neural tube defect is she is pregnant. An open neural tube defect so severe that death of the infant would be certain exposes the brain and spinal cord outside the and immediate after birth. body. SKIN and spinal structure abnormally encase See also ABORTION; CONGENITAL ANOMALY; KYPHO- a closed neural tube defect, typically involving SIS; SCOLIOSIS. only the spine (and usually the lower spine). Though there are associations between neural occupational health and safety Work-related tube defects and CHROMOSOMAL DISORDERS such as injuries account for about 6,000 deaths and 16 DOWN SYNDROME, most researchers believe neural million health-care visits each year in the United tube defects occur as a combination of random States. There are literally thousands of hazards in GENE MUTATION and environmental circumstances. the workplace, some common to nearly all jobs The most serious neural tube defect is anen- and others unique to specific occupations. In the cephaly, in which the brain does not form. Anen- United States, the Department of Labor, the Occu- cephaly is always fatal. SPINA BIFIDA, in which the pational and Health Safety Agency (OSHA), the spinal column does not close properly, can result Centers for Disease Control and Prevention in mild to debilitating deformity and disability. The (CDC), and the National Institute for Occupational mildest form of spina bifida is myelomeningocele, Safety and Health (NIOSH) oversee workplace in which the defect affects only a small portion of safety regulations, standards, and procedures. the lower spinal cord. Reconstructive surgery can OSHA further has enforcement authority for com- improve protection of the spinal cord, though a pliance issues. Other federal and state organiza- degree of PARALYSIS affecting bowel, BLADDER, and tions also participate in workplace safety. lower body function typically remains. Occasion- ally a neural tube defect is so minor that it does MOST COMMON CAUSES OF not become apparent until later in life, even adult- WORKPLACE FATALITIES IN THE UNITED STATES hood. drowning ELECTROCUTION Folic acid supplementation, ideally beginning falls from roofs and ladders fires and explosions before CONCEPTION, can prevent most neural tube MOTOR VEHICLE ACCIDENTS overturned equipment defects. Health experts recommend all sexually struck by falling objects substance exposure active women of childbearing age take folic acid suicide VIOLENCE supplements whether or not they plan PREGNANCY. (Folic acid supplementation also helps stabilize Employers are responsible for providing a blood glucose levels in pregnant women who have working environment free from unreasonable risk DIABETES.) ALPHA FETOPROTEIN (AFP), CHORIONIC VILLI to workers. Such an environment varies according SAMPLING (CVS), and prenatal ULTRASOUND can detect to occupation. To the extent possible, federal and 39 40 Preventive Medicine state laws mandate appropriate protective mea- • congenital anomalies, BIRTH DEFECTS, and con- sures for workers in high-risk occupations. Occu- genital disorders (such as CEREBRAL PALSY), or pational and industry standards often result in GENETIC DISORDERS (such as SICKLE CELL ANEMIA or further measures to protect people from the haz- HEMOPHILIA) ards of their jobs. Individuals are responsible for • serious injuries such as BONE FRACTURE, CONCUS- following appropriate safety procedures. SION, major trauma MOTOR VEHICLE ACCIDENTS account for about 25 • serious illnesses such as ENCEPHALITIS, MENINGITIS, percent of workplace deaths. VIOLENCE also claims a significant number of deaths, particularly among ENDOCARDITIS, HEPATITIS, PANCREATITIS retail cashiers and cab drivers who are at risk for • surgeries (including TUBAL LIGATION or death by homicide during robberies. Other occu- VASECTOMY) pations with high risk for injury and death are • pregnancies, miscarriages, abortions, deliveries logging, commercial fishing, roofing, construction, • CONTRACEPTION, SEXUALLY TRANSMITTED DISEASES and mining. (STDS) KEY INDIVIDUAL MEASURES • DIABETES FOR PREVENTING WORKPLACE INJURIES • CARDIOVASCULAR DISEASE (CVD) • Obtain proper training for operating devices and • HEART ATTACK or STROKE equipment. • HYPERTENSION (high BLOOD PRESSURE) • Integrate ergonomic standards and practices into work • ANGINA PECTORIS stations and job tasks. • ARRHYTHMIA • Use appropriate protective devices, clothing, and gear. • PERIPHERAL VASCULAR DISEASE (PVD), CORO- • Follow employer risk-management policies and procedures. NARY ARTERY DISEASE (CAD), or CORONARY • Remain DRUG-free and ALCOHOL-free in the workplace. ARTERY BYPASS GRAFT (CABG) • HEART FAILURE or CARDIOMYOPATHY See also ACCIDENTAL INJURIES; BUILDING-RELATED • VALVULAR HEART DISEASE or valve replace- ILLNESS; OCCUPATIONAL HEALTH AND SAFETY; REPETITIVE ment MOTION INJURIES; SICK BUILDING SYNDROME; TRAUMA • pulmonary disease such as CHRONIC OBSTRUCTIVE PREVENTION; WORKPLACE STRESS. PULMONARY DISEASE (COPD) or EMPHYSEMA personal health history An ongoing record of an • gastrointestinal disorders such as INFLAMMATORY individual’s health conditions including vaccina- BOWEL DISEASE (IBD), GASTROESOPHAGEAL REFLUX tions, illnesses, injuries, operations, pregnancies DISORDER (GERD), PEPTIC ULCER DISEASE and births, medications, and other information • CANCER (including SKIN CANCER) that might be relevant in the context of providing • neurologic conditions such as PARKINSON’S DIS- health-care services. A personal health history also EASE or psychiatric conditions such as SCHIZO- helps determine future health risks and appropri- PHRENIA or BIPOLAR DISORDER ate treatment options. A personal health history might include these • chronic health conditions events (including dates) • infections such as OTITIS media, SINUSITIS, BRONCHITIS, CYSTITIS • vaccinations, routine medical examinations, • OSTEOARTHRITIS, ANKYLOSING SPONDYLITIS, and routine diagnostic procedures such as MAM- GOUT MOGRAM, PAP TEST, blood cholesterol test, tuber- • thyroid disease such as HYPOTHYROIDISM, culin SKIN test, COLONOSCOPY GOITER, or HYPERTHYROIDISM • common childhood diseases such as MEASLES, • DEPRESSION or GENERALIZED ANXIETY DISOR- MUMPS, RUBELLA, CHICKENPOX DER (GAD) • uncommon childhood diseases such as SCARLET • medications (including OVER-THE-COUNTER [OTC] FEVER, rheumatic FEVER DRUGS and herbal remedies) poison prevention 41

• lifestyle factors such as smoking, EATING HABITS, Children especially are attracted to medications physical exercise, and occupational health risks that are brightly colored and that may have a sweetened coating intended to make them more It also is helpful to know about the general palatable to swallow. Medications designed for health histories of immediate family members children are sweetened, chewable, or in other (parents, siblings, and children), particularly in ways made enticing. Careful storage of potentially regard to health conditions that can have familial poisonous products could prevent many accidental tendencies such as diabetes, cancer, and cardiovas- poisonings. Older adults who are not accustomed cular disease. to having children around or who have difficulty See also HEALTH RISK FACTORS. managing child-resistant closures often keep their personal hygiene Until researchers discovered medications in other containers or dispensers. This BACTERIA and connected them with INFECTION, doc- practice is a tragically frequent source of poisoning tors went from one patient to another without in children who find the containers and think washing their hands, and people did not bathe or they hold candy. otherwise manage personal hygiene. Before the 20th century most people believed bathing caused COMMON POISONOUS YARD AND HOUSE PLANTS rather than prevented illness. Because sewage and acorns azalea garbage often contaminated water supplies, this all buckeyes buttercups too frequently turned out the case. Doctors now castor bean seeds crocus bulbs know that cleanliness prevents the spread of daffodil bulbs daphne berries many kinds of infection and disease. COMMUNITY deadly nightshade dieffenbachia SANITATION measures provide strict procedures for elderberry foxglove managing wastes, and clean DRINKING WATER STAN- hyacinth bulbs jack in the pulpit DARDS help maintain the purity of water that flows jasmine berries larkspur seeds from the tap. lily of the valley mayapple Personal hygiene—regular bathing and cleans- mistletoe berries moonseed berries ing of the body—helps control body odor, the mushrooms and toadstools narcissus bulbs result of bacterial growth on the SKIN (especially oleander leaves and branches poison hemlock the underarms) in interaction with perspiration red sage berries rhododendron the body releases. It also can help prevent condi- rhubarb leaves thorn apple tions such as athlete’s foot and jock itch (types of wisteria yew yeast infections) and reduce the risk for bacterial infection following skin wounds such as cuts and Many decorative indoor and outdoor plants are scrapes. poisonous, presenting a hazard especially for chil- See also HAND WASHING; HYPERHIDROSIS; NOSOCO- dren young enough to put everything in their MIAL INFECTIONS. mouths and older children who may use leaves, berries, and branches as “play” food. Some com- Poisoning is the third-leading poison prevention mon plants, such as oleander, are so toxic that cause of ACCIDENTAL INJURIES, often affecting chil- plant juice on the hands can cause serious and dren who ingest toxic plants, cleaning products, sometimes fatal illness. Adults should teach chil- and medications (over-the-counter as well as pre- dren to never pick and eat any kinds of berries, scription). Poisoning also may affect adults when fruit, leaves, mushrooms, nuts, or even sticks to they consume more of a medication than is safe or use for campfire cooking without a knowledgeable plants and other substances that are toxic. adult’s supervision and approval. National poison control hotline: Do not give anything to, or induce vomiting in, 1-800-222-1222 a person who may have consumed a toxic sub- Available 24 hours a day, 7 days a week, stance, unless the substance is known and its orig- from anywhere in the United States inal package or product label contains specific instructions for poisoning. Otherwise, contact 42 Preventive Medicine emergency medical assistance (911, a hospital medicine. Many such measures relate to lifestyle, emergency room, or the national poison control such as smoking, EATING HABITS, and physical exer- hotline at 1-800-222-1222) and follow the recom- cise. Others involve vaccinations to prevent dis- mended actions. ease and ROUTINE MEDICAL EXAMINATION and screening procedures to detect health conditions KEY MEASURES FOR PREVENTING POISONING for early intervention and treatment. Key self-care • Store all medications in their original labeled containers, measures are BREAST SELF-EXAMINATION (BSE) for with child-resistant lids or caps, in a locked cabinet or women and for men, TESTICULAR SELF-EXAMINATION drawer out of the reach of children. (TSE) for men, and SKIN self-examination for men • Accurately measure medication doses, especially those and women. Immunizations provide protection given to children. against numerous potentially serious or life- • Clear yards and play areas of toxic plants. threatening illnesses. • Store cleaning products in locked cabinets out of the reach Recommendations for doctor examinations and of children. screening tests vary according to gender and age. Appendix X, “Immunization and Routine Exami- See also CONTACT TOXINS; INGESTED TOXINS; INHALED nation Scheldules,” provides comprehensive infor- TOXINS; INJECTED TOXINS; OVERDOSE. mation for infants and children, adolescents, men, and women. preventive health care and immunization Pre- See also HEALTH RISK FACTORS; LIFESTYLE AND vention measures are the mainstay of preventive HEALTH; TRAVEL IMMUNIZATIONS; VACCINE. Q–R

quality of life The extent to which health sup- help put those treatments in proper perspective ports, and disease or injury prevents, a person’s and frame realistic expectations. ability to participate in and enjoy daily living Quality of life is a particular concern for people activities is highly subjective though nonetheless a who have severely debilitating or terminal health crucial measure of health care. Health experts use conditions. Issues such as independence, mobility, various tools, such as questionnaires, and method- PAIN management, and dignity often arise. Most ologies to assess health-related quality of life people are more accepting of chronic and even (HRQOL). The findings become integral in deter- terminal conditions when they are able to discuss mining the overall effectiveness of intervention their concerns and fears openly and honestly with and treatment approaches for all kinds of health their doctors, and to establish treatment plans that circumstances from surgical operations to degen- are consistent with their wishes. erative diseases. See also ADVANCE DIRECTIVES; CULTURAL AND ETHNIC Numerous factors influence quality of life for HEALTH-CARE PERSPECTIVES; END OF LIFE CONCERNS. people living with chronic health conditions or disabilities, ranging from personal satisfaction with radon exposure Radon is a naturally occurring the process and outcome of medical treatment to radioactive element, present as a gas in rocks and the removal of barriers to participation in activities soil. Radon is also a CARCINOGEN (cancer-causing of interest. Removing barriers might include substance) that is the second-leading cause of LUNG measures such as adaptive devices for HEARING LOSS CANCER in the United States. The highest rate of and VISION IMPAIRMENT, voice-activated telephones radon-induced LUNG cancer occurs among miners and other electronics, prosthetic limbs, and mobil- who work underground and breathe concentrated ity devices. Each person has activities that he or levels of radon over years to decades. Cigarette she considers essential for enjoying life. smoking, in addition to itself being the leading Individual satisfaction with of quality of life cause of lung cancer, greatly increases the risk for correlates closely to expectations for outcomes, radon-induced lung cancer. Radon becomes a gen- which vary among cultures and generations. eral health hazard when its levels rise inside Younger people tend to have higher expectations houses and workplaces such as offices and stores. for treatments that return them to “normal” in It seeps inside through cracks in foundations and relatively short order. Medical technology often floors, often drawn indoors by pressure inequali- makes such expectations reality. However, tech- ties (the air inside is generally lower pressure than nology has its limitations and sometimes expecta- the air outside). tions exceed them. Doctors may be excited about The US Environmental Protection Agency the potential of new treatments, and individuals (EPA) has established an “action level” for indoor may be less than fully informed about potential radon concentrations of 4 picocuries per liter benefits and risks. Taking the time to thoroughly (pCi/L). The typical house has a radon concentra- investigate proposed treatments, including med- tion of about 25 percent of the maximum, 1.0 to ications and surgeries, and obtaining second opin- 1.25 pCi/L; the air in an underground mine may ions from other doctors are key measures that can contain four times the maximum, 20 pCi/L, or 43 44 Preventive Medicine even more. Outdoor air typically contains about • tuning fork to screen hearing and to assess sen- 0.4 pCi/L of radon. There is no determined safe sory perception (neurologic function) in other level of radon. The public health goal is to lower parts of the body all indoor radon levels to 2 pCi/L or less, with the eventual goal of lowering indoor radon levels to Each doctor has his or her pattern for conduct- those of outdoor radon levels. ing a physical examination. A common pattern is Home test kits, available through state radon to begin with vital signs and then go from head to offices and radon mitigation contractors, can foot. measure radon levels. Among the most common Vital signs The typical vital signs are PULSE, RES- methods for lowering indoor radon levels are PIRATION RATE, temperature, blood pressure, height, beneath-ground ventilation systems that collect and weight. Temperature identifies whether there radon from under a house and release it via venti- is a FEVER. Height and weight help the doctor to lation tubing into the outdoor air. These systems assess BODY MASS INDEX (BMI) and the likelihood of often can accommodate any kind of foundation certain health conditions that correlate to body (basement, slab, or slab with crawl space). Health weight. Many doctors will take blood pressure experts recommend initial radon testing with reg- readings at the start and end of the examination, ular follow-up testing regardless of the level. because a person’s anxiety about the examination See also ENVIRONMENTAL HAZARD EXPOSURE; HEALTH may cause blood pressure to be artificially ele- RISK FACTORS. vated. The doctor will typically take the pulse at each wrist and ankle, pressing against the pulse routine medical examination The examination point with two fingers, and may check the pulses a doctor conducts to assess an individual’s health in the neck and groin as well. Respiration rate status typically includes certain procedures and includes a count of how many breaths the person tests that vary according to age and gender. A rou- takes in a minute as well as an assessment of how tine medical examination for adults consists of a deep or shallow the breaths are. physical examination, PERSONAL HEALTH HISTORY, Head, face, and neck The doctor looks in the general BLOOD tests (complete blood count [CBC], ears and the eyes, and may hold a tuning fork blood GLUCOSE, blood cholesterol), and URINALYSIS. near each ear as a basic hearing screen. Many doc- Depending on the person’s age, the doctor may tors use a SNELLEN CHART to assess basic visual acu- order other diagnostic procedures such as blood ity. When the doctor says, “Say ah,” the sound tests for thyroid hormones, chest X-RAY, tuberculin causes the soft palate and related tissues at the skin test, COLONOSCOPY, MAMMOGRAPHY, and BONE back of the MOUTH to elevate. This allows the doc- DENSITY testing. tor to visualize the top of the THROAT. Sometimes Some of the devices the doctor may use to the doctor presses a tongue depressor against the assess physical health include back of the mouth for a better view, which can unintentionally activate the GAG REFLEX. The doc- • ophthalmoscope to visualize the structures of tor also looks at the structures of the mouth the EYE including the tongue. Palpating the neck helps • otoscope to look at the structures of the outer identify thyroid nodules and enlargement; the EAR and the eardrum (TYMPANIC MEMBRANE) doctor usually will feel the neck twice, first with • STETHOSCOPE to listen to the HEART and LUNGS the person sitting quietly and then when having (AUSCULTATION) the person swallow. Chest The doctor listens to the heart and lungs • sphygmomanometer to measure the BLOOD with a stethoscope, and may tap on the chest and PRESSURE the back. The stethoscope allows the doctor to • thermometer to take the temperature hear the heart valves open and close and the • REFLEX hammer to test reflexes and other neu- rhythm of the heart as it beats. It also lets the doc- rologic responses tor hear the sounds of air entering and leaving the routine medical examination 45 lungs (breath sounds). The tapping helps to iden- mer test TENDON responses as well as neurologic tify areas of unusual density that might suggest reflexes. The doctor looks for unusual bruising, enlargement of the heart, accumulated fluids, or swelling or edema, discolorations, and disparities other circumstances that need further examina- between sides of the body. The doctor may tion. The chest examination should also include observe as the person walks across the room and breast examination for men as well as women, to back to assess gait and balance. Pulses in the feet detect lumps or other abnormalities. are good indicators of peripheral circulation. Back The doctor may look at the back from the Genitalia The doctor will palpate a man’s testi- back and each side when the person is standing, as cles to check for lumps or swellings, and examine a general screen for SCOLIOSIS, KYPHOSIS, and other the PENIS for structural anomalies or discharge. The back conditions. The doctor may palpate the spine familiar “turn your head and cough” instruction and have the person raise and lower the arms to increases pressure in the lower abdomen to reveal examine the shoulders and shoulder blades. The any HERNIA. A woman’s physical examination typi- back also is a common site for ACNE, ACTINIC KER- cally includes a PELVIC EXAMINATION and PAP TEST. ATOSIS, and other SKIN conditions. Depending on age, the doctor may include a DIGI- Abdomen The doctor palpates the abdomen TAL RECTAL EXAMINATION (DRE) for men and women. from the base of the ribs to the pelvis, feeling for Job positions with highly physical demands any usual masses or tenderness. Abdominal palpa- such as firefighter or police officer, school sports tion helps detect signs of ASCITES (collected fluid in and athletic programs, return-to-work following the abdominal cavity) abdominal ANEURYSM (weak- injury, and certifications such as for aviation and ening and ballooning of the major ARTERY in the nautical pilots are among the special circum- abdomen, the AORTA), LIVER or SPLEEN enlargement, stances that may require routine medical exami- and tenderness of organs such as the GALLBLADDER, nations. The physical examination and diagnostic STOMACH, and pancreas. The doctor will also listen procedures will include any additional tests to to the abdomen with a stethoscope, further check- meet the requirements. Appendix X, “Immuniza- ing for abdominal aneurysm as well as assessing tion and Routine Examination Schedules,” pro- BOWEL SOUNDS. The doctor may also tap on the vides information about how frequently a person belly, listening for differences in tones that might should have a routine medical examination and suggest changes in density. what components the examination should Arms and legs The doctor may move the arms include. and legs to examine the joints, MUSCLE tone, and See also HEALTH RISK FACTORS; LIFESTYLE AND range of motion. Small taps with the reflex ham- HEALTH; OCCUPATIONAL HEALTH AND SAFETY. S–Y

sexually transmitted disease (STD) prevention • men and women entering correctional facilities Doctors diagnose and treat about 12 million new • adolescents and young adults STD infections annually in the United States, and • women and infants more than 70 million Americans live with incur- able STDs. Nearly all STD infections are preventa- STDs may not cause symptoms, especially in ble through sexual abstinence, which is a certain women. A person who is unaware that he or she though often undesirable preventive measure, or has an STD continues to spread the infection. The through safer sex practices, which include using infection also has long-term personal conse- latex condoms with every sexual act and regular quences. For women, the key complication of screening tests for STDs. untreated or repeated STD infection is PELVIC INFLAMMATORY DISEASE (PID), a leading cause of SEXUALLY TRANSMITTED DISEASES (STDs) infertility. PID also can cause chronic PAIN and Curative Treatment Treatment but No Cure contribute to ECTOPIC PREGNANCY (also called tubal chancroid GENITAL HERPES pregnancy), a life-threatening circumstance in CHLAMYDIA HEPATITIS B which a pregnancy takes root in the fallopian tube GONORRHEA HIV/AIDS or elsewhere in the abdominal cavity instead of UTERUS lymphogranuloma venereum HUMAN PAPILLOMAVIRUS (HPV) the . nongonococcal URETHRITIS Oral contraceptives (birth control pills), SYPHILIS diaphragms, intrauterine devices TRICHOMONIASIS (IUDs), and spermicides do not protect women from contracting STD infec- HEPATITIS C and TUBERCULOSIS also are often con- tracted through sexual contact though are not tra- tions. ditionally considered STDs. Untreated STDs can Men may also have STDs without symptoms, have significant health consequences including though often develop urethritis (INFLAMMATION of INFERTILITY, CENTRAL NERVOUS SYSTEM damage, gener- the URETHRA) with discharge that leads to exami- alized organ damage, and death. STDs can affect nation and diagnosis. In men and women alike, anyone who is sexually active. However, certain untreated SYPHILIS goes into stages of REMISSION. In groups of people are more vulnerable to STD most STDs, the infection remains contagious INFECTION and to the consequences of untreated whether or not symptoms are present. The male STDs. Health experts classify these groups as spe- latex condom is the most effective barrier against cial focus populations transmitting STDs. The pathogens that cause STDs cannot pass through the latex. However, contact • men who have sex with other men (MSM) between body fluids and mucous membranes can • injectable DRUG users occur around the condom, so its protection is not • men and women who have unprotected sex foolproof. It is essential to use condoms properly with multiple partners (putting them on immediately upon erection and 46 substance abuse prevention 47 before pre-ejaculate appears) and consistently for • are present only when within the building maximum preventive benefit. Infants whose mothers have active STDs, par- Symptoms may affect a few people in a particu- ticularly GONORRHEA and CHLAMYDIA, during deliv- lar area or numerous people throughout the ery are at great risk for blindness. Hospitals building. Because symptoms often are general and routinely put antibiotic drops in the eyes of all are present only when the person is in the build- newborns as a prophylactic measure. Infants born ing, obtaining a diagnosis of illness is challenging. to HIV-positive mothers are also at risk for acquir- Sometimes symptoms improve with ANTIHISTAMINE ing the VIRUS during birth; prophylactic medica- MEDICATIONS to combat allergic response, though tions such as azidothymidine (AZT) can help most people do not want to take medications for thwart infection. symptoms they can relieve by being in a different location. The US Centers for Disease Control and The causes of sick building syndrome are Prevention (CDC) has a national unclear though scientists believe they may relate STD/HIV hotline available 24 hours a to INDOOR AIR QUALITY, chemicals in the air from day, 7 days a week, for questions and indoor or outdoor sources such as exhaust fumes information: 800-227-8922 or glues, contaminants such as molds or fungi that cause allergy-like reactions, and inadequate venti- Prevention efforts focus on education about lation. Increased ventilation (higher turnover of STDs and their potential health consequences in air volume) and air-filtration systems may combination with appropriate methods to reduce improve indoor air quality sufficiently to mitigate the likelihood of infection. The most effective pre- symptoms for most people. Some individuals may vention method is abstinence from sexual activity, have heightened sensitivity to airborne sub- or, when sexually active, sex exclusively within a stances. monogamous relationship. Because some STDs See also ALLERGIC RHINITIS; BUILDING-RELATED ILL- may be present without symptoms in up to 70 NESS; ENVIRONMENTAL CIGARETTE SMOKE; OCCUPATIONAL percent of people infected, health experts recom- HEALTH AND SAFETY. mend routine screening for all sexually active individuals as a preventive measure to help con- substance abuse prevention SUBSTANCE ABUSE is tain the spread of infection. a complex health and social problem with public health as well as personal health consequences. KEY MEASURES FOR PREVENTING STDS Accordingly, substance abuse prevention efforts • Use a latex condom for every sexual act. require coordinated efforts that align individuals, • Restrict sexual activity to a monogamous relationship. parents, schools, employers, and health-care • Receive regular screening tests for STD infection. providers toward common goals. Though educa- tion is the cornerstone of substance abuse preven- See also CONTRACEPTION; HEALTH RISK FACTORS; tion, it is naive to believe education alone is LIFESTYLE AND HEALTH; YOUTH HIGH-RISK BEHAVIOR. sufficient to stop a person from trying or using TOBACCO, ALCOHOL, drugs, and illicit substances. sick building syndrome A set of symptoms that Many knowledgeable people have substance appear when in a particular building and go away abuse problems. upon leaving the building. The US Environmental Parents, teachers, sports figures, and other Protection Agency (EPA) defines sick building syn- adults significantly influence the attitudes and drome as symptoms that actions of children. Adults who do not smoke or use illicit drugs and who use alcohol and medica- • include HEADACHE, NAUSEA, itchy eyes and NOSE, tions appropriately and responsibly help model and dry COUGH attitudes and behaviors that discourage substance • doctors cannot diagnose as any specific health abuse. Focused prevention efforts target underage condition smoking and drinking, emphasizing abstaining 48 Preventive Medicine from both. Other efforts attempt to address issues maturely and those whose mothers smoked during of ADDICTION through treatment programs. pregnancy appear to have higher risk for SIDS. Pediatricians may recommend special monitors for KEY MEASURES FOR PREVENTING SUBSTANCE ABUSE especially vulnerable infants that sound an alarm • education through schools and community outreach regard- when the infant’s breathing rate or body tempera- ing the health risks of substance abuse ture becomes higher or lower than normal. • effective and appropriate modeling by adults • access to treatment programs KEY MEASURES FOR PREVENTING SIDS • take medications, over-the-counter or prescription, only as • Place infant on his or her back to sleep, not on the side or needed and directed STOMACH. • restrict underage access to TOBACCO, ALCOHOL, and medica- • Place infant to sleep in his or her own crib. tions of abuse • Maintain the infant’s room at a temperature warm enough to allow sleeping without blankets but not hot. See also ALCOHOLISM; OVERDOSE; SMOKING CESSA- • Keep heavy blankets, quilts, and stuffed animals out of the TION; TOLERANCE. infant’s crib. • Maintain a smoke-free living environment and prevent sudden infant death syndrome (SIDS) The exposure to cigarette smoke in general. unexpected and unexplainable death of an infant under age one year, most commonly between the See also NERVOUS SYSTEM; PRENATAL CARE. ages of two and four months. Researchers do not know what causes SIDS, though believe a mal- trauma prevention Firearms, MOTOR VEHICLE function occurs in the infant’s basic metabolic reg- ACCIDENTS, SEXUAL ASSAULT, DOMESTIC VIOLENCE, CHILD ulatory mechanisms that allows BLOOD PRESSURE, ABUSE, workplace and school VIOLENCE, animal BREATHING, and body temperature to fluctuate. bites, and major falls account for the majority of Also for reasons researchers do not understand, traumatic injuries. As is the case with other kinds SIDS is three times more frequent among African of ACCIDENTAL INJURIES, most traumatic injuries are American and Native American infants. SIDS is preventable. Traumatic injuries have a high likeli- also more likely to occur among infants whose hood of death within the first several hours after mothers are under age 20 years, smoke, gain inad- the events responsible for them, and require equate weight during PREGNANCY, or have pregnan- emergency medical treatment. Traumatic injuries cies less than a year apart. Infants who sleep on their backs have a signifi- KEY MEASURES FOR PREVENTING TRAUMA cantly lower rate of SIDS than infants who sleep on • Use trigger locks and gun safes to store guns, and separate their sides or stomachs, prompting the national guns from ammunition. “Back to Sleep” campaign in 1994 to lower the risk • Take firearms safety classes before hunting or target shoot- for SIDS. Deaths due to SIDS dropped almost in half ing, and always handle a gun as though it were loaded. in subsequent years. Because researchers do not • Wear seat belts at all times when traveling in a motor vehi- know why SIDS occurs, however, they are not cer- cle and helmets when riding on a motorcycle, whether the tain how, or whether it is possible, to prevent it. driver or a passenger. Because the infant’s death is sudden and unex- • Wear or use appropriate safety gear when using power tools plained, local authorities must investigate. This and performing home repairs, and for recreational activities adds to the emotional trauma for families because it such as rock climbing. is a difficult experience to undergo and even when • Stabilize ladders and do not step higher than recommended SIDS is the conclusion, the question of why often onto a stepladder or ladder. remains unanswered. Inasmuch as the causes of • Keep dogs leashed or fenced, and do not approach wild SIDS remain unclear, health and law-enforcement animals. experts do know that SIDS is not the result of • Seek professional help for anger management and DOMESTIC VIOLENCE issues parental neglect or CHILD ABUSE. Infants born pre- water safety 49 also account for a significant percentage of long- care. The typical course of treatment for diagnosed term recovery and permanent disability due to active tuberculosis is a regimen of two or more injury. Prevention efforts focus on increasing pub- ANTIBIOTIC MEDICATIONS taken for 6 to 10 months. lic awareness and reducing exposure to risks. Prevention efforts focus on screening susceptible See also ANGER AND ANGER MANAGEMENT; BLUNT populations for early diagnosis and treatment, and TRAUMA; GUNSHOT WOUNDS; MULTIPLE TRAUMA; OCCU- on encouraging people who show symptoms of PATIONAL HEALTH AND SAFETY. tuberculosis to receive medical treatment. Anyone who has had close contact with a person diagnosed tuberculosis prevention Until researcher Selman with tuberculosis, as well as those who have Waksman (1888–1973) discovered the powerful HIV/AIDS and a marginal tuberculin skin test result antibiotic streptomycin in 1944, TUBERCULOSIS should receive more frequent screening tests and (called “consumption” because its sufferers literally discuss prophylactic antibiotic therapy with their wasted away as the INFECTION consumed lung and doctors. Research continues the quest for a tuber- other tissue) killed more people than any other dis- culosis VACCINE. The BCG vaccine currently avail- ease. Antibiotic regimens developed in the ensuing able provides very limited protection. Doctors decade significantly reduced tuberculosis infections administer it primarily to young children exposed in the United States by the mid-1960s. By the mid- to non-lung forms of tuberculosis infection. 1980s, however, strains of tuberculosis began appearing that were resistant to the conventional KEY MEASURES FOR PREVENTING TUBERCULOSIS antibiotic therapy (now called multidrug-resistant • Receive periodic tuberculin SKIN tests to screen for the pres- tuberculosis or MDR-TB). Concurrently HIV/AIDS ence of M. tuberculosis. proliferated, making those who became infected • Receive prophylactic antibiotic therapy when at high risk for highly susceptible to other infections such as tuber- INFECTION. culosis. People who have DIABETES, kidney disease, • Take protective measures such as wearing a surgical mask LEUKEMIA, or LYMPHOMA or who receive IMMUNOSUP- when in close contact with someone diagnosed with tuber- PRESSIVE THERAPY such as following ORGAN TRANSPLAN- culosis. TATION are also more susceptible to tuberculosis • If being treated for tuberculosis, take the full course of infection. Tuberculosis tends to develop more fre- antibiotic therapy as prescribed. quently among confined populations such as in prisons and crowded living conditions. See also KIDNEYS; LUNGS; OCCUPATIONAL HEALTH Doctors diagnose about 15,000 people with AND SAFETY. tuberculosis in the United States each year, about half of whom are immigrants who likely became water safety More than 4,000 people drown in infected in their native countries. Tuberculosis the United States each year, and as many as spreads by BREATHING droplets a person already 12,000 experience near-drowning (also called sub- infected with the disease breathes or coughs out mersion injury). The HYPOXIA (lack of oxygen) that into the air. Most people who have healthy occurs with submersion results in residual compli- immune systems can fight off infection, though cations in about 40 percent of people who are the causative microorganism (Mycobacterium tuber- revived, ranging from mild memory impairment culosis) may remain inactive in their bodies (called and disturbances of cognitive function to PERSIST- latent tuberculosis). Only people who have active ENT VEGETATIVE STATE. Virtually all water accidents tuberculosis can spread the infection to others. A are preventable. SKIN test can detect the presence of M. tuberculosis. The common scenarios for water-related Public health policy in the United States requires injuries correlate with age: skin testing, called a tuberculin skin test, in numerous occupations including public safety • Children under age 1 year are most likely to (police, fire, and emergency aid response), teach- drown in toilets, bathtubs, and buckets or other ing, food handling and preparation, and health containers of water. 50 Preventive Medicine

• Children between the ages of 1 and 4 years are See also COLD WATER DROWNING; HYPOTHERMIA; most likely to drown in residential swimming SPINAL CORD INJURY; TRAUMATIC BRAIN INJURY (TBI); pools. WARM WATER DROWNING. • Young people between the ages of 15 and 19 are most likely to drown in lakes and rivers, youth high-risk behavior The US Centers for Disease Control and Prevention’s (CDC’s) Youth and ALCOHOL consumption contributes up to half of their water-related injuries and deaths. Risk Behavior Surveillance System (YRBSS) moni- tors behaviors among young people that can • Boating accidents are the most common cause adversely affect their health. Key areas of focus of submersion injuries among adults. Alcohol include TOBACCO use, substance abuse, sexual consumption is a factor in nearly half of such activity, PREGNANCY, violent behavior, ACCIDENTAL accidents. INJURIES, physical inactivity, EATING HABITS, and • Among adolescents and adults, diving into shal- attempted suicide. YRBSS data help public health low water accounts for numerous HEAD AND organizations develop intervention strategies and SPINAL CORD INJURIES. programs to reduce adverse health consequences among youth. The CDC surveys students in mid- Three of four people who drown are adults. dle schools and high schools throughout the Even capable swimmers can experience exhaus- United States to collect YRBSS data. tion, MUSCLE cramps, and other challenges. Many people who die in boating accidents are not wear- HIGH-RISK HEALTH BEHAVIORS AMONG YOUTH ing personal flotation devices (PFDs) or lack other anabolic steroid use binge drinking water safety devices that could have prevented carrying a weapon cigarette smoking their deaths. Alcohol consumption and swimming does not drink milk does not eat fruit, vegetables or boating factors in about 40 percent of water- drinking and driving failure to wear bike helmet related injuries among adolescents and adults. fast food consumption fighting ILLICIT DRUG USE lack of seat belt use KEY MEASURES FOR PREVENTING DROWNING laxatives or diet aids to multiple sex partners • Learn to swim. lose weight no regular physical • Learn CARDIOPULMONARY RESUSCITATION (CPR). nonsmoking TOBACCO use exercise • Wear or use appropriate flotation devices when engaged in overweight or obese regular ALCOHOL consumption water activities such as boating. riding with intoxicated driver sexual activity without a • Closely supervise children in and near water, including suicide ideation or attempts condom pools, lakes, and rivers. • Do not drink ALCOHOL when participating in activities on or See also LIFESTYLE AND HEALTH; HEALTHY PEOPLE in the water. 2010. ALTERNATIVE AND COMPLEMENTARY APPROACHES The current time is one of a paradigm shift in the nature and delivery of health care that affects everyone— researchers, patients, doctors, and insurers—alike. Tremendous discoveries in medicine are leading to a reexamination of attitudes and practices across the spectrums of health and of disease. As conventional medicine intensifies its focus on lifestyle management and preventive measures and on viewing the patient as a “whole” person (the holistic view com- mon to many alternative and complementary health systems), both doctors and individuals are finding therapeutic value in incorporating many alternative and complementary therapies within integrative treatment plans.

This section, “Alternative and Complementary ing to entertain such inclusions. Much depends Approaches,” presents an overview discussion of on the convergence of the patient’s interests and treatment approaches that are beyond the bound- condition with the doctor’s knowledge and trust aries of conventional medicine yet still within the in specific alternative and complementary thera- realm of which conventional doctors may respon- pies. The efficacy of some ancient healing systems sibly include them as elements of integrative and methods is perhaps more trustworthy than treatment plans. The entries that follow represent that of isolated or obscure practices. The challenge the range of the alternative and complementary for doctors and patients alike is to evaluate what therapies available from ancient healing systems, bodies of knowledge exists about popular thera- such as TRADITIONAL CHINESE MEDICINE (TCM) and pies, to understand which of them may have ther- AYURVEDA, to MEDICINAL HERBS AND BOTANICALS. As apeutic value. well, several entries present methods that are con- Most alternative therapies derive from healing troversial and potentially hazardous from the con- systems deeply rooted in philosophical frameworks ventional medicine perspective, such as CHELATION that differ dramatically from those of conventional THERAPY. Such entries are included not to give Western medicine. A conventional physician’s them credibility but because widespread misper- training does not include most of these methods, ceptions about them persist despite a clinically even the most studied or popular ones. Doctors valid body of knowledge that supports concerns must instead rely on evaluating the available about their risks. research to determine whether, how, and when alternative and complementary approaches are Context and Perspective appropriate in conjunction with conventional care. This section presents the discussion of alternative For some methods, not much data are available. As and complementary approaches within the con- knowledge about these approaches increases, text and perspective of conventional medicine as many conventional doctors may be more confident practiced in the United States, as this is the orien- about incorporating them. Indeed, some conven- tation of The Facts On File Encyclopedia of Health and tional doctors seek additional education and certifi- Medicine. Some conventional doctors share the cation in alternative and complementary therapies interest and enthusiasm of patients who want to such as ACUPUNCTURE and herbalism so they can incorporate alternative and complementary thera- offer their patients a broader spectrum of therapeu- pies, and some conventional doctors are less will- tic and preventive options. 51 52 Alternative and Complementary Approaches

The conventional framework that guides the Historical Traditions in practice of medicine in the United States is physi- Alternative Healing Systems cian centered and based in measurable evidence The oldest known healing systems still in practice and reliably repeatable results through controlled today, traditional Chinese medicine (TCM) and clinical studies. Though the true measure of a Ayurveda, date to perhaps 3000 B.C.E., well before treatment’s success is whether people improve or the advent of written language. NATIVE AMERICAN worsen with its use, evidence-based standards give HEALING originating among the indigenous cultures conventional physicians a sense of reasonable of the North American continent melds spirituality expectation when making treatment decisions and and health in much the same fashion as does recommendations. Many conventional doctors are India’s Ayurveda and, archaeological evidence increasingly interested and willing to add respon- suggests, could have origins that are nearly as sible alternative and complementary therapies to ancient. In these systems, healers passed their integrative treatment plans when they have rea- knowledge from one to another, generation to sonable expectations for how such therapies generation, through tradition and experience. In may benefit the patient’s condition or QUALITY OF some cultures each successive generation devel- LIFE. oped improvements on the methods of healing When looking at the broad range of alternative their ancestors used, and in other cultures each and complementary approaches from acupuncture generation of healers practiced in precise compli- to PRAYER AND SPIRITUALITY to VISUALIZATION it is also ance with the traditions they learned from the important to understand how patients look to generations before them. these methods in preventive and lifestyle contexts. Some alternative healing systems are relatively MEDITATION and YOGA, for example, have become modern, emerging within the past 100 or 200 fairly mainstream as practices to reduce stress and years as outgrowths of what were the medical are gaining acceptance for their abilities to influ- practices of their times. Though common percep- ence health conditions such as HYPERTENSION (high tion views alternative and complementary thera- BLOOD PRESSURE). As researchers and doctors learn pies as Eastern in their philosophies and practices, more about the pathways and mechanisms of these newer systems—notably HOMEOPATHY, NATUR- MIND–BODY INTERACTIONS, they understand more OPATHY, and OSTEOPATHY—are Western in origin and fully how lifestyle and preventive health meas- orientation. One alternative healing method, CHI- ures, with a holistic view of the individual, are ROPRACTIC, is uniquely American. important. Within such a context, yoga and exer- cise become comparable complements to good ALTERNATIVE HEALING SYSTEMS health. Whether one or the other is “alternative” AYURVEDA HOMEOPATHY or “conventional” has little relevance; each bene- NATIVE AMERICAN HEALING NATUROPATHY fits health in similar ways. OSTEOPATHY TRADITIONAL CHINESE MEDICINE (TCM)

Interest in, and use of, alternative therapies is a COMMON ALTERNATIVE AND growing phenomenon in the United States. COMPLEMENTARY THERAPIES According to a 2002 survey by the US National ACUPUNCTURE AROMATHERAPY Center for Complementary and Alternative Medi- ART THERAPY BIOFEEDBACK cine (NCCAM) and the US Centers for Disease Chinese herbal remedies CRANIOSACRAL MASSAGE Control and Prevention (CDC) National Center for FLOWER ESSENCES HYPNOSIS Health Statistics (NCHS), nearly two thirds of MAGNET THERAPY MASSAGE THERAPY Americans use some form of alternative health MEDICINAL HERBS AND BOTANICALS NUTRITIONAL THERAPY practice, most of them to complement their con- OSTEOPATHIC MANIPULATIVE PRAYER AND SPIRITUALITY ventional medical care. TREATMENT (OMT) TAI CHI Surveys show that half choose alternative thera- VISUALIZATION VITAMIN AND MINERAL pies on their own to complement conventional YOGA THERAPY therapies, a quarter use alternative therapies their Alternative and Complementary Approaches 53 conventional physicians recommend, and a quarter Though it is seldom harmful to drink GREEN TEA, use alternative therapies on their own because they do yoga, or have REIKI, some alternative and com- believe conventional medicine will not help their plementary methods may be hazardous as may be conditions. Nearly 12 million Americans seek relief some conventional methods—for people who from BACK PAIN alone through alternative and com- have certain health conditions. For example, peo- plementary therapies (excluding prayer). Other ple who have RHEUMATOID ARTHRITIS or other common uses of alternative and complementary degenerative musculoskeletal disorders may risk therapies (excluding prayer) include arthritis and serious injury with craniosacral therapy, OSTEO- JOINT PAIN, chronic HEADACHE, FIBROMYALGIA, anxiety PATHIC MANIPULATIVE TREATMENT (OMT), or chiroprac- and DEPRESSION, chronic gastrointestinal conditions, tic manipulation. NUTRITIONAL THERAPY may alter hypertension, and MENOPAUSE discomfort. Many medication needs for people who have DIABETES, people use alternative and complementary thera- MALABSORPTION disorders, or conditions affecting pies to provide relief during cancer treatment and the LIVER or KIDNEYS. It is important to choose the from cancer symptoms. most reliable and credible methods and practition- ers, and to coordinate care among all the NCCAM/NCHS 2002 SURVEY’S TOP 10 providers involved in its delivery, conventional Alternative/Complementary Percentage of and complementary. Practice Americans Who Use prayer specifically for one’s own Using alternative and complementary health 43.0 percent approaches in coordination with con- prayer by others for one’s ventional treatments may alleviate health 24.4 percent some symptoms but cannot effectively natural products 18.9 percent substitute for conventional medical deep BREATHING EXERCISES 11.6 percent care for many health conditions ranging participation in prayer group for from HYPOTHYROIDISM to CANCER. one’s own health 9.6 percent MEDITATION 7.6 percent For people who are undergoing conventional CHIROPRACTIC care 7.5 percent medical treatment such as CHEMOTHERAPY or RADIA- YOGA 5.1 percent TION THERAPY, it is worthy to ask doctors what to massage 5.0 percent eat, how and when to exercise, and what mea- diet-based therapies 3.5 percent sures can support health; the environment of the Source: Barnes, P; Powell-Griner, E; McFann, K; and Nahin, R. CDC body changes dramatically during such therapies, Advance Data Report #343. Complementary and Alternative Medicine and sometimes approaches that are supportive Use Among Adults: United States, 2002. May 27, 2004. and complementary to the conventional treatment can lessen the harshness of the experience. For “First, Do No Harm” many circumstances, however, available informa- Alternative and complementary approaches often tion fails to provide clear answers and it becomes draw people to try them on their own, without a matter of trusting the doctor and making com- consulting their conventional doctors. People may mon sense decisions. be curious about certain methods, frustrated or disappointed with the results of conventional Science Meets Tradition: Evidence and Standards treatments, or have limited access to conventional Scientific evidence is scarce for many alternative health care. In choosing from alternative and and complementary therapies. Many therapies complementary therapies, it is prudent to learn as have evolved over centuries of use and produce much as possible about the method so as to “first, reliable results even though contemporary clinical do no harm” as the time-honored medical dictum science cannot yet explain the mechanisms of the cautions. And, when possible, seek the advice of a method. Acupuncture, for example, has been an conventional doctor to gain perspective to what integral component of TCM, as well as other heal- often is confusing or conflicting information. ing systems, for several thousand years. At 54 Alternative and Complementary Approaches acupuncture’s foundation, within these systems, is complementary therapies. These possibilities apply the presence of an extensive network of energy as well to conventional therapies. Researchers do channels, called meridians, in the body. Though not fully understand the mechanisms of many these meridians are not tangible, perceptible struc- drugs, such as levodopa to treat PARKINSON’S DIS- tures in the conventional sense, they are nonethe- EASE, the tricyclic ANTIDEPRESSANT MEDICATIONS, and less a centuries-old map of energy pathways in the many of the medications doctors prescribe to treat body. That contemporary researchers have yet to HEART conditions. However, empirical evidence quantify them does not necessarily invalidate their (observable, reproducible effects) support their existence. Indeed, not until the invention of effectiveness to the extent that conventional doc- devices such as the microscope in the eighteenth tors are comfortable using them. Such is becoming century, and really not until its application in the case with some alternative and complemen- exploring the structure of the human body in the tary approaches that lend themselves to empirical nineteenth century, did scientists discover the net- study, such as acupuncture. works of nerves that convey information and As the current health-care paradigm continues instructions from the BRAIN to each cell in the to change, it is natural to expect conflicting view- body. Medical science is ever-evolving, and new points about the best standard of care to emerge. technologies continually reveal new and para- Until there is a truly integrated approach, there digm-shifting discoveries (such as mapping the will be a higher level of responsibility on the indi- human genome). vidual to participate in health-care decisions and Herbal remedies and medicinal foods contain to choose care that is wise and effective. This numerous potentially active ingredients. Conven- applies as much to the choice to use acupuncture tional clinical studies of the intact substance, such as to enroll in a clinical study for an experimental as the soybean, may yield different results than drug or treatment. studies of the substance’s known active ingredi- ents, such as SOY isoflavones. A substance may Breakthrough Research and Treatment Advances appear to be a “heal-all,” raising questions about Advances in medical technology, particularly PLACEBO effect. And yet the substance may simply imaging procedures, have made possible the study have such broad-reaching actions in the body, of alternative and complementary therapies in such as stimulating the immune system, that it ways that allow researchers to explore how they truly does have healing effects for numerous alter physiologic functions. POSITRON EMISSION health conditions. TOMOGRAPHY (PET) SCAN and MAGNETIC RESONANCE Evidence of effectiveness and mechanism of IMAGING (MRI), for example, allow researchers to action may be in short supply simply because the observe, in real time, the changes that take place clinical research studies that are today the founda- in the brain and other parts of the body with ther- tion of conventional medicine may not have apies such as HYPNOSIS, acupuncture, MEDITATION, investigated a particular therapy or may have pro- visualization, and even prayer. Numerous studies duced inconclusive findings. Sometimes multiple underway are investigating alternative therapies studies generate conflicting data. Some methods such as botanical and herbal remedies to relieve have been copiously studied, though according to the discomforts of menopause, CANCER and CARDIO- standards other than those common in the United VASCULAR DISEASE PREVENTION and treatment claims, States. And, of course, numerous “therapies” are methods for pain management, and mind–body available that have dubious therapeutic value (and interventions to mitigate the symptoms of chronic may appear clearly ineffective or even harmful) health conditions. and have no foundation within the context of any The current health-care culture is reaching for healing system. new understanding that can unify technology, As a result of these mixed circumstances, there conventional techniques, and complementary is considerable disagreement among conventional methods in a single, amazing paradigm for treat- doctors and clinical scientists about the effective- ment of the human being in health and in illness. ness and potential risks of many alternative and Within this paradigm is the potential for many of Alternative and Complementary Approaches 55 the complementary approaches to be as “conven- can prayer wheels, meditation rooms, and chapels tional” in their use and application as advances in provide quiet, calming environments for prayer technology such as GENE THERAPY, molecular medi- and contemplation. cine, diagnostic imaging, ORGAN TRANSPLANTATION, This is a time of record breakthroughs in med- BIOLOGICAL RESPONSE MODIFIER, and PHARMACOGE- ical discoveries. Researchers are exploring more NOMICS. and more experimental treatments, conventional Even today, hospitals are quietly becoming as well as alternative and complementary. Keep- models of such an integrative paradigm. Neonatal ing up with the incredible pace of new knowledge intensive care units employ MASSAGE THERAPY and challenges doctors and individuals alike. What is music therapy to soothe the fragile premature clear already is that as knowledge increases, the infants born before their bodies and systems best care will be that which presents an informed developed fully. Patients waiting for organ trans- integrative approach guided by progressive con- plants or undergoing high-tech cancer treatments ventional doctors based on individual patient receive instruction in meditation and visualiza- needs, using the simplest, most effective methods tion. Reflection gardens, labyrinths, Native Ameri- for restoring and maintaining health. A

acupuncture A HEALING method in which the Numerous clinical studies of acupuncture have acupuncturist inserts hair-thin needles into the provided evidence that acupuncture does indeed body at various locations along energy channels relieve pain. However, no study has yet been able called meridians. The underlying premise is that to identify the precise mechanisms by which relief disease represents imbalances of the flow of takes place. In 1997 the US National Institutes of energy (chi), and the needles redirect the flow to Health (NIH) issued a consensus statement restore balance and thus health. The practice of acknowledging the primary therapeutic value of acupuncture dates back at least 2,500 years to the acupuncture for a variety of health situations and origins of TRADITIONAL CHINESE MEDICINE (TCM), and conditions such as NAUSEA, HEADACHE, dental pain, today remains an integral component of TCM. OSTEOARTHRITIS, and ADDICTION. This marked the The Western adaptation of acupuncture views turning point for acceptance of acupuncture as a the practice primarily from the perspective of PAIN mainstream treatment option for numerous relief and shifts the underlying mechanism to one health conditions. in which the needles stimulate NERVE endings, eliciting biochemical and electromagnetic The Acupuncture Experience responses that interrupt the flow of pain messages Most people find the experience of acupuncture to the BRAIN. Another Westernization of acupunc- relaxing, calming, and even somewhat euphoric. ture is electrostimulation of the acupuncture nee- The hair-thin needles are so fine that they are dif- dles after inserting them, which intensifies the ficult to see; most people do not feel them when effect. the acupuncturist inserts them. The acupuncturist first directs the person to lie on a padded table or COMMON THERAPEUTIC sit in a recliner-style chair, depending on the loca- APPLICATIONS OF ACUPUNCTURE tion of the acupuncture points and reason for ADDICTION ASTHMA treatment, and then inserts the needles. After BACK PAIN CARPAL TUNNEL SYNDROME insertion, the needles stay in place for 20 to 30 CHEMOTHERAPY nausea CHRONIC FATIGUE SYNDROME minutes. Occasionally a needle falls out; this is CONVERT BREECH PRESENTION dental PAIN okay and does not affect the treatment. IN PREGNANCY ENDOMETRIOSIS Some conditions need only 2 or 3 treatments, FIBROMYALGIA HEADACHE usually about a week apart. Other conditions may INDUCE LABOR IN PREGNANCY IRRITABLE BOWEL SYNDROME require up to 10 or 12 weekly treatments for relief menopausal HOT FLASHES (IBS) and occasional follow-up treatments for mainte- menstrual cramps motion sickness nance. For aural, or earlobe, acupuncture to treat OSTEOARTHRITIS POLYCYSTIC OVARY SYNDROME addiction or for SMOKING CESSATION, the acupunc- postoperative NAUSEA (PCOS) turist may place a small needle, like a button, PREMENSTRUAL SYNDROME (PMS) RELIEVE NAUSEA AND leaving it in place until it falls out on its own ROTATOR CUFF IMPINGEMENT VOMITING hours to days later. SYNDROME SMOKING CESSATION In the United States acupuncturists must use sports injuries tennis elbow (EPICONDYLITIS) single-use, disposable needles to prevent the 56 anti-aging approaches 57 spread of bloodborne infections such as HEPATITIS until they go to bed at night seem to be much and HIV/AIDS. Though adverse effects are rare, they younger than their chronological ages. They look can occur. Some people experience continued tin- younger, they act younger, they feel younger. gling at the site of a needle insertion, and occa- With longevity continuing to increase, many peo- sionally there is very minor bleeding at a needle ple are searching for ways to be among those who site. People who are uncomfortable with the seem young. It is enticing to think such efforts thought or sight of needles may choose to close might be as simple as taking a pill every morning. their eyes when the acupuncturist is handling and While some methods to maintain the health and inserting needles. One of the most common side vigor of youth show intriguing promise, many are effects of acupuncture, typically among people ineffective or potentially harmful. who are new to the procedure, is fainting at the sight of a needle or when the acupuncturist inserts Aging Interventions the first few needles. Such a response relates to Products marketed to slow the aging process sel- the person’s fear or concern about the procedure, dom can substantiate their claims through clini- not the acupuncturist’s technique. cal studies and objective measures. Nonetheless, they are appealing because everyone wants to Choosing an Acupuncturist believe they can work. And some may be helpful, Most acupuncturists in the United States are though researchers do not yet know. Some prod- health-care practitioners such as conventional ucts commonly marketed as anti-aging substances doctors (MDs and DOs), naturopathic doctors include (NDs), chiropractors (DCs), and dentists (DDSs or DMDs). Most states have some level of certifica- • Hormones such as DEHYDROEPIANDROSTERONE tion or licensing, though standards are inconsis- (DHEA) (a TESTOSTERONE/estrogen precursor the tent among states. The minimum education and adrenal glands produce) and human GROWTH training required for MDs and DOs to become a HORMONE (hGH), which marketers claim reverse licensed acupuncturist in the United States is 200 aging effects such as lost MUSCLE mass and BONE hours. Some states extend this requirement to DENSITY. Some clinical studies show these hor- NDs and DCs. States that will license an acupunc- mones can indeed have such effect. However, turist who is not a trained health professional typ- health experts caution that there are as yet no ically require completion of an accredited studies that evaluate the effects and conse- acupuncture program that is about 3,000 hours of quences of these products over the long term. classroom education and experiential training. A • Antioxidants such as vitamins and COENZYME licensed acupuncturist uses the designation L.Ac. Q10, marketed as substances that can clean up after his or her name. the molecular waste that otherwise accumu- Because standards vary among states, health lates to cause disease. Indeed, antioxidants do experts recommend obtaining recommendations bind with free radicals, molecular particles that and referrals for acupuncturists, especially for remain in cells as byproducts of energy genera- people who are new to acupuncture. As with tion. What is much less clear is the precise role any health-care practitioner, it is important to free radicals have in causing diseases such as feel comfortable with, and to trust, the acupunc- DIABETES, CANCER, CARDIOVASCULAR DISEASE (CVD), turist. OSTEOARTHRITIS, PARKINSON’S DISEASE, and other See also ALTERNATIVE METHODS FOR PAIN RELIEF; health conditions typically associated with BIOFEEDBACK; MIND–BODY INTERACTIONS; OSTEOPATHIC aging. MANIPULATIVE TREATMENT; REFLEXOLOGY; TRANSCUTA- NEOUS ELECTRICAL NERVE STIMULATION. Conventional health experts believe there is lit- tle value to claims about any products that say anti-aging approaches It is a common observa- they can stop or reverse the aging process. Though tion that people who fully engage in the activities such claims remain out there, the bigger truth also of living from when they wake in the morning remains: None of these products ever kept anyone 58 Alternative and Complementary Approaches from growing older or from eventually reaching COMMON ESSENTIAL OILS FOR AROMATHERAPY the end of his or her lifetime. Essential Oil Therapeutic Use anise upper respiratory INFECTION Healthy Aging basil focus and concentration In the mid-1990s researchers at the Tufts Univer- cedarwood arthritis sity Center for Aging compared two groups of citrus mental clarity and alertness women ages 50 to 70. At the start of the study, the eucalyptus congestion women in both groups were all sedentary. One jasmine DEPRESSION group stayed that way. The other group partici- lavender anxiety, insomnia pated in progressively intense physical STRENGTH peppermint NAUSEA relief training. At the end of 1 year the women in the rose relaxation, gastrointestinal upset, dry SKIN strength training group looked, felt, and acted 20 rosemary MUSCLE relaxation years younger than the women in the sedentary sandalwood stress group. Other studies involving other groups have thyme circulation shown, too, that people who stay physically and vanilla confidence, relaxation mentally active experience fewer illnesses and ylang-ylang anxiety, PALPITATIONS, stress injuries, and maintain cognitive ability and mem- ory function. The most common method for dispensing an Many health experts believe the true “fountain essential oil is diffusion, in which a heat source of youth” is within each individual and the such as a candle or low-watt light bulb warms a lifestyle choices he or she makes. Of course no solution of water and the essential oil. Often the one chooses to be sick. In fact, illness 40 years essential oil also carries the fragrance of the plant, down the road is not what most people think giving off a pleasant smell. However, according to about when making choices about eating, exer- the principles of aromatherapy, it is the energy cise, and smoking. Yet many of the choices people nature of the essential oil, not necessarily its fra- make lead to the chronic health conditions that grance, that provides therapeutic benefit. Fra- have come to characterize growing older in Amer- granced solutions that are not essential oils may ica. Though not as glamorous as pills that promise smell no different but aromatherapists contend to turn back the calendar, doing what is possible they have no therapeutic value. to contain the risks for these conditions, many Many alternative and complementary practices health experts say, is the one anti-aging approach integrate aromatherapy, which health experts in which anyone and everyone can participate. consider to be mostly safe. Some essential oils can See also ESTROGENS; HEALTH RISK FACTORS; HOR- stimulate physiologic changes in the body that MONE; HUMAN GROWTH HORMONE (HGH) SUPPLEMENT; may be hazardous during PREGNANCY; pregnant LIFESTYLE AND HEALTH; QUALITY OF LIFE. women should discuss using aromatherapy with their obstetricians or midwives. The essential oils aromatherapy The therapeutic use of essential for aromatherapy are for external use only. Most oils of plants delivered via the sense of smell. are harmful, and some can be fatal, if ingested. Essential oils are highly concentrated liquid Many essential oils are irritating to the SKIN unless extracts from the stems, leaves, flowers, and other significantly diluted with neutral carrier oils (such parts of plants that contain the energy essence of as almond oil) before application. the plant. Aromatherapy is a form of energy HEAL- See also FLOWER ESSENCES; HOMEOPATHY; MEDITA- ING always done to complement or accompany TION; PRAYER AND SPIRITUALITY; VISUALIZATION. other therapeutic forms. A qualified aromathera- pist can mix personalized blends as recipes to meet art therapy A HEALING approach that uses the a person’s individual needs. In the United States creative arts to help people, especially children, essential oils are available in health food stores, express suppressed emotions. Art therapy may and many major grocery stores and drugstores employ drawing, writing, dancing, singing, drama, carry common oils that anyone can buy. painting, storytelling, sculpting with clay, and Ayurveda 59 other forms that allow free and creative expres- imbalances in the doshas. The Ayurvedic practi- sion. The underlying philosophy of art therapy is tioner asks many questions about the individual’s that the processes of creativity are also pathways health, health concerns, family, lifestyle, and life of insight and understanding. With focused explo- in general. Ayurvedic therapies attempt to restore ration of the art a person creates, he or she can dosha balance through herbal remedies, YOGA gain new perspectives and learn to solve problems poses, dietary changes, and lifestyle measures. or reconcile situations that cause stress, anxiety, or DEPRESSION. AYURVEDIC DOSHAS Art therapists typically have either a graduate degree in art therapy or dual graduate degrees in Dosha Elemental Energy Association art and psychology (or related fields). A registered vata ether (space) and air movement art therapist meets the education and experience pitta fire transformation requirements of the Art Therapy Credentials kapha earth and water structure Board. In the United States, each state regulates the licensing requirements for art therapists. Art Ayurvedic Practitioners therapists may work in hospitals, health-care clin- In India, Ayurvedic practitioners train for five to six ics, rehabilitation centers, and private practice. years before going into practice on their own. A US- See also COGNITIVE THERAPY; GENERALIZED ANXIETY trained Ayurvedic practitioner completes a one- DISORDER (GAD); MIND–BODY INTERACTIONS. year program of study and then can practice. There are no licensing education or requirements for Ayurveda A philosophy of HEALING based in Ayurvedic practitioners in the United States. Some ancient Hinduism that dates perhaps to 4500 B.C.E. alternative health practitioners such as naturo- or earlier. Ayurveda considers all of existence in pathic physicians or chiropractors may complete the context of energy, including human beings. additional training to practice Ayurvedic methods. Each person represents the essential elements of universal energy (fire, air, water, earth, and Benefits and Risks of Ayurveda ether), which manifest in three states of physical Ayurveda represents a lifestyle orientation to existence called doshas: vata, pitta, and kapha. health and health care. All aspects of an individ- Health exists when there is balance among the ual’s life and circumstances influence health and doshas, and illness (or ailment) represents imbal- illness, and Ayurvedic therapies target bringing all ance. The dosha’s association indicates the general back into balance. Some herbal remedies may nature of the ailment. BACK PAIN, for example, rep- interact with other substances including prescrip- resents a vata imbalance (movement) and indiges- tion medications. A conventional doctor should tion is a kapha imbalance (structure). provide clinical oversight for people who have health conditions that require conventional treat- Ayurvedic Diagnosis and Treatment ment, such as DIABETES, CANCER, and CARDIOVASCU- Key to the Ayurvedic diagnostic process is careful LAR DISEASE (CVD). assessment of the tongue and the six pulses of See also MEDICINAL HERBS AND BOTANICALS; NATIVE each arm, three superficial and three deep. The AMERICAN HEALING; TRADITIONAL CHINESE MEDICINE pulses provide information about the balances and (TCM). B

bilberry A plant (Vaccinium myrtillus) whose See also ARTERY; CATARACT EXTRACTION AND LENS berries, stems, and leaves are rich in antioxidants REPLACEMENT; RETINOPATHY; VISION IMPAIRMENT. (notably anthocyanosides) and tannins. Even pre- serves made from the blue-colored berries of this biofeedback A method in which a person learns bush contain high enough levels of these sub- to influence certain body responses, such as to stances to have noticeable effect. Anthocyanosides PAIN or stress. Biofeedback begins with learning have particular affinity for the walls of arteries, sessions that use electronic measuring devices to especially arterioles, the tiny, almost microscopic report physiologic signs such as PULSE, BREATHING arteries deep within body tissues where nutri- rate, or SKIN temperature. The device sends a ent/waste exchanges takes place. Anthocyanosides visual or sound signal to help focus concentration appear to keep the cells of these arterial walls on the particular sign, for example the pulse. The healthy and structurally intact. This action has person then concentrates on slowing the rate of pronounced effects on the tiny blood vessels that the sound or visual cue, indicating that the body is supply the RETINA, CORNEA, and other structures of relaxing and the HEART RATE is slowing. Over the the EYE, protecting them from age-related damage course of 5 to 10 biofeedback sessions, the person such as AGE-RELATED MACULAR DEGENERATION (ARMD) learns to “tune in” to the physiologic signs and no and CATARACT. The tannins in bilberry seem to longer needs the device. Once the person masters help INFLAMMATION and INFECTION affecting the the method of biofeedback, he or she can use it at MOUTH and THROAT, plus gastrointestinal upset. will. Many ophthalmologists recommend that peo- ple over age 50, who are entering the high-risk CONDITIONS BIOFEEDBACK MAY HELP period of life for conditions such as ARMD, night ASTHMA chronic PAIN syndromes blindness, and cataracts, take bilberry to help pro- HYPERTENSION migraine HEADACHE tect their eyes and vision. Bilberry seems most MUSCLE tension headache PALPITATIONS effective in combination with the amino acids RAYNAUD’S SYNDROME RETINOPATHY of DIABETES LUTEIN and ZEAXANTHIN, which also protect the SEIZURE DISORDERS stress retina and cornea. There are no known side effects STROKE recovery URINARY INCONTINENCE or interactions with bilberry, and doctors consider it safe for most people to take long-term. Though the most common application of biofeedback is stress relief, people who have BILBERRY (Vaccinium myrtillus) chronic health conditions also can use it to man- age pain and other symptoms. Numerous clinical Uses Risks/Side Effects Interactions studies over the past 25 years have supported the improve night vision none known none known effectiveness of biofeedback, especially for reliev- prevent or slow ARMD ing pain and stress. There are few risks with prevent or slow growth biofeedback, as it is noninvasive. Because biofeed- of cataracts back can alter body chemistry, it can change med- RETINOPATHY of DIABETES ication needs for chronic conditions such as 60 boswellia 61

DIABETES (INSULIN or oral ANTIDIABETES MEDICATIONS) weeks to experience benefits after starting black and HYPERTENSION (high BLOOD PRESSURE). cohosh. See also HYPNOSIS; MEDITATION; MIND–BODY INTER- Herbalists recommend black cohosh products ACTIONS; STRESS AND STRESS MANAGEMENT; VISUALIZA- that contain freeze-dried root, which appears to TION. have the most potent and consistent action. Women who are pregnant should not take black black cohosh An herbal remedy women may cohosh because its estrogen-like actions may take to treat HOT FLASHES at MENOPAUSE. The medici- interfere with the body’s hormonal balance. Some nal extract comes from the dark roots and rhi- women experience gastrointestinal upset or dizzi- zomes of the wildflower black cohosh (Actaea ness; reducing the DOSE and taking the remedy racemosa or Cimicifuga racemosa), a member of the with meals can minimize these side effects. buttercup family indigenous to North America. Women who are taking oral contraceptives (birth Medicinal uses of black cohosh derive from NATIVE control pills) should check with their doctors or AMERICAN HEALING traditions. In 2001 the Ameri- pharmacists about possible interactions. can College of Obstetricians and Gynecologists (ACOG) issued a statement of support endorsing BLACK COHOSH (Actaea racemosa, Cimicifuga racemosa) black cohosh as a short-term treatment (up to six Uses Risks/Side Effects Interactions months) for relief of menopausal discomforts. Sold relieve menopausal uterine contractions oral without a doctor’s prescription as a dietary supple- HOT FLASHES in PREGNANCY contraceptives ment in the United States, black cohosh is an ingredient in numerous women’s health products. See also DONG QUAI; GINSENG; PHYTOESTROGENS; SOY. The apparent active ingredients of black cohosh are deoxyactein, triterpenes glycosides (also called boswellia Medicinal preparations that derive triterpenes saponins), and fukinolic acid, phyto- from the resin of the Boswellia serrata tree native to estrogenic chemicals that produce a weak estrogen the desert areas of India. Boswellia has strong anti- effect in the human body. Clinical studies of black inflammatory characteristics and provides relief cohosh generally support its effectiveness for from OSTEOARTHRITIS and RHEUMATOID ARTHRITIS. It relieving hot flashes, though results for other also provides relief from symptoms of INFLAMMATORY menopausal discomforts are less consistent. Stud- BOWEL DISEASE (IBD), especially in people who have ies also have failed to demonstrate any benefit for Crohn’s disease. In the United States boswellia is a OSTEOPOROSIS. dietary supplement available without a doctor’s As hot flashes are the major symptom for about prescription. The typical course of treatment with 80 percent of women who have discomfort when oral forms of boswellia is 8 to 12 weeks. People who going through menopause, many gynecologists are taking prescription medications should check recommend an initial trial of black cohosh in lieu with their doctors before taking boswellia, though of conventional estrogen/progesterone or estrogen there are no known interactions between boswellia hormone replacement therapy (HRT) for and other substances. menopause. Many women find that a combina- tion of botanicals in addition to black cohosh BOSWELLIA (such as flaxseed, soy, and chasteberry) seems to Uses Risks/Side Effects Interactions more effectively relieve symptoms, though these OSTEOARTHRITIS none known none known clinical research studies so far have not gener- RHEUMATOID ARTHRITIS ated supportive evidence. Black cohosh does not INFLAMMATORY BOWEL seem very effective for menstrual discomforts such DISEASE (IBD) as cramps and excessive flow, though women have used it as a premenstrual/ menstrual remedy See also NONSTEROIDAL ANTI-INFLAMMATORY DRUGS for several centuries. It typically takes 8 to 10 (NSAIDS). C chamomile An herb, Matricaria recutita, used for agent, typically ethylenediaminetetraacetic acid its abilities to calm anxiety, soothe gastrointestinal (EDTA), into the body that binds with specific sub- irritation, relieve menstrual cramps, and aid in stances. The body then excretes the bound sub- sleep. Chamomile contains volatile acids and stances in the urine, safely eliminating them from flavonoids, chemical substances that ease spasms the body. Doctors first used chelation therapy in of smooth muscles, such as in the intestinal tract the 1940s to treat poisoning with lead and other and the UTERUS, and that have mild anti-inflamma- heavy metals, and that remains chelation ther- tory qualities. The most active of these is the apy’s accepted application in conventional medi- flavonoid apigenin, which has antiseptic proper- cine today. ties as well. Many of the first people to undergo chelation Chamomile tea is a common preparation for therapy were middle-aged men who had worked stress relief and relaxation. In oral forms all their adult lives in factories where lead con- chamomile is a dietary supplement in the United tamination was common. They also had the usual States, available without a doctor’s prescription. health conditions for men of their age, typically Topical forms of chamomile, also available over- CARDIOVASCULAR DISEASE (CVD). As they completed the-counter, relieve itching and other SKIN discom- the chelation therapy, many of the men also forts, including those of dermatitis, and mild to noticed they no longer had ANGINA PECTORIS (car- moderate SUNBURN. Some preparations of diac CHEST PAIN). The doctors conducting the chela- chamomile dissolve or mix in bath water, such as tion therapy treatments concluded the EDTA was powders and oils, providing full body relief. also drawing calcium and other minerals from the Though there are few clinical studies that ATHEROSCLEROTIC PLAQUE lining the CORONARY ARTER- affirm the effects of chamomile, health experts IES. The plaque narrowed the passageway for consider it a generally safe medicinal herb. There blood, causing the men to experience pain and are no known interactions or side effects. People shortness of breath particularly with exertion— who have allergies to ragweed, daisies, chrysan- the classic symptoms of CORONARY ARTERY DISEASE themums, and other plants in the Aster family may (CAD). have cross-over sensitivity to chamomile. Though further testing and X-ray fluoroscopy of the men who experienced cardiovascular CHAMOMILE (Matricaria recutita) improvement failed to substantiate the theory, it Uses Risks/Side Effects Interactions has remained popular. However, there still are no clinical studies that support it. Another theory gastrointestinal upset none known none known holds that chelation therapy removes from the sleep aid body free radicals, particles of molecular waste general relaxant that bind with any available molecule. This theory See also VALERIAN. also remains unproven. Researchers believe free radicals that bind prevent bonded molecules from chelation therapy The therapeutic process of performing their intended functions, a process injecting or otherwise introducing a chemical that over time results in degenerative diseases. 62 chiropractic 63

Though doctors in other countries may use pation and recreational interests. The chiropractor chelation therapy before turning to surgical inter- should then explain his or her findings and the ventions to treat CAD, most conventional physi- treatment options to correct them. cians in the United States feel the risks outweigh Chiropractic manipulations should not cause the benefits when it comes to chelation therapy as pain. Often the back makes popping sounds as the a treatment for atherosclerotic heart disease. chiropractor uses pressure to correct subluxations See also CORONARY ARTERY BYPASS GRAFT; HEAVY (out of position vertebrae). Some chiropractors METAL POISONING; KIDNEY; LIFESTYLE AND CARDIOVASCU- use devices, whereas others use only their hands. LAR HEALTH; LIFESTYLE AND HEALTH. Most people feel relaxed after a chiropractic treat- ment. Chiropractic manipulation may correct one Chinese herbal remedies See TRADITIONAL CHI- set of problems, which then reveals other prob- NESE MEDICINE (TCM). lems. Some conditions require only a few visits and treatments, though others may require up to chiropractic A system of health care that 10 visits over several weeks or occasionally more emphasizes manipulation of the spine and back to extensive therapy. No chiropractic therapy should align the musculoskeletal system for optimal func- continue indefinitely, though many people need tion and support of the rest of the body. Chiro- to return periodically. practic originated in the United States with the Chiropractic manipulation can restore the work of Daniel David Palmer in the late 1890s. spine’s correct alignment, but circumstances such Palmer had a keen interest in magnetic HEALING as structural asymmetries, longstanding injury, and in what he perceived to be the body’s natural and postural or function-oriented habits that tendency to keep itself in balance and thus in remain unchanged may cause the spine to eventu- health. From his observations he began head and ally return to misalignments. Many people have neck manipulations. one leg slightly different length from the other, for example, or may sit at a computer all day leaning Chiropractic Diagnosis and Treatment forward with shoulders hunched. These chronic Chiropractic views the body as a system of bal- sorts of circumstances account for about a third of ance, physical as well as emotional. When the chiropractic visits. spine is out of alignment, the rest of the body attempts to rebalance itself. When it cannot, one Chiropractic Practitioners result is PAIN. Injuries and chronic health condi- Over the decades since Palmer introduced his tions may pull the spine out of alignment as well. methods for manipulating the neck, chiropractic The leading reason people seek chiropractic care is has evolved into a comprehensive and structured for treatment of musculoskeletal injuries and pain, health-care discipline. Doctors of chiropractic (DCs) particularly lower back pain. Chiropractic often is attend eight or more years of college and chiroprac- an effective approach for treating repetitious tic medical school, completing extensive education motion injuries as well as for teaching methods to and training in a broad spectrum of health-care avoid further injury. Chiropractic may incorporate areas. Many chiropractors have further training, ACUPUNCTURE, MASSAGE THERAPY, NUTRITIONAL certification, or licensure in acupuncture, nutri- THERAPY, or CRANIOSACRAL MASSAGE in addition to tion, and specialized care such as sports injuries. All chiropractic manipulations. states in the United States require chiropractors to The chiropractor begins an examination by ask- pass a national proficiency examination and meet ing questions about why the person has come for the state’s licensing requirements. care and may take X-rays as well as look at the back. Observing posture and movement help the Benefits and Risks of Chiropractic chiropractor assess overall musculoskeletal health, At one time in its evolution, chiropractic involved and the chiropractor will palpate the neck and approaches and methods, arising from inconsis- spine. Most chiropractors also ask about diet and tencies in practice and education, that sometimes nutrition, physical activity and exercise, and occu- did harm to people. Standardizations in philoso- 64 Alternative and Complementary Approaches phy, education, and licensing in the latter half of ulant medications should check with their doctors the twentieth century solidified chiropractic as a before taking chondroitin. Though chondroitin beneficial, reputable health-care profession and does not directly affect clotting, many substances practice. In 1994 the US Agency for Health Care that affect inflammation have the potential for Policy and Research (AHCPR) endorsed chiroprac- interfering with blood chemistry. It typically takes tic as a safe and appropriate first-line treatment for two to four months to notice appreciable results low back pain. Most insurers in the United States after starting chondroitin. pay for limited chiropractic care. Chiropractors may not prescribe medications, CHONDROITIN diagnose health conditions, provide medical treat- Uses Risks/Side Effects Interactions ments outside those necessary for spinal manipu- OSTEOARTHRITIS none known possibly anticoagulants lations, or perform surgery. People who have health conditions that affect the spine such as See also ANTICOAGULANT THERAPY; AUTOIMMUNE ANKYLOSING SPONDYLITIS or RHEUMATOID ARTHRITIS DISORDERS; SAME. should talk with their orthopedists before under- going chiropractic treatment. A conventional doc- coenzyme Q10 An ANTIOXIDANT found in every tor should evaluate back pain with FEVER, as this nucleated cell in the body. It has numerous func- may be an indication of MENINGITIS or other poten- tions related to cell activity and repair. As a coen- tially life-threatening infection. zyme, coenzyme Q10 facilitates or works in See also NATUROPATHY; OSTEOPATHIC MANIPULATIVE collaboration with enzymes in the cells. Enzymes TREATMENT (OMT). carry out the genetic instructions of the cell. The more active the cell, the more coenzyme Q10 the chondroitin A chemical compound that occurs cell contains. A HEART cell has considerably more naturally in the CARTILAGE and other tissues in the coenzyme Q10 than does a SKIN cell, for example. joints, chondroitin appears to protect JOINT tissues Researchers discovered coenzyme Q10 in 1957 from damage and deterioration by blocking the and continue to investigate how it works and actions of certain destructive enzymes. There is what it does in the body. substantial evidence, through clinical studies, that People who have certain forms of heart disease, this blocking action can arrest and even reverse such as HYPERTENSION (high BLOOD PRESSURE) and OSTEOARTHRITIS. In some studies, chondroitin was at HEART FAILURE, have lower than normal levels of least as effective as the commonly prescribed NON- coenzyme Q10. In some studies, giving them STERIODAL ANTI-INFLAMMATORY DRUGS (NSAIDS) that coenzyme Q10 improved heart function, most are the standard treatment for osteoarthritis in the notably hypertension. Though researchers do not United States. Combining chondroitin with fully understand its mechanisms, boosting coen- another natural compound, GLUCOSAMINE, intensi- zyme Q10 levels in cardiac cells seems to improve fies the benefit. their efficiency. This effect is less conclusive in Though researchers and practitioners have people recovering from HEART ATTACK or who have known of glucosamine and have recommended it other forms of heart disease. to relieve joint INFLAMMATION and PAIN for decades, There is some evidence that coenzyme Q10 researchers discovered chondroitin only in the supplementation has numerous beneficial effects 1960s. A number of clinical studies conducted in on health. Researchers are exploring its role in the 1980s and 1990s began to make clear chon- preventing BREAST CANCER, periodontitis (INFLAM- droitin’s effects and benefits. Chondroitin seems MATION and INFECTION of the gums), and most effective for osteoarthritis affecting the hips ALZHEIMER’S DISEASE. Some health experts believe and knees and does not have any effect on coenzyme Q10 may improve symptoms and QUAL- RHEUMATOID ARTHRITIS, a deformative autoimmune ITY OF LIFE for people with MITOCHONDRIAL DISOR- disorder. DERS, MUSCULAR DYSTROPHY, and degenerative There seem to be few side effects or interactions neurologic conditions such as PARKINSON’S DISEASE. with chondroitin. People who are taking anticoag- Studies investigating the ability of coenzyme Q10 craniosacral massage 65 supplementation to prevent the onset of type 2 craniosacral massage A form of bodywork, also DIABETES have so far yielded no evidence that it called craniosacral therapy, in which the practi- can do so. Nor is there any conclusive evidence tioner gently manipulates the head, neck, and that coenzyme Q10 has any ability to enhance spine to balance the fluids around the head and IMMUNE SYSTEM function, though all of these effects SPINAL CORD. The movement of this fluid, in the have theoretical potential. Across the spectrum of context of craniosacral massage, is the cranial health knowledge, coenzyme Q10 is a relatively rhythmic impulse. The intended goal is somatoe- new discovery and much remains for researchers motional release, the discharge of physical and and doctors to learn and understand about its nat- emotional tension the head and spine hold as a ural functions in the body as well as the benefits result of stress and daily experiences. Injuries may and possible risks of supplements. also contribute to the tension. Coenzyme Q10 is available in the United States For many people the experience evokes the as a dietary supplement that does not require a sensation of floating or dreaming and is pro- doctor’s prescription to obtain. It does not appear foundly relaxing. Though the craniosacral thera- to have side effects or interactions with other sub- pist’s movements are gentle and touch is very stances, though health experts encourage people light, there is a sensation of movement through- to talk with their doctors about taking it if they out the body. Sometimes the craniosacral therapist are taking medications to treat health conditions, will also manipulate the spine, though also very especially hypertension and heart failure. Preg- gently and not at all in the way a chiropractor per- nant or BREASTFEEDING mothers probably should forms spinal manipulation. not take coenzyme Q10 as researchers know little A craniosacral therapist is usually trained and about how it might affect infants. Coenzyme Q10 licensed (in compliance with relevant state is fat soluble; the body best absorbs it with foods requirements) as a massage therapist or physical that contain some dietary fat. therapist, though some naturopathic physicians, chiropractors, and osteopathic physicians also COENZYME Q10 have training in craniosacral techniques. As with uses Risks/Side Effects Interactions all touch therapy, it is important to feel comfort- able with, and trust, the practitioner. The manipu- HYPERTENSION none known none known lations of the body release stored physical and HEART FAILURE emotional energy that can result in unexpected recovery after surges of feelings and even discomfort. But nearly HEART ATTACK everyone feels deeply relaxed following a cran- periodontitis iosacral massage. See also LIFESTYLE AND CARDIOVASCULAR HEALTH; See also CHIROPRACTIC; MASSAGE THERAPY; PERIODONTAL DISEASE. MIND–BODY INTERACTIONS; PHYSICAL THERAPY. D–F

dehydroepiandrosterone (DHEA) A steroid HOR- DEHYDROEPIANDROSTERONE (DHEA) MONE that occurs naturally in the body. It serves as Uses Risks/Side Effects Interactions a precursor primarily to estrogen in women and FIBROMYALGIA acne flareups none known TESTOSTERONE in men, though women also convert SYSTEMIC LUPUS mood swings small amounts to testosterone and men convert ERYTHEMATOSUS (SLE) LIVER damage small amounts to estrogen. Levels of endogenous mental alertness in DHEA gradually diminish with aging. As a supple- aging ment, DHEA provides a similar source to the body slow OSTEOPOROSIS for these hormones. DHEA is available without a doctor’s prescription in the United States, mar- See also ADRENAL INSUFFICIENCY; ANABOLIC keted as a dietary supplement sold mostly in STEROIDS AND STEROID PRECURSORS; HUMAN GROWTH health food stores. HORMONE (HGH) SUPPLEMENT; MELATONIN. People take DHEA supplement for numerous and diverse uses such as to increase libido, reduce dong quai An ancient remedy for relieving men- the effects of aging, boost immune function, pre- strual and menopausal discomforts. It contains vent OSTEOPOROSIS, relieve symptoms associated phytoestrogens, which are estrogen-like chemicals with FIBROMYALGIA and SYSTEMIC LUPUS ERYTHEMATO- that are much weaker than those the human body SUS (SLE), and prevent degenerative diseases produces though are nonetheless capable of bind- related to aging such as CARDIOVASCULAR DISEASE ing with estrogen receptors. Researchers do not (CVD). There is scant clinical evidence to support know the extent to which dong quai’s phytoestro- any of these uses, and doctors worry that increas- gens have any effect in the body, however, ing the body’s levels of sex hormones may because dong quai contains other active ingredi- increase the risk for hormone-driven BREAST CAN- ents and often appears in combination with other CER and PROSTATE CANCER. There is some evidence herbs. Dong quai (Angelica sinensis) also contains that long-term DHEA use damages the LIVER. coumarins, chemicals that cause smooth MUSCLE Though DHEA is an over-the-counter dietary tissue to relax. This effect dilates blood vessels, supplement in the United States, doctors encour- increasing blood flow. It also acts to relax the age people to obtain blood tests to measure their UTERUS, which is also smooth muscle tissue. Many levels of estrogen or testosterone before taking health experts believe coumarins are responsible DHEA. The greatest risk for adverse health cir- for most of dong quai’s effects. Dong quai is sold cumstances occurs when products such as DHEA as an over-the-counter dietary supplement in the increase estrogen or testosterone blood levels to United States. higher than normal. Researchers believe this make Dong quai also contains psoralens, chemicals increase the risk for some cancers, although again that interact in the SKIN when exposed to sunlight. clinical evidence is lacking. Health experts recom- Psoralens intensify the effects of ultraviolet light mend that people under age 50 do not take DHEA with the result of unusually rapid and severe SUN- unless a doctor prescribes it to treat conditions in BURN. Women should limit sun exposure when which endogenous DHEA levels are low. taking dong quai. Dong quai also may interact 66 feverfew 67 with NONSTEROIDAL ANTI-INFLAMMATORY DRUGS Some studies have shown echinacea to have (NSAIDS), causing stomach upset, irritation, and adverse effects in people who are IMMUNOCOMPRO- bleeding. Because dong quai affects blood flow, it MISED, although this finding has been inconsistent. may also alter the intended effects of anticoagu- Doctors generally recommend against echinacea lant medications. And because of its actions to for people who have chronic immune system dis- relax smooth muscle including the UTERUS, women orders such as RHEUMATOID ARTHRITIS, MULTIPLE SCLE- should not take dong quai when they are preg- ROSIS, and SYSTEMIC LUPUS ERYTHEMATOSUS (SLE), nant. because echinacea can overstimulate the immune system and make symptoms worse. Some people DONG QUAI (Angelica sinensis) who have CHRONIC FATIGUE SYNDROME have experi- Uses Risks/Side Effects Interactions enced improvement with echinacea and other immune-enhancing herbs, however. People who menstrual cramps excessive bleeding anticoagulants have immune system disorders should discuss menopausal stomach irritation NSAIDS echinacea with their regular doctors before taking discomforts echinacea. Echinacea is available as a dietary sup- ENDOMETRIOSIS plement in the United States. People who are See also BLACK COHOSH; DYSMENORRHEA; MENO- allergic to plants in the daisy (Aster) family may PAUSE; MENSTRUATION; PREMENSTRUAL SYNDROME; SOY. also be allergic to echinacea. echinacea An herb with immune-supportive ECHINACEA (E. angustifolia, E. pallida, E. purpurea) properties. Echinacea remedies incorporate stems, Uses Risks/Side Effects Interactions leaves, and seeds or their extracts from three of prevent COLDS and none known none known the nine species of echinacea (Echinacea angustifo- INFLUENZAnone lia, E. pallida, E. purpurea). Though herbalists typi- reduce cold/flu duration cally use certain of the species according to the general IMMUNE SYSTEM desired immune effect, commercially produced support echinacea products typically contain a mix. The most common use of echinacea is to lessen the See also CANKER SORE; GOLDENSEAL; INFECTION. severity of COLDS, INFLUENZA, and other upper respi- ratory infections. Echinacea seems most effective feverfew An herb once popular for, as its name when taken at the first indication of symptoms implies, lowering FEVER. However, current use and can shorten the length of illness by 20 to 60 focuses on its ability to prevent migraine percent. headaches from developing and to minimize the Echinacea seems less effective in protecting symptoms of migraines when they do occur. The against upper respiratory infections when taken as primary active ingredients researchers have iso- a general prophylactic measure, though regular lated in feverfew (Tanacetum parthenium) are use may prevent canker sores. Health experts cau- parthenolides, a group of mild prostaglandin sup- tion people to take echinacea for no longer than pressants. PROSTAGLANDINS are chemicals the body three weeks to give their immune systems a break releases that are associated with PAIN. Aspirin and from the echinacea’s stimulation and to wait one other NONSTEROIDAL ANTI-INFLAMMATORY DRUGS week before taking another course of echinacea. (NSAIDS) achieve much of their pain-relieving Some herbalists recommend using echinacea in effects through prostaglandin suppression. rotation with other immune-boosting herbs. There Prostaglandins also are factors in the inflammatory is no clinical evidence to support a role for echi- processes associated with fever. nacea in preventing infections such as HIV/AIDS or The form of feverfew that appears most effec- HEPATITIS. Though echinacea may additionally sup- tive in preventing migraine headaches is the port the IMMUNE SYSTEM when taken in conjunction freeze-dried herb. However, the level of partheno- with ANTIBIOTIC MEDICATIONS to treat bacterial infec- lides in feverfew plants varies widely. Capsules tions, it cannot replace antibiotics. and tablets appear to have little or no effect for 68 Alternative and Complementary Approaches migraines, though may provide a level of relief for the body to return to a state of health. In the tra- menstrual discomforts. Results become evident dition of HOMEOPATHY, Bach created mixtures that after taking feverfew for eight weeks or longer. started with parts of plants in solutions of water Feverfew inhibits PLATELET AGGREGATION, slowing and ALCOHOL. He repeatedly diluted the solutions the initiation of COAGULATION (the formation of until virtually no plant particle remained. The blood clots). People who take feverfew should let residual solution retained the energy of the their surgeons know of this, if they are planning flower, however, which could influence the emo- surgery, and stop taking the herb for the time tions of people who used the solution. period the surgeon recommends. People should No clinical studies support the effectiveness of not take feverfew with prescribed anticoagulant flower essences, though people who use them medications such as warfarin or enoxaparin. typically report improvement in their symptoms. From the homeopathic perspective the flower FEVERFEW (Tanacetum parthenium) essences influence health in the fashion of “like Uses Risks/Side Effects Interactions cures like,” the underlying philosophy of homeop- athy. From the conventional medicine perspective, migraine HEADACHE excessive bleeding anticoagulants flower essences may improve the emotional well- menstrual discomfort aspirin, NSAIDs being of people who take them through the See also ANALGESIC MEDICATIONS; BIOFEEDBACK; PLACEBO effect. Most health experts agree that with BIOFEEDBACK AND PAIN RELIEF. remedies, such as flower essences, that have no potential side effects, there is no harm in using the flower essences Remedies that capture the remedies. It is important to remember, however, energy and HEALING qualities of plants and flowers that some emotional states may reflect potentially and impart them to alter emotional responses that serious conditions such as GENERALIZED ANXIETY DIS- might be causing physical disease. The most ORDER (GAD) and DEPRESSION. There are conven- widely use flower essence formulas are the Bach tional medicine therapies for these conditions that flower essences, named for the Dr. Edward Bach, are likely to provide more rapid and effective who developed and popularized flower essence intervention. Flower essences are widely used in therapy in the 1930s. Bach, a homeopathic physi- an integrative manner in many European coun- cian, observed the correlations between emotion tries. and physical illness. He surmised that plants and See also ANTIANXIETY MEDICATIONS; ANTIDEPRESSANT flowers could alter emotional responses, freeing MEDICATIONS; AROMATHERAPY. G garlic In ancient times people used garlic to These effects seem the same whether the ward off the evil vapors and spirits they believed source of the garlic is the natural bulb or supple- responsible for illness. In modern times doctors ments. Some studies show as much as a 6 to 10 know more about what really causes many of the milligram per deciliter (mg/dL) reduction in total health circumstances that result in disease. People blood cholesterol levels after taking garlic supple- use garlic and garlic supplements to improve ments for three months, about the same result BLOOD circulation, lower BLOOD PRESSURE, and doctors expect to see with lipid-lowering medica- reduce blood cholesterol, the key factors that con- tion therapy. The combined effect of garlic’s tribute to CARDIOVASCULAR DISEASE (CVD). The active actions on the cardiovascular system help lower ingredients in garlic (Allium sativum) are allium blood pressure by decreasing the resistance blood compounds (also found in onions and leeks), sul- encounters as it flows through the arteries. fur-based substances that give garlic its distinctive Though the preventive benefit for HEART ATTACK odor and flavor as well as its medicinal benefits. and STROKE is difficult to measure, many health More than 100 clinical research studies point to experts agree that the many effects of garlic, how- allium compounds as the substances responsible ever small, add up to reduced risk for cardiovascu- for these benefits. Allium compounds contain two lar disease, especially in combination with other dozen or so chemicals that lifestyle factors such as regular daily exercise, weight loss, and SMOKING CESSATION. Some health • reduce PLATELET AGGREGATION, making it more experts believe garlic and garlic supplements also difficult for the blood cells that initiate the clot- lower the risk for DIABETES type 2 by improving ting process to stick together INSULIN sensitivity, though clinical studies so far • help maintain the FLEXIBILITY of ARTERY walls have failed to bear this out. Nor is there much evi- dence supporting garlic’s ability to reduce CANCER • may block cholesterol production in the LIVER, risk. reducing the blood levels in particular of the Garlic and garlic supplements are relatively safe low density lipoprotein (LDL) and very low for most people to take, though may intensify the density lipoprotein (VLDL) cholesterols associ- effect of many common antihypertensive medica- ated with ATHEROSCLEROSIS and CORONARY ARTERY tions. People who are taking medications to treat DISEASE (CAD) high blood pressure should first talk with their • have mild anti-inflammatory effects, helping doctors before beginning a garlic regimen. The reduce irritation and INFLAMMATION of the inner amounts of garlic a person might use in seasoning walls of the arteries that researchers believe sets foods are not enough to cause this interference, the stage for arterial plaque accumulations that though the amounts of garlic in therapeutic prod- form the basis of atherosclerosis and CAD ucts can interact with numerous medications. • have mild antibacterial effects that improve Because garlic affects clotting, surgeons generally resistance to infections affecting the MOUTH and request people stop taking it before any scheduled THROAT operations.

69 70 Alternative and Complementary Approaches

GARLIC (Allium sativum) PLATELET AGGREGATION, and thus BLOOD clotting Uses Risks/Side Effects Interactions (COAGULATION), in some people so surgeons gener- lower blood gastrointestinal upset antihypertensives ally ask people to stop taking ginger a few days cholesterol strong body and before any planned surgery. lower risk for breath odor GINGER (Zingiber officinale) ATHEROSCLEROSIS excessive bleeding reduce BLOOD with surgery Uses Risks/Side Effects Interactions PRESSURE general NAUSEA excessive bleeding anticoagulants MORNING SICKNESS ASPIRIN THERAPY See also ANTICOAGULATION THERAPY; COAGULATION; motion sickness INFECTION; LIFESTYLE AND CARDIOVASCULAR HEALTH. nausea of CHEMOTHERAPY digestive upset ginger An herb that soothes gastrointestinal upset. More likely to be in the kitchen spice cabi- See also ANTIEMETIC MEDICATIONS; ANTIHISTAMINE net than the medicine cabinet, ginger (Zingiber MEDICATIONS; HISTAMINE. officinale) is one of the most popular spices. Herbal- ists and cooks alike use the gnarly root fresh or ginkgo biloba An herbal product with many dried, sliced or powdered, in natural form or pre- uses. The ginkgo biloba tree is the oldest living pared as an extract. TRADITIONAL CHINESE MEDICINE species of tree on Earth, believed to have first (TCM) considers ginger a hot, yang energy that appeared more than 200 million years ago in the brings warmth to the HEART, LUNGS, and especially area that is now China. Individual trees typically the STOMACH to improve their functions. Folk med- live hundreds of years, with some documented to icine advises pregnant women to suck on thin be nearly 1,000 years old, and now grow in many slices of fresh gingerroot to alleviate symptoms of parts of the world. Herbal remedies made from the MORNING SICKNESS. A popular home remedy for leaves and seeds of this ancient tree have been stomach upset is sipping on a flat gingerale. Gin- popular for centuries for increasing longevity and ger also contains substances that act as mild anti- improving mental focus. It contains numerous histamines, helping relieve allergy symptoms such antioxidants (notably quercetin), collectively iden- as ALLERGIC RHINITIS. tified as ginkgo biloba extract (GBE) on supple- Clinical research studies provide supporting ment product labels. In the United States ginkgo evidence of ginger’s abilities to relieve biloba is a dietary supplement available without a doctor’s prescription. • NAUSEA, particularly that related to PREGNANCY Clinical research studies conducted in the (morning sickness), motion sickness, and 1990s and early 2000s demonstrated ginkgo’s abil- CHEMOTHERAPY ity to improve BLOOD circulation in the BRAIN and • nausea and VOMITING due to gastrointestinal the smallest of arteries, the arterioles, throughout viruses the body. Studies among people with ALZHEIMER’S DISEASE and other forms of DEMENTIA (diminished • dizziness related to motion sickness thought capacity and memory) showed significant • digestive upset, particularly FLATULENCE (intes- improvement after taking ginkgo biloba supple- tinal gas) ments for eight weeks or longer, especially in • congestion due to COLDS, INFLUENZA, and sea- combination with Panax GINSENG. Many people of sonal allergies all ages who take ginkgo biloba do so for these cerebrovascular benefits. The effect seems to arise Though some people experience mild gastric from ginkgo’s mild anticoagulant action in combi- irritation when taking ginger supplements or nation with its ANTIOXIDANT activity. Ginkgo’s abil- drinking ginger tea, ginger causes very few side ity to open up peripheral circulation also improves effects and health experts consider it safe for conditions such as PERIPHERAL VASCULAR DISEASE nearly everyone to take. Ginger may affect (PVD), NEUROPATHY of DIABETES, and ERECTILE DYS- ginseng 71

FUNCTION related to ATHEROSCLEROSIS (as is most major varieties and their subvarieties collectively; erectile dysfunction in men age 60 and older). “Panax ginseng” with both words italicized refers to There is also likely a preventive effect against Asian ginseng. The herb commonly called Siberian embolytic STROKE and HEART ATTACK. ginseng (Eleutherococcus senticosus or Acanthopanax For most people, health experts consider ginkgo senticosus) is not true ginseng but rather a “look- biloba safe at recommended doses. Because ginkgo alike” botanical cousin that has a different chemi- biloba affects blood clotting, people who are having cal composition and different effects as an herbal surgery should let their surgeons and anesthesiolo- remedy. Ginseng is sold as a dietary supplement in gists know they are taking it. The doctor may ask the United States and available in various forms the person to stop taking the supplement for a without a doctor’s prescription. week or two before the surgery and for a period of time after the surgery, until HEALING is adequate to Panax Ginseng end the risk for postoperative bleeding. People who The varieties of Panax ginseng include differing take ANTICOAGULANT THERAPY (including ASPIRIN THER- amounts of three major kinds of chemicals APY) should talk with their doctors before taking ginkgo, as it may intensify the anticlotting effect. • ginsenosides, which function as mild stimulants Gingko biloba also affects INSULIN production and to sharpen mental focus and possibly improve sensitivity, which may improve prediabetes and cognitive function and memory noninsulin-dependent type 2 diabetes though can • panaxans, which may improve INSULIN sensitiv- interfere with ANTIDIABETES MEDICATIONS and INSULIN ity THERAPY in people who have insulin-dependent dia- betes (type 1 or type 2). • polysaccharides, complex sugar molecules that aid IMMUNE SYSTEM functions GINKGO BILOBA PANAX GINSENG Uses Risks/Side Effects Interactions Uses Risks/Side Effects Interactions RAYNAUD’S excessive bleeding anticoagulants mental clarity insomnia loop diuretics SYNDROME elevated BLOOD antihypertensives and focus excitability CAFFEINE INTERMITTENT PRESSURE thiazide diuretics memory improvement CLAUDICATION trazodone IMMUNE SYSTEM PERIPHERAL VASCULAR prochlorperazine support DISEASE (PVD) ASPIRIN THERAPY ATHEROSCLEROSIS aphrodisiac INSULIN RESISTANCE CORONARY ARTERY type 2 DIABETES DISEASE (CAD) ALZHEIMER’S DISEASE The color of ginseng, red or white, reflects the See also ANTI-AGING APPROACHES; ARTERY; INSULIN kind of processing method used in its preparation. RESISTANCE; LIFESTYLE AND HEALTH. Medicinal preparations use only the ginseng root. Red ginseng is steam processed, which preserves ginseng A botanical product prepared from the more of the natural ginsenosides. White ginseng is root of the ginseng plant. There are two major sun dried. Herbalists consider red ginseng more varieties of ginseng, Asian ginseng (Panax ginseng) potent than white ginseng. Most people take gin- and American ginseng (Panax quinquefolius). As seng for improved mental alertness, and for its well, there are dozens of subvarieties within each. IMMUNE RESPONSE properties. Ginseng also has Asian ginseng, also called Chinese or Korean gin- gained popularity as an aphrodisiac, likely as a seng, is indigenous to the Asian continent. Ameri- result of its mild STIMULANT effect. Some research can ginseng, also called North American ginseng, studies support the claimed benefits of sharpened grows naturally on the North American continent. mental focus and improved cognitive function, The designation “Panax ginseng” refers to the especially when taken in combination with GINKGO 72 Alternative and Complementary Approaches

BILOBA, though any effects on LIBIDO beyond repair and maintain JOINT CARTILAGE, ligaments, heightened alertness remain unclear. A number of and tendons. In health, the body generates suffi- energy drinks and similar products contain gin- cient quantities of endogenous glucosamine seng, though not in amounts likely to produce any through a complex series of metabolic interac- effects. tions. When damage through wear and tear occurs to the joints, the body may have difficulty Acanthopanax (Siberian Ginseng) keeping pace with its glucosamine needs. The Herbalists call this ginseng cousin by the common older the person, the more quickly the body name Acanthopanax. The plants of Acanthopanax reaches the point at which it cannot produce look similar to true ginseng and are indigenous to enough glucosamine to produce the substances to northern China and the region of southern Russia repair joint tissues. The result is OSTEOARTHRITIS— once called Siberia, hence the misnomer Siberian INFLAMMATION and degeneration of the cartilage ginseng. However, Acanthopanax contains and related tissues in the joint. eleutherosides, which have strong STIMULANT char- Doctors in Europe and numerous countries acteristics, rather than ginsenosides. Both around the world prescribe glucosamine supple- eleutherosides and ginsenosides belong to the mentation to replenish the body’s supply and same chemical family, saponins, which have a allow the natural HEALING processes to take place. range of actions including CENTRAL NERVOUS SYSTEM Veterinarians in the United States similarly use stimulation, antibiotic properties, and immune glucosamine to treat osteoarthritis in domestic response. Asparagus root, onion, and GARLIC also pets as well as large animals such as horses. How- contain saponins. The stimulant effect of Acan- ever, doctors in the United States do not often thopanax is strong enough that this ginseng rela- consider glucosamine as a possible treatment for tive is on the list of banned substances for osteoarthritis, in part because NONSTEROIDAL ANTI- Olympic athletes. Herbalists value Acanthopanax INFLAMMATORY DRUGS (NSAIDS), which became popu- as a tonic (preparation that increases STRENGTH and lar in the late 1970s and early 1980s, are so ENDURANCE) rather than a medicinal herb. effective at controlling both the PAIN and the People who have HYPERTENSION (high BLOOD inflammation characteristic of osteoarthritis and in PRESSURE) and women who are pregnant should part because there were few clinical research stud- not take Acanthopanax. Women should temporar- ies to support glucosamine’s effectiveness. ily stop taking Acanthopanax during their men- Clinical studies in the 1980s and 1990s began strual periods as it may cause excessive bleeding. to show objective evidence that glucosamine sup- Most herbalists recommend taking Acanthopanax plements (exogenous glucosamine) seemed able no longer than 90 days, then taking a three- to to at least partially restore the body’s ability to six-week break before taking it again. heal osteoarthritis damage, and some doctors started recommending it for people who could not ACANTHOPANAX GINSENG tolerate the gastrointestinal irritation of NSAIDs. Uses Risks/Side Effects Interactions About half of the people in the studies experi- enced moderate to significant relieve from pain, alertness elevated BLOOD antihypertensive stiffness, and limited range of motion in arthritic athletic PRESSURE medications knees and hips. The effect seems even more pro- enhancement excitability, furosemide (Lasix) found when taking glucosamine in combination irritability with CHONDROITIN, another glucose-based structure insomnia (called a complex polysaccharide). excessive menstrual However, researchers continue to debate bleeding whether glucosamine taken as a supplement has See also TRADITIONAL CHINESE MEDICINE (TCM). the same action in the body as endogenous glu- cosamine. So far clinical research studies have glucosamine A GLUCOSE compound the body uses failed to reveal the actions of exogenous glu- to produce the chemical substances it needs to cosamine once it enters the body. Because glu- green tea 73 cosamine is a dietary supplement in the United fighting the cancer. As with other immunosup- States, it is available without a doctor’s prescrip- portive therapies, health experts recommend tion, so people who have osteoarthritis can side- using goldenseal for no longer than three weeks step the controversy and take the substance if they consecutively, with two to four weeks between choose. Glucosamine seems to have little effect on treatments. This allows the immune system to rest RHEUMATOID ARTHRITIS, an autoimmune disorder and restore itself. There are no known side effects that not only destroys but also deforms the joints. or interactions with goldenseal. Glucosamine partially blocks the absorption of many diuretic medications such as furosemide GOLDENSEAL (Hydrastis canadensis) (Lasix) and the thiazides. Though people can take Uses Risks/Side Effects Interactions both products at the same time, doctors may topical and systemic none known none known increase the diuretic DOSE for as long as the person antibioticnone is also taking glucosamine. Among the minor side stimulate IMMUNE effects are NAUSEA and gastrointestinal upset. RESPONSE soothe digestive upset GLUCOSAMINE calm and help heal Uses Risks/Side Effects Interactions canker sores OSTEOARTHRITIS gastrointestinal upset loop diuretics increase resistance to chronic BACK PAIN urinary tract infections

See also AUTOIMMUNE DISORDERS; LIGAMENT; See also CANKER SORE; GASTROENTERITIS; GREEN SAME; TENDON. TEA; RASH; SAME; URINARY TRACT INFECTION (UTI). goldenseal An herb (Hydrastis canadensis) with green tea The unfermented, dried leaves of the anti-inflammatory and possibly anti-INFECTION tea plant (Camellia sinensis), brewed into a drink. properties. Indigenous to the North American Black tea and green tea come from the same plant. continent (and in particular to the Pacific North- The difference between them is that processing and west), goldenseal is a mainstay of NATIVE AMERICAN drying of green tea leaves takes place immediately HEALING. Early tribes ground the roots into a after harvesting them and black tea leaves undergo mushy paste to use as a poultice to treat insect a processing that includes fermentation before dry- bites, LACERATIONS, and rashes. They also brewed ing. Though both kinds of tea leaves contain the the roots into tea, which though bitter to the taste same chemical compounds, green tea contains was an effective remedy for digestive upset. Today them in far greater concentrations. Green tea is also products containing goldenseal extract come in available in the United States as a dietary supple- topical, oral, and dried forms. ment, packaged in capsules or as tablets that con- Researchers have isolated goldenseal’s active tain the dried leaves ground into powder. Green tea ingredients as berberine and hydrastine, sub- contains a number of antioxidants, called polyphe- stances that now manufacturers extract and pro- nol catechins. They include gallocatechin (GC), epi- duce as prescription medications for use as in a gallocatechin (EGC), epicatechin (EC), and the number of European countries. Berberine in par- especially potent epigallocatechin gallate (EGCG). ticular has strong antibiotic action and acts to Red grapes and red wine also contain high amounts stimulate IMMUNE RESPONSE in the body. Goldenseal of these catechins. taken in combination with ECHINACEA, another EGCG appears to interfere with enzyme herb that boosts immune function, appears to processes necessary to allow healthy cells to increase resistance to many infections from COLDS mutate into cancerous cells, thus thwarting the and INFLUENZA to HEPATITIS. development of CANCER. It also seems to initiate Goldenseal is often an ingredient in herbal apoptosis, a sequence of natural events leading to preparations to relieve the adverse effects of cell death, in cancer cells that are already present. CHEMOTHERAPY and to support the IMMUNE SYSTEM in In addition to its cancer-fighting actions, EGCG 74 Alternative and Complementary Approaches has the ability to kill certain BACTERIA including too much caffeine. Because of green tea’s caffeine Helicobacter pylori, the bacteria responsible for content, health experts recommend pregnant and much PEPTIC ULCER DISEASE, and Escherichia coli, the nursing mothers limit consumption. bacteria that causes serious GASTROENTERITIS. Researchers continue to study all of these actions GREEN TEA (Camellia sinensis) to further understand how they occur and what Uses Risks/Side Effects Interactions they might bode for cancer prevention efforts. prevent development excessive CAFFEINE none known The other catechins have ANTIOXIDANT actions of cancer consumption that appear to help the body resist changes in the prevent spread of cancer cells of the ARTERY walls that allow ATHEROSCLEROSIS eliminate existing to establish itself. Other ingredients in green tea cancer cells include tannins, which act to soothe mild to mod- soothe digestive upset erate digestive upset, and fluoride, which decrease low-density strengthens the TEETH . Green tea and green tea lipoprotein cholesterol CAFFEINE extract products naturally contain . Green (LDL-C) tea also contains theanine, a substance with anti- improve circulation anxiety effects that somewhat counter the effect strengthen the TEETH of the caffeine. Though there are no known fight bacterial MOUTH health risks or interactions with green tea, people infections who ingest high quantities may experience sleep disturbances and irritability as a consequence of See also COENZYME Q10. H–I homeopathy A system of medicine based on the are no detectable molecules of the original ingre- philosophy that symptoms represent the body’s dient remaining, homeopathy asserts the remedy efforts to heal. Homeopathic treatment attempts to still holds the “molecular memory” of the active further stimulate those efforts through the prem- ingredient. The concentrations of homeopathic ise that “like cures like,” as homeopathy founder remedies reflect sequential dilutions. Mixing the Samuel Hahnemann expressed it. Treatment solution with powdered lactose creates product employs homeopathic remedies that are extremely forms other than liquids. diluted solutions of substances such as herbs, plants, and minerals; some may contain chemicals HOMEOPATHIC REMEDY DILUTIONS and even toxins. In the United States, the US Food Dilution Sequential Ratios Designation and Drug Administration (FDA) regulates homeo- decimal 1:10 C (1C, 2C, 3C, etc.) pathic remedies. Manufacturers must comply with centesimal 1:100 X (1X, 2X, 3X, etc.) the standards and procedures of the Homeopathic millesimal 1:1000 M (1M, 2M, 3M, etc.) Pharmacopoeia of the United States. Homeopathic remedies carry the Latin names Homeopathic Diagnosis and Remedies of their original ingredients, along with the desig- The homeopathic practitioner makes a diagnosis nations for their dilutions. Many also include of symptoms rather than disease. He or she does common names as well. The higher the dilution so by listening to what the person describes and ratio, the more dilute the remedy. Homeopathic conducts an examination appropriate for the prac- remedies come in tablets, granules, liquids, oint- titioner’s scope of practice. The practitioner then ments, creams, and suppositories. prescribes homeopathic remedies that support the symptoms to help the body use those symptoms to Homeopathic Practitioners rid itself of whatever ailment is present. The Homeopathy originated in Europe in the 1700s premise is that the body uses its own resources with the work of Samuel Hahnemann, a German and energy to heal itself. There are more than chemist. Hahnemann embarked on a quest to find 3,000 homeopathic remedies, each of which better ways to treat illness than the harsh and applies to a certain symptom or constitution. A often damaging methods, such as bloodletting (the person takes the remedies that apply to his or her practice of bleeding a person who was ill to rid the circumstances, making homeopathic treatment body of toxins), popular at the time. His approach entirely individualized. was, for its time, highly scientific and the mildness The essential principle of homeopathic remedy of homeopathic remedies quickly acquired a loyal preparation is that the vigorous shaking, called following. A Boston physician, Hans Burch Gram, succession, that follows each step of dilution studied homeopathy in Europe and opened a intensifies the potency of the solution by dispers- homeopathic practice when he returned to the ing the energy of its molecules into the molecules United States in 1825. The philosophy gained pop- of the water and ALCOHOL in the solution. Even ularity over the ensuing decades, peaking at the when the solution has become so dilute that there start of the 20th century with two dozen colleges 75 76 Alternative and Complementary Approaches of homeopathy and over 100 homeopathic hospi- improve after five to seven days of treatment with tals throughout the United States. Scientific dis- homeopathic remedies, the same caution they coveries in bacteriology and disease processes that extend for self-treatment with any over-the- accompanied the turn of the century marked a counter product. Clinical studies of homeopathic turning point in the practice of medicine, how- remedies have produced mixed results, with some ever, and homeopathy soon went the way of studies showing no greater effect than PLACEBO (an bloodletting. inactive substance) and others showing measura- In the United States today practitioners of ble improvement beyond placebo effect. homeopathy typically learn the philosophy and See also AROMATHERAPY; FLOWER ESSENCES. methods through graduate classes during the course of their conventional education or through human growth hormone (hGH) supplement A supplemental courses and programs they enroll in controversial anti-aging approach of injecting syn- after completing their conventional education thetic hGH to raise the body’s natural levels of this (though homeopathy is part of the regular cur- HORMONE, known as growth hormone (GH) in its riculum for NATUROPATHY). However, because fed- endogenous form (the form the body naturally eral guidelines classify most homeopathic produces). The PITUITARY GLAND produces endoge- remedies as OVER-THE-COUNTER (OTC) DRUGS, they nous GH. GH levels are highest in childhood and are available for anyone to purchase and use. ADOLESCENCE, when the body is growing. GH stim- Some remedies do contain ingredients that require ulates this growth through various biochemical a medical doctor’s prescription. Surveys show that actions. GH levels stay fairly high through early to most of the 6 million Americans who use homeo- middle adulthood, during which time GH shifts its pathic remedies treat themselves without consult- role to maintaining MUSCLE mass, BONE density, and ing a health-care practitioner. cardiac STRENGTH (the HEART’s ability to pump Each state regulates the practice of homeopathy. forcefully and efficiently). By about age 50, the In most states physicians (MD and DO), chiroprac- pituitary gland produces less GH and levels in the tors (DC), naturopathic physicians (ND), and den- bloodstream begin to decline. The characteristic tists (DDS and DMD) can make homeopathic physical changes of aging, such as increased body diagnoses and prescribe homeopathic remedies. A fat and decreased muscle mass, begin to manifest. few states have specific licensing requirements for OBESITY also slows hGH release. MDs and DOs who also practice homeopathy. In Some children have deficiencies of GH, usually Europe homeopathy remains a distinct discipline in due to a tumor, endocrine disorder, or other dys- health care, and homeopathic physicians receive function of the pituitary gland. GH deficiency in specific training and credentialing. childhood and adolescence causes stunted growth and blocks many of the body’s normal maturation Benefits and Risks of Homeopathy processes. Some adults also have GH deficiencies; Homeopathic remedies are so dilute, some as much hGH supplementation similarly restores body lev- as one part per million, that by conventional clini- els to those needed for healthy muscles, bones, cal standards they do not contain active ingredi- and cardiac function. Doctors have prescribed ents. Because of this, they do not interact with hGH supplementation to treat such deficiencies other medications or cause side effects. Aside from since the 1970s. the risks of improper manufacturing and potential Many people who support hGH supplementa- contamination, health experts generally regard tion as an anti-aging measure point to the success homeopathic remedies as safe, though some reme- of such treatments as evidence that hGH is safe. dies contain significant quantities of alcohol. FDA Some doctors agree that there is no difference regulations require homeopathic remedy labels to between therapeutic hGH given to adults whose list the ingredients as well as the instructions for GH levels fall before age-related declines naturally use (including conditions the remedy treats). take place; symptoms and response are the same. Health experts caution people to seek conven- Other doctors question the therapeutic value of tional medical care for symptoms that do not giving hGH to counter a process that seems purely hypnosis 77 the result of the aging process rather than of a dis- responsive to suggestion than during normal con- ease process. Proponents of hGH supplementation sciousness. Studies show changes in the patterns counter that reversing some of the effects of aging of electrical activity in the BRAIN when a person is prevents age-related diseases, such as ATHEROSCLE- under hypnosis, suggesting some parts of the brain ROSIS and OSTEOARTHRITIS, from developing. This, become more active and others less active. Many they argue, is clearly a therapeutic effect. Those people are able to recall details when hypnotized who question the safety of hGH supplementation that they cannot otherwise remember. Though a note that researchers do not know the functions person may not be able to recall a suggestion the of GH in adults, or how GH influences factors such hypnotherapist gives during hypnosis, he or she as body fat distribution and muscle mass. They may act on the suggestion during full conscious- further observe that though muscle mass increases ness, often without full awareness. with hGH supplementation in adults, muscle strength does not, raising more questions about FACTS ABOUT HYPNOSIS the role of GH in the adult body. The debate • A person retains full control of his or her thoughts, emo- touches on a number of key ethical issues that are tions, and actions when under hypnosis. not easy to resolve. • Hypnosis is fully voluntary. A person cannot be hypnotized At present the US Food and Drug Administra- against his or her will or without knowledge and participa- tion (FDA) approves hGH supplementation only tion. for people who have clinical GH deficiencies—that • A person will not say or do anything, under hypnosis or as is, GH deficiencies resulting from pituitary dys- the result of hypnotic suggestion, that violates his or her function rather than aging. hGH supplement is values and sense of what is right and wrong. available only with a doctor’s prescription. Treat- • Some people do not respond to hypnosis or hypnotherapeu- ment with hGH supplement can cause HYPERTEN- tic suggestions, regardless of their willingness to do so. SION, edema (fluid retention), and HEART FAILURE, • Most people fully remember everything that occurs under and hGH supplement may interact with other hor- hypnosis. mone supplements such as thyroid and hydrocor- tisone. A rare but serious complication arising Hypnotherapy may help people who are trying from too much GH is ACROMEGALY, in which the to make lifestyle changes such as in EATING HABITS bones of the jaw, hands, and feet grow dispropor- or SMOKING CESSATION. It is also a clinically accepted tionately large. Though the excessive growth stops method for managing chronic PAIN and stress. when GH levels drop, changes that have already Sometimes people use hypnosis to help them visu- occurred are permanent. alize a state of health they desire to achieve, with the residual effect supporting them while they HUMAN GROWTH HORMONE (HGH) SUPPLEMENT work toward their health goals. Such goals may Uses Risks/Side Effects Interactions include restoration of function after serious injury, weight loss, fitness level, and even REMISSION from increase MUSCLE ACROMEGALY CORTISOL, CANCER. Hypnosis should always be an adjunct, not mass edema hydrocortisone a primary, treatment; it accompanies and supports decrease body fat HEART FAILURE thyroid supplement other therapies and treatments. improve A typical hypnotherapy session takes place in a cardiovascular professional setting and may last 30 to 45 minutes. function A person should emerge from hypnosis feeling prevent OSTEOPOROSIS refreshed and invigorated, fully capable of return- See also ANTI-AGING APPROACHES; HORMONE THER- ing to the day’s regular activities. Some circum- APY; POLYGLANDULAR DEFICIENCY SYNDROME. stances may need several hypnotherapy sessions, though many require only a session or two. In hypnosis A method of induced deep relaxation, addition to performing hypnosis, a hypnotherapist sometimes perceived as an altered state of CON- can teach self-hypnosis. Self-hypnosis may be SCIOUSNESS, in which a person often is more helpful for reinforcing suggestions the hypnother- 78 Alternative and Complementary Approaches apist provides during a hypnotherapy session. plementary therapies in conjunction with one Self-hypnosis is also an effective stress relief another. In the United States integrative medicine method, particularly for people who have chronic typically refers to physicians (MDs and DOs) who health conditions that cause discomfort or pain. practice conventional medicine that incorporates Often the hypnotherapist will make a recording of complementary therapies, such as ACUPUNCTURE the first session for the person to replay at home. and herbal remedies, or who work in close associ- A person who practices hypnosis may be a doc- ation with complementary practitioners such as tor, nurse, psychologist, psychotherapist, dentist, massage therapists and chiropractors. naturopathic physician, or certified hypnotist. Most Doctors in the United States who practice inte- states do not regulate hypnotherapy, so it is impor- grative medicine typically use complementary tant to fully understand the hypnotherapist’s edu- methods that clinical studies have shown to pro- cation, credentials, and experience even when the vide therapeutic benefit or at the least have not hypnotherapist is a certified or licensed health shown to cause harm. Hospitals often use integra- practitioner. It is important to feel a high level of tive methods such as MEDITATION and VISUALIZATION trust in the hypnotherapist. Hypnosis itself is gener- with people who are undergoing major surgery or ally a safe practice, though it can allow people to CANCER treatment. The ORNISH PROGRAM for CARDIO- recall circumstances that are emotionally painful. VASCULAR DISEASE (CVD) presents an integrative Once those emotions surface, the person may need approach that has obtained Medicare approval, a professional guidance to address them. step that speaks to the effectiveness and accept- See also BIOFEEDBACK; MIND–BODY INTERACTIONS. ability of its methods. See also HOMEOPATHY; MEDICINAL HERBS AND integrative medicine An approach to the prac- BOTANICALS; NATUROPATHY; TRADITIONAL CHINESE MEDI- tice of medicine that uses conventional and com- CINE (TCM). L labyrinth A spirituality-based approach that fea- dark green vegetables such as spinach and broc- tures a geometric, symmetrical pattern that a per- coli. It is also available as a dietary supplement, son walks in prayer, MEDITATION, VISUALIZATION, or usually in combination with other carotenoids. quiet contemplation. Many hospitals have Too much lutein or other carotenoids, which typi- labyrinths, which may be small or large, indoors cally occurs only when taking high doses of or outdoors, permanent or temporary. The tradi- carotenoid supplements, can cause the palms of tion of the labyrinth dates to medieval times and the hands and soles of the feet to turn orange or has integrated with a number of religious and dark yellow. This is a temporary effect that goes spiritual practices through the centuries. The away when the amount of consumed carotenoids winding, convoluted path of the labyrinth physi- decreases. Penicillin-based ANTIBIOTIC MEDICATIONS cally and symbolically draws the person into the may decrease lutein absorption. center. Once at the center, the person turns and follows the path back out. Many people experi- LUTEIN ence profound calm and inner peace as they com- Uses Risks/Side Effects Interactions plete their labyrinth journeys. People who have prevent cataracts excessive amounts may none known chronic or terminal conditions often find the turn the palms and labyrinth gives them respite from their symptoms reserve macular soles of the feet while within the labyrinth and often for hours to function orange or dark yellow days afterward. possibly protect See also NATIVE AMERICAN HEALING; PRAYER AND against LUNG SPIRITUALITY; REIKI; TRADITIONAL CHINESE MEDICINE CANCER (TCM). See also BILBERRY; CATARACT; CATARACT EXTRACTION lutein An ANTIOXIDANT belonging to the AND LENS REPLACEMENT; LYCOPENE; RETINOPATHY; VITA- carotenoid family. Lutein, along with another MIN AND MINERAL THERAPY. carotenoid, ZEAXANTHIN, helps protect against AGE- RELATED MACULAR DEGENERATION (ARMD) and other lycopene An ANTIOXIDANT that is one of the retinal disorders. ARMD is the leading cause of carotenoids. Lycopene emerged in the 1990s as an progressive vision loss among adults. Some studies adjunct (secondary) therapy for PROSTATE CANCER suggest lutein may also help lower the risk for because of its ability to slow the growth of LUNG CANCER. Ophthalmologists often recommend prostate CANCER cells. It may also help to slow the lutein in combination with ZEAXANTHIN, an antioxi- growth of cancer cells in other locations, notably dant that occurs in many of the same foods as the LUNG and LIVER. In combination with LUTEIN lutein, for people in middle age and older. There is and ZEAXANTHIN (other carotenoids), lycopene limited evidence that lutein and other carotenoids helps protect the RETINA and vision. may also help prevent cataracts from forming. Lycopene occurs naturally in fruits and vegeta- Lutein occurs naturally in the dark yellow pig- bles that have red flesh, such as tomatoes, guava, ments found in red bell peppers, pumpkin, and in and watermelon. The highest levels of lycopene 79 80 Alternative and Complementary Approaches occur in cooked tomatoes and tomato products stance that returns to normal when carotenoid such as tomato soup, tomato sauce, and ketchup. levels drop after stopping or reducing the supple- Most studies investigating the effects of lycopene ment. There are no other known risks or side involved consuming high amounts of foods con- effects when using lycopene, though taking peni- taining lycopene, notably cooked tomato products. cillin-based ANTIBIOTIC MEDICATIONS may decrease The findings seem to substantiate lycopene’s role the amount of lycopene absorbed into the blood- in inhibiting the growth of cancer cells, particu- stream from the gastrointestinal tract. larly prostate cancer cells. However, few research studies have evaluated lycopene supplements. LYCOPENE Because tomatoes contain numerous nutrients, it Uses Risks/Side Effects Interactions is difficult to assess the effects of only one. prevent or slow excessive amounts may none known Most doctors agree that while there is likely lit- PROSTATE CANCER turn the palms and tle harm to come of taking lycopene supplements, possibly protect soles of the feet there is not enough evidence to recommend doing against LUNG orange or dark yellow so except as an adjunctive therapy (in addition to CANCER other therapeutic approaches). Men who have preserve retinal prostate disease or PROSTATE CANCER may benefit function from increasing their consumption of foods con- taining cooked tomatoes. Excessive ingestion of See also AGE-RELATED MACULAR DEGENERATION lycopene and other carotenoids can cause the (ARMD); BILBERRY; CATARACT EXTRACTION AND REPLACE- palms of the hands and the soles of the feet to MENT; RETINOPATHY; SAW PALMETTO; VISION IMPAIRMENT; turn dark yellow or orange, a temporary circum- YOHIMBE/YOHIMBINE. M magnet therapy The use of static magnets to cre- The earliest documented use of magnets for ate magnetic energy fields, which are alignments HEALING comes from medieval times, when sur- of the atoms within them. The most common use geons used lodestones and magnets made from of magnet therapy is to treat chronic PAIN such as them to locate and remove iron fragments and from OSTEOARTHRITIS, RHEUMATOID ARTHRITIS, arrowheads from soldiers on the battlefield. With FIBROMYALGIA, and CARPAL TUNNEL SYNDROME. understanding of the body’s functions in health or disease considerably limited until the start of the People who have implanted medical twentieth century, magnets remained among the devices such as pacemakers, defibrilla- most popular tools in the doctor’s medicine bag. tors, and INSULIN pumps should not use Though several theories for how magnets may therapeutic magnets because they may exert therapeutic influence seem plausible, partic- interfere with the electrical functions of ularly because neurologic and other cellular func- the devices. tions generate electromagnetic fields. so far clinical studies have not produced findings that support them. A number of studies have shown Therapeutic magnets come in many strengths therapeutic benefit with pulsed electromagnetic and configurations, from adhesive-backed strips to therapy, in which a rapidly pulsating electrical items of jewelry such as necklaces and bracelets to current creates a temporary, powerful magnetic magnets designed for placement under the mat- field. Only health-care professionals may use elec- tress. The only aspects of magnet therapy that fall tromagnetic therapeutic devices under current within regulatory reach are labeling and market- regulations in the United States. ing. Because there are no clinical studies to sup- Most health experts believe static magnets have port the therapeutic qualities of static magnets, very limited therapeutic effect though are not the US Food and Drug Administration (FDA) pro- likely to cause harm in most people. Pregnant hibits therapeutic magnet manufacturers from women (because effects of magnetic energy fields claiming health benefits from their products. Mag- on a developing fetus remain unknown) and peo- net STRENGTH varies widely among manufacturers ple who have implanted electronic devices and products, and often varies from the stated (because the magnet may interfere with the strength on the product packaging. device’s electromagnetic field) should not use magnet therapy. Magnets cannot treat or cure dis- MAGNETIC ENERGY MEASURES eases such as CANCER, DIABETES, and CARDIOVASCULAR Earth’s magnetic field 0.5 gauss DISEASE (CVD), though some disreputable vendors refrigerator magnets 35 to 200 gauss may represent them as being able to do so. A doc- therapeutic magnets 300 to 5,000 gauss tor should evaluate any condition that does not MAGNETIC RESONANCE IMAGING 200,000 gauss improve within 7 to 10 days. (MRI) magnet See also ALTERNATIVE METHODS FOR PAIN RELIEF; Source: National Center for Complementary and Alternative Medicine BIOFEEDBACK FOR PAIN RELIEF; TRANSCUTANEOUS ELEC- (NCCAM) TRICAL NERVE STIMULATION (TENS). 81 82 Alternative and Complementary Approaches massage therapy A touch therapy, also called tional tension. The result of this release can be therapeutic massage or bodywork, that acts on the quite profound. Many people begin to cry during body as well as the mind and the emotions. About massage therapy or find themselves recalling past 25 percent of people who seek massage therapy experiences that caused them pain or grief. From do so to relieve PAIN and stiffness related to mus- a holistic perspective, this release is essential to culoskeletal injuries, and a third are interested in healing in a broad context. stress relief. There are dozens of therapeutic mas- Massage therapy also facilitates the flow of sage techniques and methods, though all share the lymph, helping the body to clear metabolic toxins common intent of stimulating the flow of BLOOD stored in the muscles. Particularly in people who through the muscles and soft tissues to cleanse are sedentary, lymph flow may be sluggish. metabolic toxins, tone MUSCLE tissues, and release Chronic health conditions also may impair lymph tension. circulation. People who have had lymph nodes Though a doctor may recommend massage surgically removed (lymphectomy) to treat cancer therapy in conjunction with PHYSICAL THERAPY, the may have gaps in the lymph circulatory struc- two have distinctly different approaches. Physical tures; massage therapy helps LYMPH to work therapy is fix-oriented: there is a problem and around those areas to restore its movement massage can help make it better. Therapeutic mas- (lymphatic drainage). As the LYMPHATIC SYSTEM is sage in the context of physical therapy is one com- key to immune function, stimulating lymph ponent of a treatment plan that might also include circulation improves resistance to illness and therapies such as hydrotherapy (whirlpool or INFECTION. soaking bath), ULTRASOUND, and electrotherapy In the United States, each state regulates the (gentle stimulation of the muscles with mild elec- practice of massage therapy. Thirty states have trical current). The treatment plan focuses on the specific education, training, and certification injured body part, and the massage therapist or requirements. Health experts recommend that physical therapist does not usually massage other regardless of state standards, massage therapists parts of the body. should have passed the certification requirements of the National Certification Board for Therapeutic INFANT MASSAGE Massage and Bodywork (NCTBMB) and belong to Many neonatal care units use massage therapy the American Massage Therapy Association with premature infants. The gentle touch of the (AMTA). Naturopathic (NDs), CHIROPRACTIC (DCS), massage therapist seems to calm and relax these and osteopathic physicians (DOs) are among the babies born before their bodies are quite ready practitioners who most often also have formal to process the stress of external stimulation. training in massage therapy. In addition to an Studies show that infants who receive massage individual’s credentials, however, the most impor- therapy gain weight and grow faster, and go tant factors in selecting a massage therapist are home earlier from the hospital. trust and comfort. See also LYMPHEDEMA; REFLEXOLOGY; REIKI. Massage therapy independent of physical ther- apy has a holistic orientation, approaching manip- medicinal herbs and botanicals Plants have ulation of the body within the context that the been the source of HEALING therapies for all of body holds physical, emotional, and spiritual ten- known history and among all societies. The earli- sion. The massage therapist may focus on a partic- est written records across cultures make reference ular area of the body that he or she detects is to teas, berries, salves pounded and mixed from holding more tension than other parts of the body. leaves and barks, seeds, roots, and other plant Though the intent is not necessarily one of HEAL- parts as remedies for ailments ranging from ING a musculoskeletal injury, massage therapy typ- HEADACHE to digestive upset to GOUT. The ubiqui- ically results in improvement of FLEXIBILITY and tous aspirin, whose chemical basis is salicylic acid, mobility. When the muscles release stored physi- derives from the bark of the willow tree. For cen- cal tension, they often also release stored emo- turies Native Americans chewed this bark to medicinal herbs and botanicals 83 relieve TOOTHACHE, headache, and other pains, yet research continues in the areas of botanicals and it was not until 1899 that researchers isolated and herbal remedies. synthesized this key ingredient. About 30 percent of the drugs and medicines in use today derive Forms and Preparations from plant sources—the HEART medication digoxin The part of the plant from which the botanical from foxglove, for example, and the anticancer product derives also affects its potency. Seeds and DRUG tamoxifen from the yew tree. Complemen- roots generally contain the highest concentrations tary and alternative therapies employ hundreds of of plant chemicals, while leaves or stems contain plant-based remedies. weaker concentrations. Common preparations of botanicals include the following: Effectiveness Until the 1980s, there were few US clinical • Extracts are made by soaking the plant in water research studies to evaluate the benefits, risks, and to draw out its active ingredients, and the liquid effectiveness of botanical therapies, though Euro- becomes the product. Extracts also are evapo- pean countries have conducted countless clinical rated out to leave the product in a powder form studies. Germany’s Commission E Monographs, a that manufacturers may package as loose pow- document that extensively documents the effec- der or in capsules, or form into tablets. tiveness and safety of more than 300 herbs and • Tinctures are made by soaking the plant in botanicals, stands as one of the definitive treatises ALCOHOL or a mixture of alcohol. The water on botanical remedies, analogous to Western med- draws out the active ingredients, and tinctures icine’s pharmacopoeias. The Commission E remain in liquid form. updates the Monographs every few years as it com- • Teas are made from fresh, dried, or freeze-dried pletes investigation of additional products. Many parts of the plant. Manufacturers may package practitioners around the world rely on the Mono- them loose or in tea bags. graphs for information about benefits, risks, dosages, and forms of botanical therapies. • Capsules contain powdered plant parts (usually As interest has surged among Americans in extracts). using these therapies, US researchers have • Tablets are compressed powders containing the expanded their studies of them. Plant-based thera- plant ingredients as well as inert binders and pies in the research spotlight are PHYTOESTROGENS, fillers. for their effects in relieving hormonal discomforts • Liquids are usually extracts or decoctions in related to MENOPAUSE and their potential ability to bottled form. head off PROSTATE CANCER and BREAST CANCER, and SOY for its role in preserving cardiovascular health. Most herbalists recommend staying as “close to Recent clinical studies have demonstrated the the earth” as possible, using actual plant parts value of the herb BILBERRY to improve night vision (fresh, dried, or extracted) rather than supple- and prevent cataracts, the herb MILK THISTLE to pro- ments manufactured from isolated ingredients. tect the LIVER’s ability to restore itself, the herb ST. JOHN’S WORT to treat mild to moderate DEPRESSION, Standardization and the extract SAW PALMETTO to treat BENIGN PRO- Medicinal botanicals have been in use in Europe STATIC HYPERPLASIA (BPH). for millennia, and strict standards now govern Other remedies have failed to produce clinical their manufacture and use in most European evidence of their effectiveness, such as the herb countries. Many require a doctor’s prescription. In DONG QUAI to treat HOT FLASHES and other discom- the United States, most medicinal botanicals and forts of menopause. This does not mean the rem- herbal preparations fall under minimal regulatory edy is ineffective; it means only that so far oversight as dietary supplements. The US Congress researchers do not understand how the remedy passed the Dietary Supplement Health and Educa- functions in the body and cannot consistently tion Act in 1994, allowing dietary supplement reproduce the claimed beneficial results. Much classification for any substance other than TOBACCO 84 Alternative and Complementary Approaches that, according to the US National Institutes of Another factor affecting the consistency of Health (NIH) Office of Dietary Supplements botanical supplements manufactured from har- vested plants (as opposed to synthesized ingredi- • has the intention to supplement dietary intake ents) is the wide variation possible among the • contains dietary ingredients such as vitamins, source plants. Soil conditions, mineral content of minerals, amino acids, or botanical substances, the water, the amounts of water and sunshine, the including herbs part of the world where the plant grows, and • is taken in some form by MOUTH (such as liquid, numerous other environmental factors influence tablet, capsule, gel, tea, freeze-dried, or powder) the plant’s growth and the potency of its active either by itself or mixed with food or water ingredients. The time and method of harvest also affects potency. As well, there may be different • carries clear labeling on the front of the pack- species of the plant, such as GINSENG (Siberian, age that identifies the product as a dietary sup- Korean, Red, Panax), that have differing potencies plement and characteristics. Manufacturers may blend sev- Further, dietary supplements may not make eral species or use whatever species is available or health claims unless the US Food and Drug less expensive. Administration (FDA) approves them. Dietary Safety supplements are thus exempt from the rigorous standards that medications must meet. There is a tendency to view herbs and botanicals In the United States, there are no standards for as “safe” because they are natural. However, any product ingredients or consistency for dietary sup- substance that alters the functions of the body has plements, other than the product may not contain the capacity to be both helpful and harmful. Fox- substances that the law prohibits or claim to con- glove provides digoxin, a medication that main- tain ingredients that it does not. The term stan- tains heart rhythm and STRENGTH in millions of dardized on a dietary supplement label can mean people. Foxglove also is one of the most potent anything the manufacturer desires, from consis- poisons; the sap residue left on the fingers after tency in following the same recipe and balance of picking its beautiful purple and white bell-like ingredients in making every batch of the supple- flowers is enough to cause life-threatening ment to all tablets in the same bottle are the same ARRHYTHMIA (disturbance of the heart’s rate and color. Many manufacturers strive to produce sup- rhythm) especially in children. plements that have consistent ingredients and Herbal remedies, like conventional medica- potency across batches though some do not. tions, can interact with each other as well as with Though reading product labels for the percentages conventional medications. Most herbal products or measurements of included ingredients is help- available over-the-counter are mild formulas that ful, health experts point out that because there are generally are safe when people take them accord- no standards to control those measurements, ing to recommended guidelines or package there is no way to know how accurate they are. instructions. Some herbal formulas are potent enough, or carry sufficient risk for harmful effects, THE USP QUALITY STANDARD that the FDA regulates them as drugs. An example The United States Pharmacopeia (USP) maintains is the “herbal Viagra” remedy YOHIMBE/YOHIMBINE, a verification program of stringent guidelines to derived from the bark of the African yohimbe assure the quality of dietary supplements. Manu- tree, which is available in the United States only facturers whose products meet the quality guide- with a doctor’s prescription. It is important for lines may place the designation “USP” on doctors to know, when considering prescription product labels. The organization’s Web site medications, all of the remedies, including vitamin (www.usp.org) maintains a current list of USP- and mineral supplements, people are taking. verified products. See also ALTERNATIVE AND COMPLEMENTARY REME- DIES FOR CANCER; TRADITIONAL CHINESE MEDICINE. medicinal herbs and botanicals 85

THERAPEUTIC BOTANICALS, HERBS, AND SUPPLEMENTS Name Common Uses/Benefits Risks/Side Effects BILBERRY (Vaccinium myrtillus) improve night vision, prevent AGE-RELATED none known MACULAR DEGENERATION (ARMD), prevent cataracts, prevent RETINOPATHY of DIABETES

BLACK COHOSH (Actaea relieve menopausal HOT FLASHES can cause uterine contractions and racemosa, Cimicifuga racemosa) interfere with oral contraceptives

BOSWELLIA (Boswellia serrata) relieve pain of OSTEOARTHRITIS, RHEUMATOID none known ARTHRITIS, IRRITABLE BOWEL DISEASE (IBD), and other AUTOIMMUNE DISORDERS

CHAMOMILE (Matricaria recutita) relieve gastrointestinal upset, sleep aid, none known general relaxation

CHONDROITIN reduce INFLAMMATION and relieve PAIN of may interfere with actions of anticoagulant osteoarthritis medications may prevent or reverse damage to JOINT tissues

COENZYME Q10 lower BLOOD PRESSURE, strengthen force of HEART’s none known contractions, help heart to recover after HEART ATTACK, prevent PERIODONTITIS may prevent cancers and chronic health conditions related to oxidation

DONG QUAI (Angelica sinensis) relieve menstrual cramps, menopausal may cause STOMACH irritation and discomforts, and ENDOMETRIOSIS symptoms excessive menstrual bleeding may interfere with actions of anticoagulant medications and NONSTEROIDAL ANTI- INFLAMMATORY DRUGS (NSAIDS)

ECHINACEA (Echinacea prevent or reduce symptoms of upper none known angustifolia, Echinacea pallida, respiratory infections such as COLDS and Echinacea purpurea) INFLUENZA (flu) general IMMUNE SYSTEM support

FEVERFEW (Tanacetum relieve migraine HEADACHE and menstrual may cause excessive bleeding parthenium) discomfort may interfere with anticoagulant medications, aspirin, and NSAIDs

GARLIC (Allium sativum) lower BLOOD cholesterol and risk for interferes with many antihypertensive ATHEROSCLEROSIS, CORONARY ARTERY DISEASE (CAD), medications and PERIPHERAL VASCULAR DISEASE (PVD) may cause excessive bleeding with surgery 86 Alternative and Complementary Approaches

Name Common Uses/Benefits Risks/Side Effects GINGER (Zingiber officinale) relieve general NAUSEA, nausea of CHEMOTHERAPY, may interfere with anticoagulant MORNING SICKNESS, motion sickness, and medications and ASPIRIN THERAPY digestive upset may cause excessive bleeding

GINKGO BILOBA relieve symptoms of RAYNAUD’S SYNDROME, interferes with numerous medications INTERMITTENT CLAUDICATION, and ALZHEIMER’S including anticoagulants, DISEASE antihypertensives, thiazide diuretics, may improve PVD, CAD, and atherosclerosis prochlorperazine, trazodone interferes with aspirin therapy

GINSENG (Panax ginseng, improved mental clarity and focus, memory interferes with loop diuretics Panax quinquefolius) general immune system support can result in excitability and insomnia improved INSULIN sensitivity when combined with CAFFEINE aphrodisiac

GLUCOSAMINE reduce inflammation and relieve pain of may cause gastrointestinal upset osteoarthritis interferes with loop diuretics relieve chronic BACK PAIN may prevent or reverse damage to joint tissues

GOLDENSEAL (Hydrastis topical and systemic antibiotic none known canadensis) general immune system support relieve digestive upset relieve and help heal canker sores increase resistance to URINARY TRACT INFECTION (UTI)

GREEN TEA (Camellia sinensis) prevent development and spread of CANCER contains significant amount of caffeine lower low-density lipoprotein (LDL) cholesterol improve circulation strengthen TEETH and resist bacterial MOUTH infections

LUTEIN preserve macular structure and function, none known protect vision, prevent cataracts

LYCOPENE prevent development and spread of PROSTATE none known CANCER preserve retinal function and protect vision

MELATONIN relieve insomnia causes strong drowsiness prevent jet lag numerous medication interactions alter sleep patterns to accommodate shift work may raise blood pressure should not take with diabetes, CARDIOVASCULAR DISEASE (CVD), kidney disease medicinal herbs and botanicals 87

Name Common Uses/Benefits Risks/Side Effects MILK THISTLE (Silybum marianum) protect the LIVER from damage due to CIRRHOSIS, interferes with insulin therapy for diabetes chronic HEPATITIS, mushroom poisoning, and DRUG poisoning

PHYTOESTROGENS relieve menopausal discomforts and may diminish fertility PREMENSTRUAL SYNDROME (PMS) symptoms may increase risk of certain kinds of lower blood cholesterol breast cancer enhance BONE DENSITY and STRENGTH to prevent osteoporosis possibly prevent prostate cancer and some kinds of BREAST CANCER

SAME (S-adenosylmethionine) relieve mild to moderate DEPRESSION may cause insomnia and gastrointestinal relieve symptoms of osteoarthritis, back pain, upset and CHRONIC FATIGUE SYNDROME interferes with monoamine oxidase inhibitor (MAOI) antidepressants

SAW PALMETTO (Sabal serrulata) stop PROSTATE GLAND from enlarging may interfere with some treatment for relieve symptoms of benign PROSTATIC prostate cancer HYPERPLASIA (BPH) soy lower LDL cholesterol, reduce risk for CAD may cause gastrointestinal upset reduce risk for osteoporosis, prostate cancer, may increase risk for certain estrogen- and certain breast cancers driven breast cancers relieve menopausal discomforts, especially hot flashes

ST. JOHN’SWORT(hypericum relieve mild to moderate depression increases sensitivity to the sun and perforatum) ultraviolet light interferes with some chemotherapy agents, HIV/AIDS medications, immunosuppres- sive drugs, and selective serotonin reuptake inhibitor (SSRI) and MAOI antidepressants

SUN’S SOUP slow metastasis of non-small cell LUNG CANCER none known (NSCLC) reduce HIV/AIDS symptoms and progression

VALERIAN (Valeriana officinalis) sleep aid may cause excessive drowsiness in relieves anxiety combination with other substances and medications that also cause drowsiness

YOHIMBE/YOHIMBINE treat ERECTILE DYSFUNCTION may cause elevated blood pressure (Pausinystalia yohimbe) aphrodisiac interferes with MAOI antidepressants interacts with foods containing tyramine 88 Alternative and Complementary Approaches

Name Common Uses/Benefits Risks/Side Effects ZEAXANTHIN prevent cataracts none known preserve macular function and protect vision possibly protect against LUNG CANCER and OVARIAN CANCER

meditation A method of focusing the mind for Many people take five-minute meditation breaks HEALING VISUALIZATION, relaxation, stress relief, and while at work to help dissipate job stress. Children contemplation. Though meditation can have a also can learn to meditate. Meditation has no spiritual dimension for people who desire it, medi- known health risks. tation is not a religious practice. Clinical studies See also MIND–BODY INTERACTIONS; PRAYER AND show that daily meditation has the ability to SPIRITUALITY; STRESS AND STRESS MANAGEMENT.

• reduce EPINEPHRINE production, thereby lower- melatonin An endogenous (naturally occurring ing BLOOD PRESSURE and the frequency of ANGINA within the body) HORMONE the PINEAL GLAND pro- PECTORIS duces that maintains the body’s circadian rhythms • relax BLOOD vessels, which also lowers blood (cycles of waking and sleeping). Melatonin may pressure also have ANTIOXIDANT functions, helping protect cells from damage. Researchers first discovered • relax musculoskeletal structures melatonin in the late 1950s, and early studies sug- • instill a sense of inner calm and peacefulness gested endogenous melatonin (melatonin the • decrease the frequency, duration, and severity body manufactures) production diminished with of menopausal HOT FLASHES increasing age. This gave rise to speculation that melatonin played a role in the aging process. Sub- When meditation becomes a routine of daily sequent studies have been unable to substantiate life, these effects can help lower blood pressure by such involvement, however, and most doctors do reducing the resistance blood encounters as it not believe melatonin can halt, prevent, or reverse flows through the arteries. They also increase the aging. flow of blood to muscles, helping muscle cells to The daily level of melatonin in the body cycles more efficiently clear lactic acid accumulations a pattern of peaking between 2 o’clock and 4 and other metabolic wastes that cause cramping o’clock in the morning (which is the middle of the and discomfort. Some people use meditation as a night for most people) and reaching its lowest platform to “go within” their bodies and visualize point around midday. Researchers believe the healthy, strong cells, tissues, organs, and func- HYPOTHALAMUS, a structure deep within the BRAIN tions. Such visualization may aid in healing during that regulates vital body functions such as BREATH- illness or injury as well as in maintaining health. ING and BLOOD PRESSURE, receives signals from the There are many methods of meditation. Medi- RETINA via the OPTIC NERVE that indicate whether it tation centers, YOGA centers, community centers, is light or dark. When it is dark, the hypothalamus and health organizations often teach classes in signals the pineal gland to begin releasing mela- meditation techniques. Meditation may take place tonin and when it is light, to stop releasing mela- while sitting quietly, while walking, or while tonin. This may in part explain why people feel engaged in mind–body practices such as yoga and drowsy when spending several hours in dark set- TAI CHI. Some people chant when meditating, to tings such as movie theaters, or want to go to focus their meditations with specific sounds or sleep earlier in the winter when daylight is short intents. Though a quiet location best facilitates and have trouble falling asleep in summer when meditation, a person can meditate anywhere. daylight is much longer. milk thistle 89

Raising the level of melatonin in the blood- MELATONIN stream increases drowsiness, which has led to the Uses Risks/Side Effects Interactions use of melatonin supplement as a sleep aid. In the sleep aid drowsiness CORTICOSTEROID MEDICATIONS United States melatonin is available as an over- possible fertility prescription sleep aids the-counter dietary supplement. In most Euro- problems ASTHMA medications pean countries, however, melatonin is available may elevate BLOOD ANTIHISTAMINE MEDICATIONS only with a doctor’s prescription. This is because PRESSURE narcotic ANALGESIC researchers do not fully understand the functions insomnia MEDICATIONS of melatonin in the body though they do know fatigue ANTIANXIETY MEDICATIONS that as a hormone, melatonin has numerous MUSCLE RELAXANT effects within the body in addition to the roles it MEDICATIONS plays in sleep cycles and the circadian rhythm. ANTIDEPRESSANT MEDICATIONS Some studies have found that melatonin causes blood vessels to constrict, perhaps by stimulating See also ANTI-AGING APPROACHES; SLEEP DISORDERS; the release of CORTISOL, raising blood pressure. VALERIAN. Though this finding is not conclusive, health experts advise people who have HYPERTENSION (as well as people who have other forms of CARDIOVAS- milk thistle A medicinal herb, also called holy CULAR DISEASE (CVD), DIABETES, and KIDNEY disease) thistle, that helps protect the LIVER from INFECTION not to take melatonin to avoid this risk. and improves the liver’s ability to regenerate from A number of studies support melatonin’s ability damage. Numerous clinical studies support this to relieve jet lag and help people adjust to sleeping benefit. The active ingredient in milk thistle is sily- during the day when they work during the night. marin, a composite of five flavonoids (siliandrin, However, there are no studies that conclusively silibinin, silydianin, silymonin, and silychristin), identify supplemental melatonin’s benefits or which is in highest concentrations in the milk risks. Melatonin interacts with numerous prescrip- thistle seeds. Silymarin strengthens the structure tion medications and should be taken only after a of hepatocytes, the cells in the liver that metabo- doctor’s examination determines there are no lize toxins. It may also influence aminotrans- neurologic or other physiologic causes for insom- ferases, the enzymes the liver produces to break nia. Even people taking melatonin for jet lag or to down chemical substances the liver extracts from restructure their sleep patterns to accommodate the blood. shift work should first consult with their doctors Doctors often recommend milk thistle for peo- to make sure they have no health conditions that ple who have LIVER DISEASE OF ALCOHOLISM, CIRRHO- make it unsafe for them to take melatonin supple- SIS, or chronic HEPATITIS, or who have ingested ments. toxic mushrooms or toxic doses of medications Melatonin causes drowsiness within 20 to 30 such as acetaminophen. Some people who have minutes of taking a DOSE, an effect that lasts four to HIV/AIDS take milk thistle or silymarin extract to six hours. Some people experience a “hangover” protect their livers from the potentially damaging effect when they wake up, feeling groggy and dis- effects of some of the medications used to treat oriented for as long as several hours. People must HIV/AIDS. There also is limited evidence that milk not drive or operate machinery after taking a mela- thistle has a similarly protective function in the tonin dose, as the onset of sleepiness can be sudden kidneys though researchers continue to explore and irresistible. Some people also experience this possible effect. A folk medicine use for milk increased insomnia or have vivid dreams and thistle, likely the origin of the plant’s name, is to nightmares as well as fatigue after taking mela- stimulate BREAST milk production in nursing moth- tonin. Melatonin taken in combination with other ers. Of the few studies that have investigated this medications that cause drowsiness can result in an use, there have been no conclusive findings about intensified effect (excessive sleepiness). benefits or risks. Because the effects are unknown, 90 Alternative and Complementary Approaches health experts recommend BREASTFEEDING mothers vent or heal significant physical conditions such as do not use milk thistle or silymarin extract. CANCER or CARDIOVASCULAR DISEASE (CVD), an indi- Milk thistle is available in dried plant form in vidual’s mindset shapes the determination with teas, and also in preparations of silymarin extract which he or she approaches treatment and treat- in tablet form. People who are allergic to common ment’s ultimate success or failure. thistle, daisies, artichokes, or kiwi (all of which are in the same plant family as milk thistle) should MIND–BODY THERAPIES not take milk thistle or silymarin in any form. AROMATHERAPY ART THERAPY Milk thistle or silymarin extract may cause diges- BIOFEEDBACK CRANIOSACRAL MASSAGE tive upset including NAUSEA and DIARRHEA. Because HYPNOSIS MASSAGE THERAPY of its enzymatic inhibitory actions, milk thistle MEDITATION PRAYER AND SPIRITUALITY may interfere with INSULIN–GLUCOSE processes. Peo- REIKI TAI CHI ple who have DIABETES should consult with their VISUALIZATION YOGA doctors before using milk thistle or silymarin. At the most basic level, perceptions about MILK THISTLE (Silybum marianum) health, illness, and the success or failure of treat- Uses Risks/Side Effects Interactions ment influence a person’s compliance with the doctor’s recommendations from the taking of pre- CIRRHOSIS allergic reaction INSULIN therapy scription medications to lifestyle modifications chronic HEPATITIS digestive upset such as weight loss or SMOKING CESSATION. At a mushroom more sophisticated level, clinical studies demon- poisoning strate the ability of some people to consciously DRUG poisoning alter body functions such as HEART RATE and BLOOD See also HEPATOTOXINS. PRESSURE through methods such as BIOFEEDBACK and MEDITATION. Cancer treatment programs use mind–body interactions Approaches of care that healing visualization, in which the person in treat- engage the interrelationships between the mind ment meditates to visualize his or her cancer gone and the body for HEALING and health. Healers have and the body strong and healthy. Surgeons and known for centuries that the state of the mind anesthesiologists often recommend visualization influences the condition of the body. Contempo- before and after surgery, encouraging people to rary physicians will not hesitate to say that the “see” the surgery succeed and the body restore patient’s attitude and outlook are at least as itself to health. important as any technology modern medicine See also BEHAVIOR MODIFICATION THERAPY; LIFESTYLE has to offer. Though the mind alone cannot pre- AND HEALTH; ORNISH PROGRAM. N–O

Native American healing A spirituality-based to body (north), spirit (south), mind (east), and approach, also called traditional North American inner peace (west). medicine, that incorporates ceremony, ritual, and See also AYURVEDA; MIND–BODY INTERACTIONS; symbolism. In the Native American tradition, PRAYER AND SPIRITUALITY; TRADITIONAL CHINESE MEDI- intent is as important as action and there are no CINE (TCM). distinctions between body, mind, and spirit. The illness or health of one affects the well-being of naturopathy A system of medicine that uses the whole. As well, traditional Native American methods and substances found in nature to main- medicine holds that HEALING takes place within the tain and restore health. The philosophical founda- body’s sense of time and timing, and efforts to tion of naturopathy rejects interventions such as rush or otherwise influence this timing extend major surgery, RADIATION THERAPY, and drugs other rather than shorten the healing process. than elements, minerals, and other natural com- Traditional Native American healing practices pounds. Naturopathy incorporates or supports made use of the sweat lodge, a small enclosed therapeutic approaches such as ACUPUNCTURE, structure in which a fire burned hot. The heat energy medicine, NUTRITIONAL THERAPY using diag- would flush the cause of the ailment to the sur- nostic testing through functional medicine, face, where it would manifest in the form of a hydrotherapy, physiotherapy, MEDICINAL HERBS AND vision. People stayed in the sweat lodge until the BOTANICALS, HOMEOPATHY, and manipulative thera- heat initiated within them the vision necessary for pies (such as CHIROPRACTIC, MASSAGE THERAPY, and healing. The person might then go into the forest, OSTEOPATHIC MANIPULATIVE TREATMENT [OMT]). desert, or mountains to be with the vision and allow the natural environment to reveal its mean- Naturopathic Diagnosis and Treatment ings. The experience also restores the balance The naturopathic physician assesses symptoms between the individual and the natural environ- and examines patients in much the same fashion ment, an essential component of the healing as a conventional doctor, though spends consider- process from the traditional perspective. ably more time addressing lifestyle factors such as Some hospitals in areas where there are Native nutrition, activity, relationships, stress, and emo- American populations are beginning to incorpo- tional well-being. The naturopathic physician may rate Native American healers among the comple- function as a consultant for botanical or nutri- mentary providers available to patients, notably in tional therapies, or as a primary-care provider the American Southwest. Drumming, chanting, who works collaboratively with other health-care smudging, and dancing may be among the ele- professionals and refers people for specialty care as ments of healing rituals. One of the most common needed, as would a conventional doctor (MD or ceremonies is the medicine wheel, a form of ritual DO). The naturopathic approach considers the MEDITATION or prayer similar to a LABYRINTH. The person holistically and incorporates therapeutic circle of the wheel represents the continuous har- methods that both treat symptoms and restore mony of the universe, with the four spokes repre- overall health and well-being. Naturopathic physi- senting the four directions and their correlations cians spend much time educating people about 91 92 Alternative and Complementary Approaches how to better manage their health to prevent From a conventional medicine perspective, the illness. premise that nutrition and diet influence health and disease is not new or unique. Foods may con- Naturopathic Practitioners tribute to numerous health conditions. Some Naturopathy traces its origins to ancient HEALING foods energize and others relax the body. Foods methods based entirely on natural methods, the also can be harmful to people who have certain only approach available for centuries. Today in the medical conditions. For example, people who United States, naturopathic physicians complete have HEMOCHROMATOSIS, a metabolic disorder that comprehensive education and training programs allows iron to accumulate in various organs, and must pass licensing examinations in the states worsen the condition when they eat foods high in in which they practice. A naturopathic physician iron such as spinach. Food allergies, such as to receives a doctor of naturopathy degree and puts peanuts, can have lethal consequences. the initials “ND” or “NMD” after his or her name. Many naturopaths have additional training and HEALTH CONDITIONS FOODS INFLUENCE certification in ACUPUNCTURE and TRADITIONAL CHI- ANEMIA ATHEROSCLEROSIS NESE MEDICINE (TCM), broadening the scope of their ATTENTION DEFICIT HYPERACTIVITY AUTISM perspectives and abilities to accommodate diverse DISORDER (ADHD) CARDIOVASCULAR DISEASE interests in health care among the people who CELIAC DISEASE (sprue) (CVD) come to them for care. chronic OTITIS media ECZEMA GASTROESOPHAGEAL REFLUX GOUT Benefits and Risks of Naturopathy DISORDER (GERD) HEMOCHROMATOSIS Naturopathy as practiced in the United States INFLAMMATORY BOWEL DISEASE IRRITABLE BOWEL SYNDROME today functions synergistically with conventional (IBD)(IBS) therapies. The risks of naturopathic remedies vary migraine HEADACHE multiple metabolic according to the person’s primary and secondary OBESITY syndrome health conditions and with the therapeutic OSTEOARTHRITIS OSTEOPOROSIS approach. Within such a context, and because PREMENSTRUAL SYNDROME (PMS) PSORIASIS naturopathy does not use medications or major RECURRENT YEAST INFECTIONS RHINITIS surgery, naturopathy is overall less risky than con- type 2 DIABETES WILSON’S DISEASE ventional medicine. It is important for people to receive appropriate conventional medical treat- Many of the most significant health conditions ments for conditions that require it, such as type 1 facing Americans today in some way relate to EAT- DIABETES. Herbal remedies can interact with each ING HABITS. Many people eat too much in general, other as well as with conventional medications. A too much of foods that do not support health, or person who receives care from conventional as not enough foods that provide the body with the well as naturopathic doctors should be sure all nutritional foundation it needs to meet its energy practitioners know they are collectively participat- and maintenance requirements. The most com- ing in that care. pelling evidence of this is the OBESITY rate in the See also OSTEOPATHY; REFLEXOLOGY. United States; more than two thirds of Americans are overweight (5 to 20 percent above healthy nutritional therapy A therapeutic approach that weight) and nearly a third have obesity (20 per- uses nutraceuticals, foods, vitamins, minerals, and cent or higher above healthy weight). Of special special diets to fight disease and maintain health. concern is the significant rise in the number of Nutritional therapy as a complementary method is children who have obesity, particularly children not the same as the NUTRITIONAL ASSESSMENT a regis- under 10 years old. Some studies also link dietary tered dietitian (RD) might provide for compliance habits with health conditions such as COLORECTAL with conventional nutrition requirements. Nutri- CANCER. tional therapy instead blends holistic concepts Because many people do not eat nutritiously, with dietary modifications. dietary changes to improve nutrition nearly always osteopathy 93 result in health improvements. However, the scien- the structure of the body supports the body’s tific connections between nutrition and health or health. Often, a doctor of osteopathy (DO) has the disease are not entirely clear and sometimes appear training and expertise to perform OMT. even conflicting. As yet, there are very few circum- See also ALTERNATIVE METHODS FOR PAIN RELIEF; stances (other than those that are the direct result CHIROPRACTIC; JOINT; MASSAGE THERAPY; MUSCLE; of nutritional deficiencies) in which consuming or REFLEXOLOGY. not consuming certain foods can prevent health conditions. Foods, and the nutrients they contain, osteopathy A philosophy of health care that certainly can support wellness or contribute to dis- emphasizes preventive approaches and self-care to ease. But nutritional therapy that restricts or manage lifestyle choices in ways that encourage emphasizes certain nutrients may create nutritional wellness. Osteopathy strives to support the struc- deficiencies and imbalances. tures of the body to maintain health. In the See also ALTERNATIVE AND COMPLEMENTARY REME- United States, a doctor of osteopathy (DO) has the DIES FOR CANCER; DRUG INTERACTIONS; LIFESTYLE AND same practicing privileges and licensing require- HEALTH; MALNUTRITION; NUTRITIONAL NEEDS; NUTRI- ments as a medical doctor (MD) and is considered TIONAL SUPPLEMENTS. a conventional physician. The osteopathic medi- cine curriculum is comparable to the curriculum osteopathic manipulative treatment (OMT) A at a conventional medical school, typically a four- touch therapy that uses pressure, stretching, and year graduate program with a subsequent intern- manipulation of the muscles and joints to relieve ship and residency though with more opportunity musculoskeletal discomfort. The goal of OMT is to to learn manipulations such as OSTEOPATHIC MANIPU- release restrictions within musculoskeletal struc- LATIVE TREATMENT (OMT) and craniosacral massage. tures to restore FLEXIBILITY and mobility. OMT may Though many osteopathic physicians choose to improve chronic BACK PAIN, FIBROMYALGIA, CHRONIC practice in primary care, they may become spe- FATIGUE SYNDROME (CFS), and REPETITIVE MOTION cialists in any area of medicine. INJURIES such as CARPAL TUNNEL SYNDROME, and ROTA- See also AYURVEDA; HOMEOPATHY; NATUROPATHY; TOR CUFF IMPINGEMENT SYNDROME. OMT represents OSTEOPATHIC MANIPULATIVE TREATMENT; REFLEXOLOGY; one of the founding principles of OSTEOPATHY, that TRADITIONAL CHINESE MEDICINE (TCM). P–R

phytoestrogens Plant-based ESTROGENS, many of stances often combine the various phytoestrogens which are similar in chemical structure to the estro- into formulas for specific uses, such as MENOPAUSE gens the human body produces. In plants, phytoe- symptoms or DYSMENORRHEA (difficult menstrual strogens are part of the botanical IMMUNE SYSTEM, periods or menstrual cramps). helping protect the plant from fungal and bacterial The primary therapeutic uses for phytoestro- INFECTION. In humans, phytoestrogens exert a weak gens are to improve the discomforts of PREMEN- estrogenic effect relative to that of endogenous STRUAL SYNDROME (PMS) and menopause. Some (produced within the body) or supplemental estro- studies support the value of some phytoestrogens, gen. Though an abundance of research supports notably isoflavones, in preventing or limiting numerous health benefits from eating foods high in PROSTATE CANCER and BREAST CANCER though health phytoestrogens, questions remain about the effec- experts do not agree on the extent to which these tiveness of phytoestrogens in supplement forms as actions result from the isoflavones. Studies using well as the precise mechanisms and consequences isoflavone extracts in supplement form produce of them in the human body. less conclusive findings than those studies that use isoflavone-containing (SOY-based) foods. Isoflavones may also help reduce the risk for CAR- DIETARY SOURCES OF PHYTOESTROGENS DIOVASCULAR DISEASE (CVD) by lowering blood cho- Isoflavones Lignans Coumestans lesterol levels and for OSTEOPOROSIS by aiding the soybeans flaxseed red clover bones in retaining calcium. Some studies show soy SOY-based foods flaxseed oil pinto beans has limited ability to slow osteoclastic activity red clover lentils lima beans (bone destruction) and promote osteoblastic activ- textured vegetable protein carrots split peas ity (bone construction). soy protein isolate oat bran alfalfa sprouts Because their chemical structures are similar to soy milk oatmeal red clover sprouts those of endogenous estrogens, phytoestrogens licorice asparagus are able to bind with estrogen receptors (special- ized molecular “switches” in cells) in the body. There are two main classifications of phyto- However, the bond is an incomplete fit and more estrogens: isoflavonoids (isoflavones) and lignans. fragile than the bond of endogenous or supple- Soybeans are the primary source of isoflavones mental estrogen, and produces a weaker estrogen such as genistein and daidzien, and nuts and flax response. Health experts disagree on the role this are the primary sources of lignans. A third classifi- weaker bond and response may play in reducing cation of phytoestrogens, coumestans, appears to the risk for breast cancer in women. Some believe have an even stronger estrogen effect in the body phytoestrogens, because they occupy estrogen though research has not focused on them. Red receptors, prevent more potent endogenous estro- clover and alfalfa, especially sprouts, contain gen from binding and thus suppress estrogen coumestans. Most plants have combinations of availability. Less estrogen means less fuel for phytoestrogens with one that is dominant. Sup- potential CANCER cells, theoretically inhibiting their plements prepared from extracts of these sub- ability to manifest as breast cancer. 94 reflexology 95

Other health experts worry that by only par- immune systems of people who regularly partici- tially blocking estrogen effect in the body, phyto- pate in religious or spiritual activities (regardless of estrogens allow other chemical communications belief system) have higher levels of INTERLEUKINS to take place that could actually increase the risk and other immune factors. for estrogen-driven breast cancers in some women Two thirds of American medical schools now who have previously had estrogen-driven breast teach courses in prayer and spirituality, and all cancer. However, it remains unclear whether hospitals have chaplains on staff or clergy on call. endogenous estrogen binding creates a greater Most hospitals have chapels or meditation rooms risk. Some studies show a stronger preventive for where patients can go privately, as well as effect in premenopausal women and a less conclu- locations where family members and friends may sive preventive effect in postmenopausal women, gather to pray or meditate. Many people partici- which researchers correlate to the differences in pate in prayer circles, through churches or the kinds of breast cancers likely to affect each age through other common structures, in which they group. Research continues to explore these issues, pray specifically for others who are injured or ill. and doctors remain divided in their recommenda- A number of studies suggest that the beneficiaries tions. Many health experts recommend obtaining of these prayers, called intercessory prayers, tend phytoestrogens through natural food sources to improve more quickly. In degenerative condi- rather than supplements, to receive the additional tions such as ALZHEIMER’S DISEASE, the ritual of benefits of other nutrients in the foods. shared spiritual or religious practices often pro- vides comfort and a sense of stability. Spiritual practices also help provide a sense of meaning and PHYTOESTROGENS acceptance when health conditions are terminal. Uses Risks/Side Effects Interactions See also END OF LIFE CONCERNS; NATIVE AMERICAN relieve MENOPAUSE fertility disturbances none known HEALING; SPIRITUAL BELIEFS AND HEALTH CARE. discomforts possible increased relieve PREMENSTRUAL risk of breast qigong See TRADITIONAL CHINESE MEDICINE (TCM). SYNDROME cancer in certain lower blood women reflexology A therapeutic approach that uses cholesterol massage and pressure on the feet and hands. The enhance BONE philosophy of reflexology holds that the soles of calcium the feet (and to lesser extent, the palms of the possibly prevent hands) contain reflex points that correlate to body BREAST CANCER structures and functions. Activating these points possibly prevent affects the correlating structure or function, reliev- PROSTATE CANCER ing energy blockages that might be causing symp- toms or disease. People receiving reflexology See also BLACK COHOSH; DONG QUAI; SOY AND CAR- treatments often experience the pressure of the DIOVASCULAR HEALTH. reflexologist’s touch as well as tingling or other sensations in the area of the body that correlates prayer and spirituality Faith-based approaches with the reflex point. to HEALING. Numerous anecdotal reports as well as The sole of each foot contains more than 7,000 clinical studies support a connection between NERVE endings. Nerve pathways branch through healing and belief practices such as prayer and various regions of the body on their way to or spiritual MEDITATION. Researchers at Duke Univer- from the SPINAL CORD and BRAIN. One theory for sity’s Center for Spirituality, Theology, and Health how reflexology might work is that activating a have conducted a number of studies measuring nerve ending such as on the bottom of the foot different immune function indicators in people could result in a nerve response elsewhere along who regularly attend religious services and in peo- the path of the nerve structure. Other theories ple who do not. Over time, researchers found, the correlate reflexology to energy channels and net- 96 Alternative and Complementary Approaches works similar to those of ACUPUNCTURE (though touching. The primary concern of conventional acupuncture and reflexology are not related in doctors is that people continue to receive conven- philosophy or practice). However, there are no tional medical care when necessary. clinical studies to substantiate any of these theo- A number of hospitals make Reiki practitioners ries, or that reflexology produces objective results. available to people who are waiting for transplant Most conventional doctors are skeptical that organs or undergoing strenuous CANCER treatment. reflexology has therapeutic value beyond that Some conventional health-care practitioners, such which one might expect from a thorough foot as nurses, become Reiki practitioners. Some massage. researchers believe the deep relaxation that people See also MASSAGE THERAPY; REIKI. experience with Reiki sessions causes the body to release natural PAIN-relieving chemicals (endor- Reiki A 3,000 year-old system of energy HEALING phins and enkephalins), accounting for effects that originated with Tibetan monks. The word such as pain relief and stress reduction. Reiki may Reiki means “universal life force.” Reiki practition- be especially helpful for people who have condi- ers use their hands, without touching the person, tions, such as BURNS or major trauma, that make to focus energy. The energy might come from the touch therapies difficult or unfeasible. person’s body, identifying the location of illness or Reiki practitioners designate their levels of injury. Sometimes the Reiki practitioner experi- expertise according to degrees. A first-degree Reiki ences these locations as feeling hot or cold. The practitioner has received basic Reiki training, typi- energy also comes through the Reiki practitioner cally a two-day session. A second-degree Reiki to the person, focusing healing where the body practitioner has been practicing Reiki for a mini- needs it. Many people feel profound relaxation mum of three months and has completed an addi- and release during a Reiki session and often relief tional Reiki training session, typically a two-day from PAIN. It is common for both the person workshop, to learn more advanced techniques receiving Reiki and the Reiki practitioner to including mental healing and distance healing. A emerge from a Reiki session feeling a heightened third-degree Reiki practitioner is a Reiki master. A sense of awareness. Reiki master has practiced Reiki for at least a year Because there is no clinical substantiation for the and then has completed a year-long training pro- effects of Reiki, many doctors tend to be skeptical. gram. Reiki masters also teach Reiki. As with However, there are no known risks associated with other forms of bodywork and energy healing, it is Reiki when it is a complementary component of essential to trust in, and feel comfortable with, the overall care and treatment. Unlike MASSAGE THER- Reiki practitioner. APY, with Reiki there is no, or only very light, See also ACUPUNCTURE; REFLEXOLOGY. S

SAMe A chemical that occurs naturally in the antidepressants target. While doctors monitor peo- BRAIN. SAMe, which is short for S-adenosylme- ple taking tricyclics for evidence of serotonin syn- thionine, participates in the brain’s synthesis of drome, a person who is self-medicating with DOPAMINE and serotonin, neurotransmitters that SAMe may not recognize the symptoms of sero- have key functions in brain communication tonin toxicity (HEADACHE, dizziness, vomiting, dis- regarding emotions and mood. SAMe is available orientation and confusion, unconsciousness) as in the United States as a dietary supplement and related to SAMe. Also because of SAMe’s as a prescription medication in most European monoamine oxidase inhibition ability, people who countries. People commonly take SAMe to relieve are taking monoamine oxidase inhibitor (MAOI) symptoms of DEPRESSION, OSTEOARTHRITIS, chronic antidepressants should not take SAMe. BACK PAIN, and CHRONIC FATIGUE SYNDROME (CFS). Clinical studies support SAMe’s effectiveness in Serotonin syndrome is a serious and treating depression and osteoarthritis, though are potentially fatal SIDE EFFECT of ANTIDE- not entirely conclusive. So far research findings PRESSANT MEDICATIONS. It requires imme- have failed to support a conclusive benefit from diate medical attention. SAMe for chronic back pain and CFS. Osteoarthritis Depression A number of clinical research studies show that In a number of clinical studies SAMe appears as osteoarthritis improves after taking SAMe for four effective as prescription tricyclic ANTIDEPRESSANT to six weeks. However, researchers have yet to MEDICATIONS for treating mild to moderate depres- identify the actions of SAMe responsible for this sion and without the side effects, such as drowsi- improvement. The METABOLISM of endogenous ness and dry mouth, common to them. However, (naturally occurring) SAMe produces various depression can be a serious medical condition. chemical substances (notably amino acids) that Doctors worry that people who use over-the- the body can use to repair JOINT tissues and pro- counter remedies to self-treat depression may put duce the synovial fluid that lubricates joints. Some themselves at risk. Conventional medical researchers believe SAMe as a supplement pro- approaches to treating depression may incorporate vides more of these amino acids. Because of the antidepressant medications with PSYCHOTHERAPY to length of time it takes to see improvement, how- resolve the underlying causes of the depression. ever, other researchers question whether it is As well, any substance that alters the produc- the SAMe supplement or the natural processes of tion and ratio of brain neurotransmitters has the the body that result in reduced PAIN and INFLAMMA- potential to create imbalances in those vital brain TION. chemicals that cause further problems. One such consequence is serotonin syndrome, a serious and Chronic Back Pain and CFS potentially fatal accumulation of serotonin in the Chronic back pain and CFS can be debilitating brain. SAMe appears to suppress monoamine oxi- conditions that defy attempts to improve symp- dase, the same NEUROTRANSMITTER that tricyclic toms. The mechanisms of both are poorly under- 97 98 Alternative and Complementary Approaches stood, though theories abound. Most doctors feel Men who take saw palmetto for BPH should that low doses of SAMe do no harm and thus are have an annual prostate examination to check for worth trying if they might bring improvement. early signs of prostate cancer. Saw palmetto is The precautions that apply to other uses of SAMe available in numerous formulations as dietary remain pertinent. People taking SAMe for chronic supplements, many of which include other ingre- back pain or CFS should do so only with the dients. Health experts recommend choosing prod- knowledge of their doctors, to avoid any possible ucts that contain 90 to 95 percent saw palmetto interactions with prescription medications and to sterol oils or fatty acids. Combination products monitor for adverse effects or further deterioration may not contain enough saw palmetto to be effec- of the underlying condition. tive. Saw palmetto can cause gastrointestinal dis- tress; doctors recommend taking it with meals. SAMe Men who have prostate cancer should take saw Uses Risks/Side Effects Interactions palmetto only if their doctors approve; saw pal- metto may interfere with some hormone-based DEPRESSION serotonin syndrome MAOI antidepressants prostate cancer treatments. OSTEOARTHRITIS gastrointestinal upset chronic BACK insomnia PAIN SAW PALMETTO (Sabal serrulata) CHRONIC FATIGUE Uses Risks/Side Effects Interactions SYNDROME stop PROSTATE stomach upset some PROSTATE See also CHONDROITIN; GLUCOSAMINE; ST. JOHN’S gland enlargement CANCER WORT. relieve BPH treatments symptoms A botanical preparation made saw palmetto See also AGING, URINARY SYSTEM CHANGES THAT from the berries of the saw palmetto tree (Sabal OCCUR WITH; LYCOPENE; PROSTATE HEALTH; PROSTATITIS. serrulata) native to the American coastal south- west. Saw palmetto prevents the PROSTATE GLAND soy Researchers have noticed since the 1970s from enlarging, though it does not appear to that people whose diets include soybeans and soy- reduce enlargement that has already occurred. based foods such as tofu have lower blood choles- Though many people believe saw palmetto can terol levels and lower rates of CARDIOVASCULAR prevent PROSTATE CANCER, so far there is no conclu- DISEASE (CVD). Numerous research studies have iso- sive evidence to support this effect. lated various soy proteins such as genistein and Researchers do not know for certain what daidzein that have demonstrated their ability to ingredients in saw palmetto have an active effect, decrease low-density lipoprotein (LDL) choles- though believe its fatty acids contain substances terol. The US Food and Drug Administration that mildly suppress TESTOSTERONE and its precur- (FDA), which regulates the health claims manu- sors (chemicals the body converts to testosterone). facturers may make about their products, allows This action reduces testosterone levels enough to manufacturers to tout this effect on products that inhibit the growth of prostate cells but not so contain 25 grams or more of soy protein. much as to cause other symptoms related to low testosterone such as diminished LIBIDO or ERECTILE FOOD SOURCES OF SOY DYSFUNCTION. Such symptoms are common with conventional medications such as finasteride immature soybeans (edemame) mature soybeans (Proscar) to treat BENIGN PROSTATIC HYPERPLASIA roasted soy nuts textured vegetable (BPH), a condition affecting about half of men over tofu protein (TVP) age 60. Many doctors recommend a trial of saw miso dried soybeans palmetto before moving to finasteride, as saw pal- tempeh soymilk metto is significantly less expensive as well as less soy protein isolate soy flakes likely to cause undesired side effects. soy cheese Sun’s Soup 99

The primary active ingredients in soybeans are these substances do not produce the same results PHYTOESTROGENS, chemicals that function in the as the intact herb. These are the substances most human body like weak ESTROGENS. Researchers commonly available in extract products. have connected estrogen with numerous health Most health experts agree that while St. John’s conditions including BREAST CANCER, PROSTATE CAN- wort may help mild to moderate depression as CER, cardiovascular disease, and OSTEOPOROSIS. well as mild to moderate anxiety, it is not effective Though soy and phytoestrogens appear to in major depression or in BIPOLAR DISORDER, a com- improve these conditions, researchers remain bination of depressive and manic symptoms. St. uncertain as to the mechanisms of phytoestrogens John’s wort interacts with a number of medica- in the human body and the potential risks that tions, including some HIV/AIDS medications, certain they present. Estrogen can both prevent and cause CHEMOTHERAPY agents, and IMMUNOSUPPRESSIVE MED- BREAST cancer, for example. Much research contin- ICATIONS such as cyclosporine taken following ues to explore these issues. In the meantime, ORGAN TRANSPLANTATION. Because St. John’s wort health experts recommend most people substitute extends the presence and action of serotonin, peo- soy products for meats to reduce dietary saturated ple who take SSRI or monoamine oxidase fats as a measure for reducing the risk of heart dis- inhibitor (MAOI) antidepressants should not take ease. Soybeans are the only plant-based source of St. John’s wort. A serious and sometimes fatal complete protein, providing all of the essential complication, serotonin syndrome, may result. proteins the body requires. Serotonin syndrome is a serious and SOY potentially fatal SIDE EFFECT of ANTIDE- Uses Risks/Side Effects Interactions PRESSANT MEDICATIONS. It requires imme- diate medical attention. lower LDL cholesterol may increase risk for none known reduce risk for HEART estrogen-driven breast Because depression can be a serious medical disease cancers condition, most doctors prefer that people receive reduce risk for gastrointestinal upset conventional medical treatment. That treatment OSTEOPOROSIS may include St. John’s wort, after a thorough relieve menopausal evaluation of the person’s physical and mental discomforts health status. But health experts caution that self- reduce risk for PROSTATE diagnosis and self-treatment can be risky. CANCER reduce risk for some ST. JOHN’S WORT (Hypericum perforatum) BREAST CANCERS Uses Risks/Side Effects Interactions See also GREEN TEA; HORMONE-DRIVEN CANCERS; mild to moderate serotonin syndrome CHEMOTHERAPY HORMONE THERAPY; SOY AND CARDIOVASCULAR HEALTH. DEPRESSION sun sensitivity agents HIV/AIDS An herb, Hypericum perforatum, St. John’s wort medications that healers have used for centuries to treat immunosuppressive DEPRESSION. The actions of St. John’s wort appear drugs similar to those of the serotonin reuptake inhibitor SSRIs and MAOIs (SSRI) antidepressants. St. John’s wort is available in teas, extracts, and capsules as a dietary supple- See also SAME; VALERIAN. ment in the United States, and as a medication that requires a doctor’s prescription in most of Sun’s Soup A formula of herbs and vegetables, Europe. In Europe, St. John’s wort is the most formally called Sun Farms Vegetable Soup (SFVS) widely prescribed of the ANTIDEPRESSANT MEDICA- and sometimes referred to as Selected Vegetables, TIONS. Researchers believe the active ingredients developed to treat non-small cell LUNG CANCER are hypericin and hyperforin, though in isolation (NSCLC) and HIV/AIDS. The formula’s developer, 100 Alternative and Complementary Approaches

Alexander Sun, a biochemist and former ited the value of the findings. Researchers are con- researcher at Yale and Mount Sinai schools of tinuing to evaluate Sun’s Soup in its various for- medicine, selected ingredients that appear to have mulations. cancer-fighting properties. There appear to be few side effects with Sun’s Though the actual formula is proprietary, pub- Soup, with the primary complaints being dissatis- lished reports identify the original ingredients as faction with the taste and gastrointestinal upset. shiitake mushrooms, mung beans, hawthorn fruit, As with other complementary therapies, it is onion, GINGER, American GINSENG, lentils, leeks, important to continue appropriate conventional and the Chinese herbs bai hua she she cao and treatments. The conditions Sun’s Soup targets, ban zhi lian. Sun’s Soup comes in freeze-dried NSCLC and AIDS, are very serious diseases. packages that the person mixes with hot water or Though there are few cures with NSCLC and there hot soup once daily. In several small clinical stud- is no known cure for AIDS, there are treatments ies with people who had moderate to advanced that prolong life and improve QUALITY OF LIFE. NSCLC, Sun’s Soup produced measurable See also NUTRITIONAL THERAPY; TRADITIONAL CHI- improvements. However, the small study size lim- NESE MEDICINE (TCM). T tai chi A gentle form of martial art that features as much mobility as possible for as long as pos- slow, fluid movements (called forms) combined sible with MEDITATION. Tai chi forms represent imagery • have ALZHEIMER’S DISEASE, to encourage social found in nature. Tai chi improves balance, engagement and for the sense of comfort that STRENGTH, FLEXIBILITY, and breath control. Most the routine of tai chi imparts people participate in tai chi in groups with a • have CARDIOVASCULAR DISEASE (CVD) such as leader (master) who guides the session’s move- HYPERTENSION (high BLOOD PRESSURE), ATHEROSCLE- ments and length, though some choose to do tai ROSIS, mild to moderate HEART FAILURE, or PERIPH- chi as a solitary practice. Many community cen- ERAL VASCULAR DISEASE (PVD), to improve blood ters, health clubs, programs for seniors, and some- flow and strengthen the HEART times colleges offer tai chi classes. A typical tai chi session may take 10 minutes to • have OBESITY or are overweight and need a mild an hour, depending on the form. Most people method to ease back into physical activity begin a tai chi session with a few minutes of medi- • have CEREBRAL PALSY or other congenital disor- tation and BREATHING EXERCISES to help cleanse the ders that affect coordination and movement body and focus the thoughts. Sometimes the focus on performing the motions of the form is its own Because tai chi’s movements are slow and gen- meditation, and sometimes the person has a spe- tle, there are few risks for most people. A tai chi cific meditative focus that he or she holds for the master can help individuals modify tai chi forms duration of the session. Though tai chi is not typi- to accommodate specific limitations and needs. cally aerobic because its movements are so slow, it People who have significantly impaired balance does stretch and exercise the entire body. Often tai should do tai chi only in a group or with a partner, chi groups meet outdoors, and some people like to in case they do stumble or fall. Medications that do tai chi barefoot to symbolically and tangibly cause drowsiness may decrease stability and bal- connect themselves with the Earth and nature. ance. Most people feel relaxed yet invigorated fol- Anyone of any age can benefit from tai chi as a lowing a tai chi session. meditation practice and for improved balance and See also HIP FRACTURE IN OLDER ADULTS; TRADI- coordination. Doctors often recommend tai chi for TIONAL CHINESE MEDICINE (TCM); YOGA. people who therapeutic massage See MASSAGE THERAPY. • are older and have increased risk for age- related falls, to help prevent injuries such as traditional Chinese medicine (TCM) A philoso- fractured hip phy of holistic HEALING that dates to about 100 • have chronic health conditions such as B.C.E., anchored in the premise that the energy OSTEOARTHRITIS or RHEUMATOID ARTHRITIS that that sustains the universe also sustains the body. threaten to restrict mobility Energy in balance is health; energy in imbalance is • have degenerative conditions such as PARKIN- illness. Disease reflects blockages of energy that SON’S DISEASE or MULTIPLE SCLEROSIS, to maintain TCM therapies attempt to clear. The primary 101 102 Alternative and Complementary Approaches energy balances are yin and yang, reflecting dual channels called meridians. In the United States, qualities of hot and cold, dark and light, male and TCM physicians and other acupuncturists use ster- female, and so on. TCM also draws from the five ile, single-use needles. The needles, according to elements of nature—fire, earth, water, metal, and TCM, redirect the flow of energy. Contemporary wood—and symbolic representations of organ sys- Western medicine, which also incorporates tems. TCM’s primary therapeutic approaches are acupuncture for treating chronic PAIN, ADDICTION, herbal remedies and ACUPUNCTURE. and other conditions, views the placement of nee- TCM physicians, also called doctors of Oriental dles as stimulating electrochemical responses in the medicine (OMDs), complete experience-based NERVE endings. The process is painless, though some programs of study in which they serve in an people feel a tingling sensation. apprentice fashion with a practicing TCM physi- The TCM physician may place the needles in cian. Many of the written guidelines TCM physi- locations considerably distanced from the affected cians follow today derive from texts nearly as old organs. For example, numerous acupuncture as the practice of TCM itself, updated to accommo- points on the outer EAR correlate to structures date modern knowledge and methods. Some throughout the body. The outer ear is also the pri- states in the United States require specific licens- mary location for acupuncture points related to ing for TCM physicians and others for acupunctur- addiction. The needles typically stay in place for ists. A few states limit the practice of acupuncture 20 to 30 minutes. Simple or acute conditions may to conventional health-care practitioners. require one to three treatment sessions; chronic or complex conditions may require a number of ses- The TCM Physician’s Examination sions over a period of weeks. Seldom does a con- The TCM physician’s examination differs from a dition require more than 12 treatments in total. conventional physician’s examination in that there is considerable focus on factors such as pos- Chinese Herbal Remedies ture, SKIN texture and tone, and how a person Chinese herbal remedies derive from ancient handles or carries his or her body. These factors recipes handed down through generations and often reveal to the TCM physician where and how generations of practitioners. They are precise the body’s energy channels are blocked. The TCM measures of specific herbs, in specific preparations physician also closely examines the tongue, from and intended for use exactly as the TCM physician which TCM derives information about the state of prescribes, and there are thousands of different the body’s energy balances and blockages. The formulas as well as custom preparations that blend TCM physician also checks the PULSE at numerous specific herbs into a combination to meet an indi- points, some of which are not conventional pulse vidual’s health needs. The remedies typically have points. The TCM physician also asks many ques- Chinese names that reflect either the herbs they tions about the symptoms, how the person feels contain or the effects they are intended to (physically and emotionally), the person’s life achieve. Major remedies have four groups of herbs experiences and circumstances, and in general lis- to treat four levels of the condition. The order in tens closely to what the person describes and which the herbalist mixes the herbs together has explains. TCM diagnoses blend symptoms, energy symbolic significance that is as important as the balance and imbalance, and the elements with herbs themselves. Major remedies have an perceptions of the affected organ systems and emperor, minister, assistant, and envoy. their functions. Treatments then undertake to Most Chinese herbal remedies, when experi- release energy blockages to restore the flow of enced and knowledgeable herbalists prepare them, energy to organ systems and throughout the body. are safe to take as the physician prescribes. Many herbal combinations contain potent ingredients Acupuncture and can evoke strong responses. It is important to Acupuncture is a key therapeutic form in TCM. In know the source of the herbs as some herbs that traditional acupuncture, the TCM physician inserts come from directly from China may contain heavy hair-thin needles into specific points along energy metal contamination. Some herbs interact with traditional Chinese medicine (TCM) 103 medications, so the person always should tell the practice qigong privately as they would TCM physician of any medications he or she is MEDITATION. The movements are more simple than taking. Similarly, a person taking conventional those of tai chi or yoga, and easier to learn from medications should first discuss Chinese herbal videotapes or books. Conventional doctors may remedies with his or her doctor before taking the recommend qigong separate from TCM as a means remedies. of improving balance, FLEXIBILITY, and mobility in people who are elderly or who have chronic Moxibustion health conditions that make movement difficult. Moxibustion is a technique for heating an herbal Many communities have classes in qigong, and remedy, which the TCM physician often rolls into some hospitals use it as part of their rehabilitation a wicklike structure and holds just above the skin programs or for stress relief. Qigong is gentle and while the herbs burn. The heat further stimulates rhythmic, providing a sense of calm and relax- the acupuncture point below the herb, drawing ation at the same time that it tones and stretches the herb’s healing qualities into the body’s meridi- the muscles and joints. Qigong is especially helpful ans (energy channels) to release stubborn energy for people who have conditions that restrict blockages. The TCM physician may combine mox- mobility, because its regular practice improves ibustion with cupping, in which the physician flexibility and range of motion. places a small glass cup over the skin while it is still warm. The cup contains the heat, which sucks Benefits and Risks of TCM the skin surface into the cup. This also intensifies When practiced as a complementary approach, the herb’s actions. TCM offers considerable benefits without many risks. As with all alternative and complementary Qigong methods, conventional doctors become concerned Qigong is a form of energy work that employs when people forgo proven conventional treat- structured breathing, meditation, and physical ments in lieu of alternative practices. TCM meth- movements, similar to TAI CHI or YOGA. Qigong is ods are not proven to cure HEART disease, CANCER, an integral aspect of nearly all TCM treatment DIABETES, and other such conditions. Most TCM approaches because it emphasizes balancing the physicians in the United States are accustomed to flow of energy. The movements and BREATHING working in close coordination with conventional stimulate the flow of blood as well as the LYMPH practitioners, and refer people for conventional circulation, helping clear toxins and metabolic care for conditions that require it. wastes more quickly from the body. Many people See also AYURVEDA; NATIVE AMERICAN HEALING. V valerian A medicinal herb (Valeriana officinalis) sumption also intensifies the drowsiness effect. that causes drowsiness and relaxation, commonly There are no known health risks associated with taken as a sleep aid. Until the twentieth century valerian, though women who are pregnant or physicians also used valerian for seizures, to relieve BREASTFEEDING should not take it because doctors anxiety, for mild sedation, and as a diuretic. The and researchers do not know what effects, if any, valerian root, or rhizome, contains the highest con- it might have on the developing fetus or newborn centration of active ingredients and is the source of infant. medicinal preparations. Though valerian has an See also GENERAL ANXIETY DISORDER (GAD); MELA- unpleasant taste and smell, herbalists recommend TONIN; SLEEP DISORDERS. the tea, brewed from freshly harvested or freeze- dried rhizomes, for optimal benefit. Other forms, visualization A form of MEDITATION in which the including capsules and tablets containing ground person envisions his or her desired state of health valerian root, are also available as dietary supple- or a treatment outcome such as surgery. Hospital ments in the United States. surgery programs, CANCER recovery programs, and hospice programs began to integrate visualization methods in the 1990s. Many people find it calm- VALERIAN (Valeriana officinalis) ing and comforting to visualize themselves as Uses Risks/Side Effects Interactions healthy and whole, and many practitioners insomnia excessive drowsiness other sleep aids or believe such visualization improves recovery rates relieve medications and levels. Some people prefer guided imagery, in anxiety narcotic ANALGESIC which a practitioner offers suggested visualizations MEDICATIONS and guides the person through the visualization ANTIANXIETY MEDICATIONS process. Other people prefer to establish their own ANTIDEPRESSANT visualizations, and may integrate them with MEDICATIONS PRAYER AND SPIRITUALITY practices. ANTIHISTAMINE MEDICATIONS See also BIOFEEDBACK; LABYRINTH; MIND–BODY MUSCLE RELAXANT INTERACTIONS; NATIVE AMERICAN HEALING. MEDICATIONS vitamin and mineral therapy Doses of vitamins Efforts to isolate valerian’s active ingredients and minerals that are higher than those typically have so far eluded researchers, though a number recommended for health maintenance. Vitamin of clinical studies affirm its effectiveness as a mild and mineral therapy derives from the perspective sedative and sleep aid. Health experts recommend that depletions of vital nutrients are the primary using valerian, like any other sleep aid, for no cause of disease and that preventing these deple- longer than two weeks. A doctor should evaluate tions can prevent the health concerns. Vitamin sleep disturbances that continue longer. People and mineral therapy in this context differs from who are taking other medications that cause routine vitamin supplementation and treatments drowsiness should not take valerian. ALCOHOL con- that target specific nutritional deficiencies. 104 vitamin and mineral therapy 105

Vitamins and minerals are important nutrients The body requires fairly small amounts of the body needs to carry out its many functions. All many minerals and vitamins to meet its functional such nutrients the body needs exist in nature and needs, and excretes or stores any excess. Accumu- typically enter the body through foods and drinks. lations of certain vitamins, such as the fat-soluble Even drinking water contains numerous minerals. vitamins A and E, may become toxic and cause Most people in the United States obtain adequate health problems. Excessive mineral consumption amounts of vitamins and minerals through appro- (sodium, potassium, calcium, magnesium) can priate dietary choices, despite concerns that the affect the body’s electrolyte balance, consequen- American diet on the whole is less than ideal to tially altering KIDNEY function, cardiovascular func- support health. People who live in areas where cer- tion, and NERVOUS SYSTEM function with potentially tain essential nutrients are lacking, such as sele- harmful or life-threatening outcomes. The body nium, which occurs in specific kinds of soil and the excretes excess water-soluble vitamins (the B vita- foods grown in them, may need to take supple- mins and vitamin C), so ingesting more than the ments to acquire adequate amounts of those nutri- body needs has no value. Researchers have estab- ents. Women who menstruate monthly may need lished nutritional value ranges for most identified supplemental iron to replace that lost to menstrual nutrients. bleeding, and health recommendations call for sup- Nonetheless, many complementary approaches plementation of calcium and other key minerals at incorporate moderate to high doses of certain vita- age 50 and older to maintain BONE density. mins and minerals, depending on the person’s Conventional health experts are divided about symptoms. Health experts urge caution, and sug- whether healthy adults need or benefit from addi- gest a comprehensive NUTRITIONAL ASSESSMENT tional vitamins and nutrients. Some believe the before beginning any intensive vitamin and min- ANTIOXIDANT actions of vitamins helps to prevent eral therapy. Pregnant or BREASTFEEDING women chronic diseases that result from cumulative dam- and people receiving treatment for chronic or age to cells from free radicals, molecular particles degenerative health conditions who take regular that are the waste products of OXYGENATION func- medications should consult with their doctors, as tions (the ways in which cells metabolize nutri- some medications and vitamins interact to alter ents to produce energy). Clinical research studies the action of one or the other or both. Practition- have produced conflicting results about antioxi- ers such as naturopathic physicians and chiroprac- dants, however, and there remains little scientific tors often incorporate vitamin and mineral evidence that they prevent disease or the degener- therapy in their practices. ation associated with aging. See also DRUG INTERACTIONS; NUTRITIONAL THERAPY. Y–Z yoga A 5,000-year old practice originating in practices, events, and competitions. Pregnant China that blends exercise and MEDITATION. Yoga women, particularly those in the third trimester of incorporates specific configurations of the body pregnancy, often find yoga an effective way to called poses. Many poses are gentle and easy for stay fit and relieve stress. A yoga instructor can most people to perform regardless of fitness level help an individual select poses specifically for his or expertise with yoga, and some poses are com- or her condition as well as modify poses to accom- plex and difficult for the novice or the uncondi- modate any limitations. tioned to perform. Some poses are static (the Health clubs, community centers, and private person moves into and holds the pose) and some yoga instructors offer classes and sessions in yoga are dynamic (moving). There are several kinds of in many communities throughout the United yoga. The yoga most Americans practice is Hatha States. Numerous books and videotapes also can yoga and its derivations. Astanga yoga, also called teach yoga poses, though most people benefit power yoga, is highly aerobic and requires a good from having a qualified yoga instructor observe FITNESS LEVEL. Some people chant during yoga, their poses and help them get them right. Even while others meditate quietly. the basic poses are precise in how they position The essence of yoga is breath control, which and hold the body, and doing them incorrectly ancient practitioners believed was the connection lessens the benefit and may cause discomfort or among body, mind, and spirit. Every yoga pose injury. There are no health risks associated with incorporates patterned, structured BREATHING. properly performed yoga poses. There are dozens of such breathing patterns, See also TAI CHI. which a person also can perform independent of the yoga postures that employ them. Pulmonary yohimbe/yohimbine An herbal preparation care specialists often recommend yogic breathing from the bark of the African yohimbe tree for people who have chronic LUNG diseases or (Pausinystalia yohimbe) taken to improve erectile who are recovering from extensive injuries or sur- function in men or as a treatment for ERECTILE DYS- gery. Yogic breathing emphasizes opening the full FUNCTION. Yohimbe may also produce a mild sense body to the breath, and uses methods that help of euphoria, resulting in its reputation as an the body to extract more oxygen from each aphrodisiac. In the United States yohimbe is mar- breath. keted as a dietary supplement and available with- People who have musculoskeletal conditions out a doctor’s prescription. The active ingredient such as chronic BACK PAIN or REPETITIVE MOTION in yohimbe is yohimbine. Yohimbine is available INJURIES often experience pronounced benefits as a concentrated extract, which is much more from yoga. Yoga can help such conditions heal by potent than herbal yohimbe, and requires a doc- increasing blood flow to the area and by gently tor’s prescription. stretching, toning, and strengthening the involved People sometimes call yohimbe “herbal Viagra,” musculoskeletal structures. Athletes may use spe- a reference to the prescription medication (silde- cific yoga poses to stretch and warm up before nafil) for erectile dysfunction. Yohimbine,

106 zeaxanthin 107 yohimbe’s active ingredient, works in somewhat YOHIMBE (PAUSINYSTALIA YOHIMBE) similar fashion to sildenafil in that causes an Uses Risks/Side Effects Interactions increase in the body’s production of NOREPHINE- aphrodisiac elevated BLOOD PRESSURE MAOI medications PHRINE which in turn increases the flow of blood to ERECTILE tyramine in foods PENIS the . Norepinephrine has numerous other DYSFUNCTION effects on cardiovascular function, including BLOOD PRESSURE and HEART RATE, so the US Food and Drug See also AROMATHERAPY; GINKGO BILOBA; LIBIDO; Administration (FDA) restricts the amount of it SAW PALMETTO. that is permissible in over-the-counter products. Most health experts feel the amount of yohim- bine, and thus the amount of norepinephrine, in zeaxanthin An ANTIOXIDANT that is one of the over-the-counter yohimbe herbal remedies is too carotenoids. Zeaxanthin helps protect the health low to have a physiologic effect. They recommend of the RETINA and to prevent AGE-RELATED MACULAR that men instead see their doctors when erectile DEGENERATION (ARMD). Ophthalmologists often rec- dysfunction is a concern, to identify any physical ommend zeanthin in combination with another problems that might be responsible as well as to carotenoid, LUTEIN, for people who are middle- discuss options for treatment. The doctor can write aged and older. These antioxidants are present in a prescription for the more potent yohimbine the cells of the retina, where they absorb blue extract if that is an appropriate therapeutic light that can damage the retina. As an antioxi- approach. Common causes of erectile dysfunction dant, zeaxanthin helps the retinal cells rid them- include ATHEROSCLEROSIS and PERIPHERAL VASCULAR selves of metabolic waste. Some studies suggest DISEASE (PVD) resulting from CARDIOVASCULAR DIS- zeaxanthin and lutein may also help prevent EASE (CVD) or DIABETES. Treating these underlying cataracts from forming in the EYE’s LENS. conditions often improves erectile function at the same time that it improves overall health. Men ZEAXANTHIN who have these conditions, or who take antihy- Uses Risks/Side Effects Interactions pertensive medications to treat HYPERTENSION (high blood pressure) generally should not take prevent CATARACT excessive amounts none known yohimbe and yohimbine products. preserve macular may turn the palms Yohimbe and yohimbine also block the actions function and soles of the feet possibly protect orange or dark yellow of the NEUROTRANSMITTER monoamine oxidase, which may account for the mild euphoria some against LUNG people experience when taking yohimbe-derived CANCER possibly protect products. Monoamine oxidase affects BRAIN activ- ity related to mood and emotion. Men who are against OVARIAN taking monoamine oxidase inhibitor (MAOI) CANCER medications, either as ANTIDEPRESSANT MEDICATIONS or as treatment for PARKINSON’S DISEASE, should not Foods that contain zeaxanthin include dark use yohimbe products. Men who do use yohimbe leafy vegetables such as spinach, collard greens, products should avoid foods containing the amino broccoli, and kale. Yellow fruits and vegetables acid tyramine, which requires monoamine oxidase such as peaches, mangoes, squash, and corn also for METABOLISM. Excess tyramine can produce contain zeaxanthin. Many of the foods that are numerous unpleasant symptoms, including severe rich in zeaxanthin also contain lutein and other HEADACHE and possible extreme spikes in blood carotenoids. As an antioxidant, zeaxanthin may pressure that could result in STROKE. Foods also protect against certain cancers, notably LUNG that contain tyramine include red wines, CANCER and OVARIAN CANCER. In supplement form, smoked meats and fish, aged cheeses, and dark zeaxanthin typically appears in products that are chocolate. blended carotenoids. Carotenoids appear to have 108 Alternative and Complementary Approaches greater effect in combination rather than in isola- amounts of carotenoids present in the body to tion, which is how they occur in nature, despite decrease. Taking zeaxanthin with foods that con- their individual actions and benefits. tain some fat increases the amount of zeaxanthin People who take excessive amounts of that enters the bloodstream from the digestive carotenoid supplements may find the palms of their tract. Taking penicillin-based ANTIBIOTIC MEDICATIONS hands and soles of their feet take on a yellowish may decrease zeaxanthin absorption. orange discoloration. This is a temporary effect that See also BILBERRY; LYCOPENE; PHYTOESTROGENS; wears off when stopping the supplement allows the RETINOPATHY. GENETICS AND MOLECULAR MEDICINE Genetics and molecular medicine are the disciplines in health care that focus on genetic encoding and molecular func- tion within the cell as the foundations for health and disease. Many medical researchers believe nearly every compo- nent of health—and correspondingly, every presentation of disease—has some degree of genetic involvement and an individual acquires whatever propensity toward health that his or her genes convey. The manifestations of health and disease in many situations then become a combination of genetics and environment (lifestyle factors). The specialists who diagnose and treat GENETIC DISORDERS are geneticists.

This section, “Genetics and Molecular Medicine,” CHROMOSOME has a single and specific task. It presents an overview discussion of the structures accomplishes this task by instructing the cell to and functions of human genetics and entries make a particular protein, a process called protein about genetic health and disorders. The entries in encoding. Through protein encoding genes direct this section focus on genetic consequences for every action of every cell. health across the spectrum of the body as a The genome: the book of life The complete com- whole, including disorders and diseases that affect plement of chromosomes is the human GENOME, multiple systems. Entries in other sections of The quite literally the book of life. The genome contains Facts On File Encyclopedia of Health and Medicine pro- all of the instructions the body requires to take vide detailed content about conditions that result shape and to function. Within a single individual, from genetic disorders that affect single body sys- every one of the body’s 100 trillion cells contains tems. Cross-references connect entries with one the same set of chromosomes, so all cells in the another. body read from the same book of life. DNA (deoxyribonucleic acid) is the ink of the Structures of Genetics genome, the biochemical substance that allows GENE/ALLELE cell the GENETIC CODE to express itself. DNA organizes CHROMOSOME nucleus itself in chemical presentations called nucleotides, DNA cytoplasm which function somewhat like letters. Human RNA ribosome DNA presents a surprisingly brief alphabet for the mitochondrion extensive range of genetic expression it permits, molecule forming only four NUCLEOTIDE compounds that subsequently shape the 30,000 or so genes the Functions of Genetics human genome contains. One of the most intrigu- Genetics determines every aspect of human exis- ing discoveries of the HUMAN GENOME PROJECT is tence, from appearance and structure to function. that there are vast amounts of “empty” DNA. Each individual acquires one set of chromosomes, Only 1 to 2 percent of DNA encodes. The remain- the molecular presentation of heredity, from each ing 98 to 99 percent of DNA is noncoding, much parent. Each complete complement of chromo- like white space on the printed page of a book. somes (23 pairs) contains 25,000 to 30,000 genes, Researchers believe noncoding DNA somehow the smallest structural and functional units of stabilizes or in other ways supports the structure heredity. Each GENE pair within the structure of a of DNA within the chromosomes. 109 110 Genetics and Molecular Medicine

Each gene, like a word, contains patterns of HAIR or green eyes. There are not really “disease” nucleotides. Chromosomes, like sentences and genes, however. There are instead flaws and errors paragraphs, present strings of genes that convey in the structures of certain genes (mutations) that integrated and coordinated sets of instructions for cause them to give the wrong instructions for syn- specific structures and functions throughout the thesizing their specific proteins. The consequence body. Collectively these genetic instructions are is a gap, expansion, or rearrangement in the infor- the pages, written in code, that form an individ- mation. In some situations a gene, or more com- ual’s GENOTYPE. The outcome, the individual’s out- monly a segment of or an entire chromosome, is ward presentation of his or her genetic code from missing—as if pages or chapters are torn from the appearance to health, is the PHENOTYPE. genetic book of life. In other situations the gene Decoding the messages: the cells The cells may have extra material or its material is decode, interpret, and implement an individual’s rearranged—as if pages or chapters are inserted genotype. Each gene carries an encoded message into the book. The resulting errors in structure or that it transcribes to RNA (ribonucleic acid), a carrier function can be quite significant. molecule within the cell. The RNA conveys the gene’s message to the cell’s ribosomes. Ribosomes IDENTIFIED GENETIC AND MOLECULAR DISORDERS are organelles (defined structures with specific ALPORT SYNDROME CLEFT PALATE/CLEFT PALATE AND functions) within the cell. The job of the ribosome CONGENITAL HEART DISEASE LIP is to translate the gene’s message into a specific pro- CYSTIC FIBROSIS DOWN SYNDROME tein. The protein then carries the message to its tar- EDWARDS SYNDROME EPIDERMOLYSIS BULLOSA get within the body, which is usually molecular. FAMILIAL ADENOMATOUS FAMILIAL MEDITERRANEAN FEVER Transmitting the code: inheritance patterns POLYPOSIS (FAP)FANCONI’S SYNDROME The function of conveying a genotype is as much FRAGILE X SYNDROME G6PD DEFICIENCY one of mathematics as biology. INHERITANCE PAT- HEMOCHROMATOSIS HEMOPHILIA TERNS—the ways in which genes reorganize into HEREDITARY NONPOLYPOSIS HUNTINGTON’S DISEASE new pairs at CONCEPTION—are the patterns of statis- COLORECTAL CANCER (HNPCC) hypertrophic tics. A geneticist can calculate with astonishing KERATOCONUS CARDIOMYOPATHY accuracy the likelihood of certain traits passing KLINEFELTER’S SYNDROME LONG QT SYNDROME (LQTS) from parents to offspring. Such calculations MARFAN SYNDROME MUSCULAR DYSTROPHY accommodate the potential combinations that can MYOPATHY myotonia congenita arise from each parent’s genotype. NEURAL TUBE DEFECTS PATAU SYNDROME PHENYLKETONURIA (PKU) POLYDACTYLY Health and Disorders of Genetics PORPHYRIA PROGERIA In some respects what is perhaps most remarkable RETINOBLASTOMA SICKLE CELL DISEASE about human genetics is the precision and consis- SYNDACTYLY TAY-SACHS DISEASE tency with which myriad, intricate, and complex THALASSEMIA TRIPLE X SYNDROME biochemical actions take place not only to produce TURNER’S SYNDROME VACTERL a new human being but also to choreograph its WILSON’S DISEASE VON WILLEBRAND’S DISEASE functions for eight decades or longer. Though WOLFF-PARKINSON-WHITE everyone’s genotype contains some mutations, SYNDROME researchers believe most mutations have no con- sequence for the body’s structure or function. Researchers have identified more than 6,000 However, understanding of the complex interac- monogenic (single gene) mutations that result in tions among genes continues to evolve as geneti- health disorders, affecting 1 child in every 200 cists engage in further research. born. Among them are CYSTIC FIBROSIS, SICKLE CELL It is a common misperception that there are DISEASE, MARFAN SYNDROME, HUNTINGTON’S DISEASE, genes that cause disease, such that there are spe- and HEMOCHROMATOSIS. Other disorders, such as cific genes for HEMOPHILIA or CYSTIC FIBROSIS in the CLEFT PALATE/CLEFT PALATE AND LIP, result from poly- same fashion as there are certain genes for brown genic (multiple gene) mutations or CHROMOSOMAL Genetics and Molecular Medicine 111

DISORDERS, such as DOWN SYNDROME. Though as yet Mendel crossbred his sweet peas, detailing the pat- there are few treatments to alter the course of terns of their varieties and alternate characteris- genetic and chromosomal disorders, continuing tics. Mendel would later achieve full recognition research holds promise that doctors may in the for identifying the predictable variations that foreseeable future have the ability to offer effec- occurred as the consequence of what he called tive therapeutic interventions. paired elements of heredity. Less than two years apart these two researchers, the chemist and the Traditions in Medical History botanist, published their respective findings. In the 1660s English scientist Robert Hooke In 1933 Thomas Hunt Morgan (1866–1945) (1635–1703) used his newest invention, the com- received the Nobel Prize in Physiology or Medi- pound light microscope, to examine a thin slice of cine for proving the existence of chromosomes. By cork. The increased magnifying power of this new the 1940s numerous scientists were trying to microscope’s dual lenses was considerable com- unravel the cryptogram of the chromosome. pared to the standard single-lens microscope of the James Watson and Francis Crick, working in col- time; and with its improved light source of reflected laboration, and Maurice Wilkins, working inde- and focused candlelight, it revealed a level of struc- pendently, finally succeeded. In 1953 Watson and ture in living organisms scientists had not known Crick unveiled their model of the double-helix existed: the tight clustering of tiny compartments. structure of deoxyribonucleic acid. DNA, the mas- Hooke called these compartments cells because ter code of genetics, was no longer a secret. Wat- they reminded him of the living quarters of monks son, Crick, and Wilkins received the 1962 Nobel in monasteries. Hooke described his findings and Prize in Physiology or Medicine “For their discov- explorations of cells in his 1665 manuscript eries concerning the molecular structure of Micrografia, which became an epochal publication nucleic acids and its significance for information in the field of biology during Hooke’s lifetime— transfer in living material.” short order for such significant recognition. Increasingly sophisticated technology made it Not for another 150 years, however, did biolo- possible to study the activity of the cell at the level gists finally and fully comprehend the interrela- of the molecule. Following numerous affirming tionships and organizations of cells within discoveries about genes and DNA sequencing in the organisms. British botanist Robert Brown 1960s, 1970s, and 1980s, scientists began to talk of (1773–1858) discovered the cell nucleus in 1831, sequencing the human genome—unraveling the establishing it as the foundation of cell division; 36 molecule of heredity. The effort began formally in years later Swiss biologist and chemist (Johann) 1988 with James Watson at the helm of the plan- Friedrich Miescher (1844–1895) isolated and iden- ning process. Watson saw the Human Genome tified the active protein–acid structure in the cell Project through its official launch in 1990. Only 13 nucleus responsible for cell division. Miescher years later, 2 years ahead of schedule and on the called the structure nuclein, and speculated that it 50th anniversary of Watson and Crick’s unveiling not only was the key player in cell reproduction of the double helix, the Human Genome Project but also was the decanter of heredity itself. announced completion of the sequencing of the Miescher would never know the prophecy of his human genome. “Never would I have dreamed in speculation because the technology to further 1953 that my scientific life would encompass the explore such a hypothesis was still three quarters path from DNA’s double helix to the three billion of a century away. steps of the human genome,” Watson said in com- The words might well have gone from the sci- ments to the media at the events celebrating the entist’s mouth to the monk’s ear, however. Merely completion of the Human Genome Project. a country’s border away Gregor Johann Mendel (1822–1884) spent his days nurturing sweet peas Breakthrough Research and Treatment Advances in his monastery’s gardens. Mendel, an Augustin- The high-tech world of genetics and molecular ian monk, observed in nature what Miescher medicine continues to drive the direction of medi- studied in the laboratory: the paths of heredity. cine. RECOMBINANT DNA technology debuted in the 112 Genetics and Molecular Medicine

1970s, representing a breakthrough in the ability to life-altering treatments and altering life itself manipulate synthetic substances such as INSULIN to becomes increasingly blurred. GENETIC TESTING has create products biologically identical to endoge- the capability to tell not only what is already nous substances and launching what has become wrong with a person but what will go wrong in known as the biotech industry. Pharmacogenomics the future, and sometimes even with a timeline. expands the intersection of genetics and pharma- Medical ethicists worry that such information is cology, with researchers in both disciplines devel- too much to know and that the risk is high for oping customized medications that integrate with physicians and their patients (and other parties an individual’s genotype to produce predictable, that have access to the information) to believe the reliable, and effective results with minimal poten- book of life, as it were, is carved in stone rather tial for adverse DRUG reactions. Many researchers than set in proteins. Many variables still remain believe aging itself is a function of genetics. within the control of individuals in regard to Continued work to understand the details of the health and medical decisions. Environmental human genome makes it not only conceivable but interactions—lifestyle factors—can modify most likely that on the horizon are therapies to correct health conditions associated with genetic alter- genetic mutations and chromosomal errors, and ations. Even with all the knowledge arising from perhaps to overcome the dimensions of aging, that the science fiction–like world of genetics and are deleterious to health. molecular medicine, for many people lifestyle Genetics and molecular medicine open new remains the critical turning point between health vistas in medical ethics as well. The line between and disease. A

allele Any of the variations of a GENE that may dominant. When the 9q34IA and 9q34IB alleles occupy the same position (locus) on a CHROMO- pair, their expression is codominant. The possible SOME. The gene controlling a particular trait or allele pairings for blood type can produce any of function always occupies the same locus on the these expressions. same chromosome. Genes occur as pairs, with one For further discussion of alleles within the con- gene coming from each parent. The pairing deter- text of the structures and functions of genetics, mines how the gene’s traits are expressed in the please see the overview section “Genetics and individual. For example, the gene for BLOOD TYPE Molecular Medicine.” occurs at region 34 on the long arm of chromo- See also GENOTYPE; INHERITANCE PATTERNS; PHENO- some 9, indicated as 9q34. This gene has three TYPE. alleles, identified as 9q34IA, 9q34IB, and 9q34i (which geneticists sometimes abbreviate as IA, IB, apoptosis The natural mechanism through and i, respectively). These alleles can occur in one which a cell engages in actions that lead to its of six pairings to produce the blood type A, B, O, death, often called programmed cell death or cell or AB. suicide. Apoptosis appears linked to SENESCENCE, an When the two alleles at the same locus are the inherent limitation on the number of times a cell same the individual is said to be homozygous for can divide. Both apoptosis and senescence play that gene; when the alleles are different the indi- significant roles in the aging process. Once the cell vidual is heterozygous. In a heterozygous individ- initiates apoptosis there is no reversal; the process ual generally one allele is dominant and the other proceeds until the cell dies. recessive. Occasionally each allele in a pairing has Apoptosis begins when the cell’s DNA fragments, equal dominance, a circumstance called codomi- signaling or switching the rest of the process in nance. The 9q34i allele (type O) is recessive; the motion. Once activated apoptosis sets in motion 9q34IA and 9q34IB alleles (type A and type B) are the subsequent events result in the cell’s disman-

EXAMPLE ALLELE PAIRINGS AND EXPRESSION: BLOOD TYPE Allele Pairing Expression Blood Type IaIa (A+A) Homozygous dominant Type A Iai (A+O) Heterozygous dominant

IbIb (B+B) Homozygous dominant Type B Ibi (B+O) Heterozygous dominant ii (O+O) Homozygous recessive Type O

IaIb (A+B) Heterozygous codominant Type AB

113 114 Genetics and Molecular Medicine tling, assimilation, and recycling. In some respects because the rate of CONCEPTION is significantly cells become endlessly renewable resources for the higher among younger women. The risk is highest body. Specialized cells called phagocytes break for women who have previously given birth to a down dying and dead cells into basic components child with a trisomy disorder. Obstetricians can such as amino acids that other the body can use to detect fetal trisomy disorders generally within the construct new cells. first and early part of the second trimesters of Apoptosis is necessary for growth, develop- PREGNANCY with prenatal tests. The diagnostic path ment, and change in the body. The process of the usually incorporates a combination procedures death of cells that experience injury or damage is including called necrosis and by definition occurs outside the natural order of cell life expectancy. Extrinsic, • BLOOD tests that look at the levels of proteins rather than intrinsic, factors initiate necrosis. the FETUS and placenta are making See also CELL STRUCTURE AND FUNCTION; METABO- • ULTRASOUND, which shows physical anomalies LISM; PHAGOCYTE; PHAGOCYTOSIS; STEM CELL. that suggest a chromosomal disorder • CHORIONIC VILLI SAMPLING (CVS) and autosomal trisomy A chromosomal disorder in AMNIOCENTESIS, which permit examination of which there are three instead of the normal two fetal cells copies of an AUTOSOME (nonsex chromosome). An autosomal trisomy may be complete (affect all See also BIRTH DEFECTS; CHROMOSOMAL DISORDERS; cells) or mosaic (affect only some cells). The most CONGENITAL ANOMALY; GENETIC COUNSELING; GENETIC commonly occurring complete autosomal trisomies TESTING; MOSAICISM; PREGNANCY. that are survivable are those involving chromo- somes 21, 18, and 13, which result in the chromo- autosome A CHROMOSOME that appears as a pair somal disorders DOWN SYNDROME (trisomy 21), in which both chromosomes are the same in EDWARDS SYNDROME (trisomy 18), and PATAU’S SYN- either sex, also called a nonsex chromosome. In DROME (trisomy 13). These trisomy disorders may contrast, the sex chromosomes appear as a pair also occur as a mosaic. Mosaic autosomal trisomies that is different in males and females. The human typically produce less severe, though still signifi- GENOME contains 22 autosomes and one pair of sex cant, physical and mental impairments. Complete chromosomes for a total complement of 46 chro- autosomal trisomies affecting other chromosomes mosomes as 23 pairs. are often lethal, nearly always causing death early For further discussion of autosomes within the in development and well before birth. context of the structures and functions of genetics, Though the risk for autosomal trisomy disor- please see the overview section “Genetics and ders increases with a woman’s age at the time she Molecular Medicine.” becomes pregnant, most autosomal trisomy disor- See also GENE; GENOTYPE; KARYOTYPE; PHENOTYPE; ders occur in pregnancies in younger women SEX CHROMOSOME. C cell structure and function The cell is the basic has the ability to differentiate into various types of structural and functional unit of all living organ- blood cells throughout life. Other adult stem cells isms. About 100 trillion cells make up one of the (also called somatic stem cells to distinguish them most complex of such organisms, the human. from embryonic stem cells) exist in most body tis- sues though are interspersed among other cells. Types of Cells in the Human Body Their role remains unclear though they appear There are three basic types of cells in the body: responsible for large-scale regeneration of tissue stem cells, germ cells, and somatic cells. such as can occur in the LIVER. The foundation of life: stem cells Stem cells are The cells of reproduction: germ cells Germ cells, the primal, undifferentiated cells that give rise to also called gametes, are the cells of reproduction: all other cells. They are primarily abundant and the OVA or eggs (female) and the spermatozoa or functional during early embryonic development SPERM (male). Gametes are haploid cells; each (embryonic stem cells). These are the cells of the GAMETE contains one-half the complement of chro- blastocyst, the earliest form of a new life, and at mosomes. When two gametes merge in CONCEP- this stage are totipotent: They have the ability to TION, the resulting ZYGOTE acquires the full become any other kind of cell. Genes instruct complement of genetic material. dividing stem cells how to differentiate or form The cells of the functioning body: somatic cells specific kinds of cells that then develop into vari- All cells that are not stem cells or germ cells are ous organs and body structures. somatic cells. Somatic cells make up more than 99 percent of the cells in the adult body. They are UMBILICAL CORD BLOOD STEM CELLS diploid cells; each somatic cell contains the full The BLOOD that remains in the UMBILICAL CORD complement of chromosomes. Somatic cells make and PLACENTA at birth is an abundant source of up the organs and structures of the body. They are multipotent BLOOD STEM CELLS. Cord blood trans- the body’s primary working units, responsible for plantation is an emerging treatment for LEUKEMIA carrying out the myriad functions of METABOLISM and other cancers as well as SICKLE CELL DISEASE that support life. Though similar in structure and and other blood disorders. Many people now opt function, somatic cells are broadly diverse in their to collect and store or donate the cord blood of activities and specializations. their newborns after birth. Cell Structure As the body takes shape stem cells become Most cells have standard, key structural compo- increasingly diffuse and specialized, transitioning nents in common. These include to pluripotent (able to become cells of distinct body systems such as cardiovascular or gastroin- • PLASMA membrane, the cell’s outer wall made testinal) and finally multipotent (able to become up of a protein layer and a lipid (fatty) layer, cells of specific kinds, such as BLOOD or BONE). The that separates the cell’s contents from its exter- most versatile stem cell that remains when devel- nal environment yet permits interaction opment is complete is the blood stem cell, which between the cell and the external environment 115 116 Genetics and Molecular Medicine

• cytoskeleton, a dynamic construct of filaments mediated limits to the number of times cells may and fibers that support the cell’s shape and divide. inner components Cells replicate by dividing themselves, a process • cytoplasm, a watery fluid that suspends the called mitosis (somatic cells) or meiosis (gametes). inner structures of the cell, moves substances Mitosis is a multistage process during which the through the cell, and conducts electricity cell’s chromosomes pull together and duplicate themselves. When this duplication is complete the • nucleus, the core of the cell, separated from the cell then pulls apart into two new cells, called cytoplasm by a thin membrane called the daughter cells, with one package of chromosomal nuclear envelope, which contains the cell’s content (called a CHROMATID) going with each chromosomes and genetic material daughter cell. In this way each daughter cell • mitochondria, self-replicating structures called receives the full complement of chromosomes. organelles that generate the energy, in the form Meiosis has two stages, meiosis 1 and meiosis 2. of adenosine triphosphate (ATP), the cell needs There is duplication of chromosomal material in to function meiosis 1 but not in meiosis 2, such that one cell • ribosomes, another type of organelle, which ultimately produces four gametes. synthesize proteins according to genetic direc- For further discussion of cell structure and tions the mitochondrial RNA brings to the ribo- function within the context of genetics, please see somes the overview section “Genetics and Molecular • lysosomes and peroxisomes, also organelles, Medicine.” which contain enzymes to break down cellular See also APOPTOSIS; BLOOD TRANSFUSION; CEN- wastes into component molecules the cell can TROMERE; CHROMOSOME; HORMONE; INHERITANCE PAT- recycle TERNS; PREGNANCY; SENESCENCE; SOMATIC CELL; STEM CELL; TELOMERE. Cell Function The cell is responsible for all of the functions of centromere The position on a CHROMOSOME metabolism that support the body. Most of the where the chromosome separates during cell divi- body’s 100 trillion cells have specialized responsi- sion. The centromere is a structure of noncoding bilities. Blood cells transport oxygen, GLUCOSE, and DNA (DNA that does not convey genetic informa- other NUTRIENTS throughout the body and collect tion). When the cell divides the strands of the molecules of metabolic waste that cells in the liver chromatids migrate in opposite directions (pull and KIDNEYS dismantle, recycle, or eliminate from apart) at the centromere. In a photomicrograph, the body. NERVE cells conduct electrical impulses. the centromere appears as an indented, waistlike MUSCLE cells contract the HEART and move the area on the chromosome. Geneticists use the cen- body. Other cells make hormones, absorb nutri- tromere’s position, along with other characteristics ents, fight INFECTION, and so on. Regardless of their of the chromosome, to match chromosomes into specializations, however, the primary activity of all their pairs when creating KARYOTYPES. cells is the synthesis of the enzymes and proteins For further discussion of centromeres within that carry out the biochemical tasks of living. the context of the structures and functions of genetics, please see the overview section “Genetics Cell Division and Molecular Medicine.” One of the most important functions of a cell is to See also ALLELE; CELL STRUCTURE AND FUNCTION; replicate itself, as this is the activity that sustains CHROMATID; GAMETE; GENE; GENOTYPE; PHENOTYPE; life. Some cells, such as those that line the gas- SOMATIC CELL; TELOMERE. trointestinal tract, replicate every 12 hours. Other cells, such as those in the heart and the liver, chromatid A replica of a CHROMOSOME that divide perhaps once every 12 months or so. develops in preparation for cell division. Chro- Though cells have vast ability to perpetrate them- matids are “sister” pairs of each chromosome that selves in such fashion, there appear to be gene- contain identical genetic material. They remain chromosomal disorders 117 attached to each other at the CENTROMERE until cell Trisomy Disorders of trisomy occurs when the division. When the mother cell divides, the sister ZYGOTE receives three instead of the normal two chromatids separate at the centromere and copies of a chromosome. Most trisomies are auto- migrate into the new daughter cells, forming the somal, and most autosomal trisomies are lethal chromosome pairs for the new cells. Though very early in embryonic development. Most early minor variations are normal and frequently occur losses due to trisomy thus likely escape detection. without causing problems because they affect rela- The survivable autosomal trisomies affect chromo- tively few cells, errors in chromatid replication some 13 (PATAU’S SYNDROME), chromosome 18 and separation affect many or all cells and can be (EDWARDS SYNDROME), and chromosome 21 (DOWN responsible for CHROMOSOMAL DISORDERS such as SYNDROME). Trisomies can also involve the sex DOWN SYNDROME. chromosomes. The most common such disorder is For further discussion of chromatids within the KLINEFELTER’S SYNDROME, in which the zygote context of the structures and functions of genetics, receives two (and sometimes more) X chromo- please see the overview section “Genetics and somes and one Y chromosome. Though the Y Molecular Medicine.” chromosome determines the gender as male, the See also CELL STRUCTURE AND FUNCTION; DNA; additional X chromosome affects sexual develop- GENETIC DISORDERS; MOSAICISM; MUTATION; NUCLEOTIDE; ment and FERTILITY. The zygote may also receive VARIATION. three X chromosomes (triple X syndrome) or one X chromosome and two Y chromosomes. These chromosomal disorders Abnormalities affecting trisomies may not produce obvious symptoms, the chromosomes that result in syndromes (con- though often boys who have XYY syndrome have stellations of symptoms) having characteristic developmental delays and learning disabilities. physical or functional anomalies. Most chromoso- Monosomy Monosomy occurs when the zygote mal disorders occur because of alterations in the receives only one copy of a chromosome and number of chromosomes or the structure of chro- overall occur far less frequently than trisomy mosomes. Though an individual may inherit a because an entire missing autosome (nonsex chro- chromosomal disorder, more commonly chromo- mosome) is nearly always lethal. The monosomy somal disorders represent random occurrences. disorder Turner syndrome, in which the zygote Typically all the cells in the body reflect the abnor- receives only one X SEX CHROMOSOME, is one of the mality. Occasionally some but not all cells carry few survivable monosomy disorders. Because the the chromosomal abnormality; this is a mosaic single sex chromosome is X, the zygote is female chromosomal disorder. A mosaic presentation although breast development at sexual maturity is tends to be milder than that observed when all diminished. cells carry the chromosomal abnormality Uniparental disomy In uniparental disomy the zygote receives two copies of a chromosome from Disorders of Replication one gamete and none from the other gamete. Normally chromosomes exist in pairs. Replication Though in many cases this REPLICATION ERROR may errors can result in an incorrect number of chro- result in no adverse symptoms or consequences, it mosomes passing to new cells. Though such errors can allow rare recessive disorders to manifest. can occur in any cell with any episode of cell divi- Uniparental disomy also causes symptoms when sion, they are most harmful when they affect the involved chromosome is one in which GENETIC gametes (the sex cells, the ovum in the female and IMPRINTING is essential. In such circumstances the the spermatozoon in the male). Replication errors chromosome pairing requires one chromosome in gametes become chromosomal disorders in the from each parent to activate the chromosome’s new life created through their union. These errors genetic functions. may take the form of trisomy (an extra CHROMO- SOME), monosomy (a missing chromosome), or Disorders of Structure uniparental disomy (both copies of a chromosome Chromosomal disorders of structure occur when come from the same GAMETE or parent). there are physical changes to the chromosome 118 Genetics and Molecular Medicine that alter its configuration. In TRANSLOCATION, frag- Treatment Options and Outlook ments of a chromosome break away and reattach For nearly all chromosomal disorders, treatment to other chromosomes or are lost, potentially focuses on improving physical anomalies and changing several chromosomes with unpredictable maintaining function to the extent possible. Chil- and random results. Inversions, rings, duplica- dren born with chromosomal disorders often tions, and deletions are other disorders of struc- require ongoing medical care and other kinds of ture involving fragments of the chromosome that support. Outlook and QUALITY OF LIFE vary widely are fairly uncommon though tend to produce even within the same syndrome. symptoms when they occur. The types of symp- toms depend on the involved chromosome. Risk Factors and Preventive Measures Inversions In a chromosomal inversion the Most chromosomal disorders are random events chromosome breaks in two or more locations, for which there are no preventive measures. then the segments rejoin with one or more seg- Parental age and exposure to teratogenic sub- ments inverted (upside-down). Some genetic stances (chemicals, drugs, or other materials that material may be lost in the process, and the genes disrupt embryonic or fetal development) are risk are out of position. Inversions may or may not factors for certain chromosomal disorders. Doctors cause symptoms, depending on the involved chro- recommend all women of childbearing age who mosome and the degree of inversion. could become pregnant, whether or not they Rings Chromosomal rings occur when the ends are planning PREGNANCY, take folic acid supple- of the chromosome are missing and the remaining mentation, which appears to reduce the risk for chromosome reshapes itself into a ring. The extent numerous congenital anomalies and perhaps and nature of symptoms depends on the involved chromosomal damage. chromosome and the amount of missing genetic See also CONGENITAL ANOMALY; GENETIC DISORDERS; material. A ring of chromosome 15, for example, INHERITANCE PATTERNS. tends to produce symptoms such as facial anom- alies and growth deficiency. chromosome A coiled DNA molecule within the Duplications and deletions In duplications and cell’s nucleus that carries an individual’s GENETIC deletions, the chromosome acquires (duplication) CODE. Most of the time the chromosome’s struc- or loses (deletion) fragments of its structure. The ture is loose and indistinguishable. Only in the severity of the consequences depends on the chro- stage of cell division immediately before the cell mosome involved and the extent of the altered divides (the metaphase) does the chromosome genetic material. draw itself into a compact, rodlike structure the geneticist can see under a microscope after apply- Symptoms and Diagnostic Path ing a special dye to the cell that the chromosomes The symptoms of chromosomal disorders vary absorb. It is this ability to absorb a colored dye with the chromosome involved and the extent of that gives the chromosome its name, which means damage present. Because chromosomal disorders “colored body.” tend to affect large segments of genetic material, the resulting symptoms and syndromes are often Chromosome Complements complex and affect multiple organs, structures, The nucleus of every diploid cell, also called a functions, and systems. The diagnostic path may SOMATIC CELL, contains the full complement of 46 include imaging procedures such as ULTRASOUND, chromosomes arranged in 23 pairs. One pair con- COMPUTED TOMOGRAPHY (CT) SCAN, and MAGNETIC RES- tains the sex chromosomes that establish gender, ONANCE IMAGING (MRI) to evaluate structural anom- paired either as XX (female) or XY (male). The alies of internal organs. A KARYOTYPE (picture of other 22 pairs are autosomes. The haploid cells, the chromosomes a in a cell) reveals overt chro- the gametes (spermatozoa and OVA), contain one mosomal problems, and molecular studies may be half the chromosome complement. When gametes necessary to unravel the circumstances of less merge in CONCEPTION the diploid cell they form, the obvious chromosomal disruptions. ZYGOTE, acquires the full chromosomal comple- cloning 119 ment. The only cells in the body that do not have example, is identified as CFTR 7q31.2—cystic chromosomes are the erythrocytes, which do not fibrosis transmembrane conductance regulator have nuclei. located in band 31, region 2, on the long arm of Autosomes carry the bulk of genetic code. chromosome 7. Thousands of genes line each autosome, each in For further discussion of chromosomes within its ordained position. The sex chromosomes carry the context of the structures and functions of several hundred genes. The GENE positions, called genetics, please see the overview section “Genetics loci (in the singular, each position is a locus), are and Molecular Medicine.” constant. For example, the gene loci for the ABO See also AUTOSOME; ERYTHROCYTE; GAMETE; GENETIC BLOOD TYPE are always on chromosome 9, those for DISORDERS; GENOME; GENOTYPE; PHENOTYPE; SPERM; the rhesus (Rh) blood type are on chromosome 1, TELOMERE. and those for EYE color on chromosomes 15 and 19. cloning The creation of exact copies of a GENE, cell, or entire organism. Such exact copies occur naturally when a ZYGOTE divides to become identi- CHROMOSOME SIZE cal multiples such as twins or, less commonly, The HUMAN GENOME PROJECT, completed in 2003, triplets. Manipulated cloning is primarily a revealed the structure of chromosomes to be research method at present, though scientists use much larger and more complex than scientists cloning for therapeutic applications in creating previously had theorized. Chromosome 1, the RECOMBINANT DNA products such as INSULIN. Insulin largest CHROMOSOME, contains 2,968 genes. The was the first human gene cloned (1978) as well as smallest chromosome, the Y chromosome, con- the first genetically engineered product approved tains 231 genes. for use in the United States (1982). The cloning of entire organisms, such as Dolly the sheep in 1997, Nomenclature though sensational, is extraordinarily challenging. Geneticists designate the normal female chromo- Currently, cloned organisms appear prone to some complement as 46,XX and the normal male numerous health problems and tend to die prema- chromosome complement as 46,XY. Deviations turely, which somewhat mystifies researchers from the norm are CHROMOSOMAL DISORDERS geneti- because natural clones such as identical twins do cists designate according to the deviation, for not experience these challenges. Numerous ethical example 47,XY,+21 denotes AUTOSOMAL TRISOMY 21 issues surround the use of entire organism (DOWN SYNDROME) in a male. The designation 45,X cloning, particularly EMBRYO cloning. denotes TURNER SYNDROME, a monosomy disorder Scientists create gene clones by removing the (missing chromosome) affecting the SEX CHROMO- DNA from a vector such as a bacterium cell and SOME in a female. A comprehensive standard of replacing it with the DNA of choice. The bac- nomenclature (naming) exists so all geneticists terium rapidly replicates, creating multiple identi- can use a common “language” when describing cal copies of the DNA. Similarly, this process can chromosomal and genetic configurations. create identical replicas of cells. Researchers are A chromosome’s structure consists of two hopeful that this technology will someday lead to telomeres (end segments), a CENTROMERE (waistlike the ability to generate replacement tissues and indentation), and two arms (the segments above organs to treat various health conditions that and below the centromere). The centromere is currently rely on therapies such as ORGAN TRANS- somewhat off-center, such that each chromosome PLANTATION. This technology further holds promise has a short arm (designated “p” for petite) and a for treating degenerative conditions such as long arm (designated “q” because scientific PARKINSON’S DISEASE and HUNTINGTON’S DISEASE. nomenclature is alphabetical). The regions of each Cloning is also one method of potential GENE arm are numbered. Geneticists identify a gene’s THERAPY. locus relative to its placement on the chromo- See also CELL STRUCTURE AND FUNCTION; ETHICAL some. The gene responsible for CYSTIC FIBROSIS, for ISSUES IN GENETICS AND MOLECULAR MEDICINE. 120 Genetics and Molecular Medicine congenital anomaly A physical abnormality know of approximately 600 CFTR mutations, one present at birth. Congenital anomalies, also called MUTATION, called the delta F508 mutation, accounts BIRTH DEFECTS, can affect nearly any structure in for about 70 percent of cystic fibrosis in the United the body and may be hereditary or random. States. About 30,000 Americans live with cystic GENETIC DISORDERS and exposure to teratogens fibrosis. (substances, such as drugs, that alter the develop- CFTR is a protein that, when functioning nor- ment of the embryo or fetus) account for the mally, facilitates the transport of chloride and majority of congenital anomalies. The symptom other ions across cell membranes. In cystic fibrosis constellations that characterize CHROMOSOMAL DIS- the presence of CFTR is greatly diminished and ORDERS typically contain multiple congenital salts fail to properly cross the cell membranes. anomalies. One result is very high concentrations of salts in Some congenital anomalies are almost always the sweat, particularly chloride, giving the SKIN a treatable, such as atrial septal defect (an abnormal salty taste. The effect of diminished CFTR is most opening in the septum, or wall, between the two pronounced on epithelial secretory cells—the cells atria in the HEART) or CLEFT PALATE/CLEFT PALATE AND that form mucous membranes and make up the LIP (failure of the oral structures to properly close). linings of the intestinal tract, LUNGS, and urinary Other congenital anomalies are life-altering or system, which rely on sodium chloride and other life-threatening, such as severe forms of SPINA salts to draw fluid into their secretions. Without BIFIDA (in which the spine fails to form properly) CFTR the normal watery secretions of these cells or transposition of the great arteries (incorrect become thick and sticky. alignment of the major BLOOD vessels in the heart). Cystic fibrosis most seriously affects the pul- Many congenital anomalies are physically monary and gastrointestinal systems, and does so apparent at birth or manifest symptoms that in all people who have the disorder, though the reveal their presence. An infant born with con- disorder involves all body systems to varying genital anomalies of the heart, for example, may extents. Thickened secretions accumulate in the have a bluish hue to the SKIN (CYANOSIS) that indi- airways in the lungs, creating obstructions that cates insufficient oxygen to the tissues. The diag- interfere with BREATHING as well as establish breed- nostic path may include imaging procedures such ing grounds for BACTERIA and other pathogens. as ULTRASOUND, COMPUTED TOMOGRAPHY (CT) SCAN, Furthermore, the high chloride content on the and MAGNETIC RESONANCE IMAGING (MRI) that allow surface of the epithelial cells that line the the neonatologist to visualize and identify the bronchial structures suppresses the body’s natural anomaly. GENETIC TESTING may also be appropriate, bacterial-control mechanisms. People who have depending on the nature of the anomaly. Treat- cystic fibrosis have frequent or chronic upper res- ment depends on the type, extensiveness, and piratory infections and pneumonias. About 85 complexity of the anomaly. Surgeons often can percent of people who have cystic fibrosis also easily repair isolated anomalies, such as cleft lip or develop pancreatic insufficiency, in which the atrial septal defect, with minimal or no residual DIGESTIVE ENZYMES the PANCREAS normally secretes consequences. Extensive or multisystem anom- do not adequately support digestion. alies may not be treatable. See also CONGENITAL HEART DISEASE; HORSESHOE Symptoms and Diagnostic Path KIDNEY; REPLICATION ERROR. Infants who have cystic fibrosis may have MECO- NIUM ileus at birth, an obstruction of the bowel cystic fibrosis An inherited genetic disorder with meconium, a tarry substance that normally resulting from multiple mutations of the cystic passes from the RECTUM within a few hours of fibrosis transmembrane conductance regulator birth. Other signs and symptoms of cystic fibrosis (CFTR) GENE on CHROMOSOME 7, inherited as auto- may emerge at any time and include somal recessive mutations. Researchers believe as many as 10 million people may be cystic fibrosis • large, foul-smelling, greasy-looking stools carriers and unaware of it. Though researchers • frequent bowel blockages cystic fibrosis 121

• thick SPUTUM tions so the person can more easily COUGH them • coughing and wheezing up. Other treatments may include pancreatic enzyme supplementation and high liquid con- • clubbing of the fingers and toes sumption. • INTUSSUSCEPTION (a segment of the bowel “tele- Cystic fibrosis is the leading reason for LUNG scopes” into another segment), a potentially TRANSPLANTATION, which is a treatment that life-threatening circumstance becomes necessary when the lungs can no longer • RECTAL PROLAPSE function. Some people who have severe cystic • nasal polyps fibrosis undergo simultaneous pancreas and lung transplantation. Such surgery is extensive and Men who have cystic fibrosis nearly always ORGAN TRANSPLANTATION requires lifelong IMMUNO- have congenital bilateral absence of the vas defer- SUPPRESSIVE THERAPY. These treatments are rela- ens, which results in INFERTILITY, though the TESTES tively new, so doctors do not know their and other structures of the male sex organs func- long-term success. With appropriate medical man- tion normally. agement some people who have cystic fibrosis can The diagnostic path begins with a skin salt test live into at least midlife with relatively few signifi- that measures the amount of chloride present on cant complications. the surface of the skin. In cystic fibrosis these lev- els are five to six times normal; such a finding is Risk Factors and Preventive Measures generally conclusive of a diagnosis of cystic fibro- Cystic fibrosis is an autosomal recessive disorder sis, especially in combination with other charac- acquired when each parent carries the gene muta- teristic symptoms. A BLOOD or saliva test also can tion. Preconception GENETIC SCREENING is the only confirm the presence of a cystic fibrosis mutation. way to prevent parents from passing cystic fibrosis Other blood tests help to assess the level of dam- to their children. Because the projected number of age organ systems have experienced. cystic fibrosis carriers is so high (1 in 20 among Caucasians of northern European ancestry), many Treatment Options and Outlook doctors offer cystic fibrosis screening to adults who The most serious and common consequence of are planning families. Though researchers hope cystic fibrosis is lung damage. Doctors may pre- GENE THERAPY may offer a cure for cystic fibrosis in scribe ANTIBIOTIC MEDICATIONS to curtail infections, the future, such approaches are only in the early mucolytic agents and mechanical methods such as stages of experimentation. CHEST PERCUSSION AND POSTURAL DRAINAGE to help See also CARRIER; CYSTIC FIBROSIS AND THE LUNGS; thin secretions, and bronchodilator medications to FAMILY PLANNING; GENETIC COUNSELING; GENETIC DISOR- open the airways. An aerosol spray medication, DERS; INFECTION; INHERITANCE PATTERNS; NASAL POLYP; dornase alpha, uses enzymes to break up secre- PATHOGEN; PNEUMONIA. D

DNA The abbreviation for deoxyribonucleic CONCEPTION the ZYGOTE thus ends up with three acid. DNA is the molecule of heredity; its instead of the normal two copies of chromosome sequences form the body’s GENETIC CODE. Each cell 21, which ultimately produces multiple congenital in the body contains DNA within the chromo- anomalies. When all cells carry the extra chromo- somes in its nucleus (except erythrocytes, which some, the resulting anomalies occasionally may be do not have nuclei). DNA has a characteristic dou- so severe that the disorder is lethal before birth. ble-helix structure that resembles a gently twisting Sometimes Down syndrome occurs as a mosaic ladder. The supporting rails of this structure are disorder in which some but not all cells contain deoxyribose, a sugar-phosphate, and the cross- the extra chromosome 21, which typically pro- bands are nitrogen bases: adenine (A), thymine duces milder symptoms. (T), guanine (G), and cytosine (C). These bases Down syndrome occurs in about 1 in 1,200 live pair in precise, predictable patterns arranged in births in the United States and about 350,000 nearly endless combinations, more than three bil- Americans currently live with Down syndrome, lion in all. many independently. Though the risk for Down British scientists James Watson and Francis syndrome increases dramatically with maternal Crick unraveled the double-helix structure of age, most infants who have Down syndrome are DNA in 1953, identifying its two spiraling, born to younger mothers because the increased sugar–phosphate (deoxyribose) supports and rate of CONCEPTION more than offsets the increase cross-bands of paired nucleic acids. Just 50 years in age-related risk. Down syndrome is the most later researchers involved with the HUMAN GENOME commonly occurring of the autosomal trisomy dis- PROJECT concluded their mapping of the human orders. GENOME, which included determining the entire biochemical sequence of human DNA. Chromo- Symptoms and Diagnostic Path somes are structures of DNA, and genes are seg- Children born with Down syndrome often have ments of chromosomes (also made up of DNA). characteristic facial features, which include For further discussion of DNA within the con- text of the structures and functions of genetics, • flat, upwardly slanting eyes with extra fatty tis- please see the overview section “Genetics and sue in the lids Molecular Medicine.” • rounded face with a small NOSE and MOUTH See also CELL STRUCTURE AND FUNCTION; CHROMO- • small ears SOME; ERYTHROCYTE; GENOTYPE; RNA. • broad, short neck Down syndrome An AUTOSOMAL TRISOMY disorder • short stature with noticeably small hands and that results from a REPLICATION ERROR during cell short fingers division in which a GAMETE (sex cell) ends up with two copies of CHROMOSOME 21 instead of the nor- Other findings of Down syndrome include con- mal single copy (as haploid cells, gametes contain genital anomalies affecting the HEART, intestines, one half the complement of chromosomes). At and other organs. About half of infants born with 122 Down syndrome 123

Down syndrome have atrial or ventricular septal can occur in a mosaic rather than a complete pres- defects (openings or holes in the septum, or wall, entation, some people who have it are able to lead between the chambers of the heart). About half relatively independent and productive lives, living also have impaired vision (notably, congenital into their mid-50s or beyond. Early treatment for cataracts and AMBLYOPIA) and partial to complete the anomalies common with Down syndrome, HEARING LOSS. About 10 percent have malforma- such as septal defects, and ongoing care for other tions of the intestines that require surgical correc- health conditions, such as HYPOTHYROIDISM and tion. All individuals with Down syndrome have VISION IMPAIRMENT, have greatly improved both some intellectual impairment. Mild to moderate health and QUALITY OF LIFE for people who have intellectual impairment is most common. Some Down syndrome. children who have Down syndrome do well in regular classes in school and grow up to be capa- Risk Factors and Preventive Measures ble of independent living. Down syndrome occurs as a replication error that Doctors often can diagnose Down syndrome does not appear to be preventable, though recent and other autosomal trisomy disorders before research suggests that folic acid supplementation birth using prenatal screening methods such as beginning before conception and extending blood tests, ULTRASOUND, AMNIOCENTESIS, and CHORI- through PREGNANCY, such as obstetricians recom- ONIC VILLI SAMPLING (CVS). These methods retrieve mend for preventing NEURAL TUBE DEFECTS, may cells from the FETUS from which a geneticist can reduce the risk for Down syndrome. Older construct a KARYOTYPE, which presents photomi- women, who have a higher risk of conceiving a crographic images of the fetus’s or infant’s chro- child with Down syndrome, may opt for genetic mosomes. Advanced maternal age (mother’s age testing early in pregnancy to determine whether over 40) and the previous conception of a child the fetus has the trisomy 21 GENOTYPE. Knowing with Down syndrome or another autosomal tri- allows the woman to make appropriate plans and somy disorder are the leading risks for Down syn- decisions regarding the pregnancy and potential drome. Whether done prenatally or after birth the care needs of the child. karyotype provides definitive diagnosis. CONGENITAL ANOMALIES Treatment Options and Outlook CHARACTERISTIC OF DOWN SYNDROME There are no specific treatments for Down syn- AMBLYOPIA atrial septal defect drome. Because children who have Down syn- BOWEL ATRESIA broad, short neck drome are more susceptible to INFECTION, they congenital cataracts developmental delays often need more medical care while growing up. flat, upwardly slanting eyes HEARING LOSS There is a high correlation between early-onset intellectual impairment rounded face ALZHEIMER’s DISEASE and adults who have Down short stature small ears syndrome. Typically men who have Down syn- small hands and short fingers small NOSE and MOUTH drome are sterile, though women who have ventricular septal defect Down syndrome may be fertile and can become pregnant. Their risk for conceiving a child with See also AUTOSOME; CATARACT; CONGENITAL ANOM- Down syndrome is very high, however, and doc- ALY; CHROMOSOME DISORDERS; CONGENITAL HEART DIS- tors strongly recommend GENETIC COUNSELING. EASE; EDWARDS SYNDROME; ETHICAL ISSUES IN GENETICS About 350,000 Americans live with Down syn- AND MOLECULAR MEDICINE; GENETIC SCREENING; INHERI- drome. Because Down syndrome is the mildest of TANCE PATTERNS; MOSAICISM; PATAU’S SYNDROME; PRE- the survivable trisomy disorders and because it NATAL CARE. E–F

Edwards syndrome An AUTOSOMAL TRISOMY disor- These methods retrieve cells from the FETUS from der that results from a REPLICATION ERROR during which a geneticist can construct a karyotype. cell division in which a GAMETE (sex cell) ends up Advanced maternal age (mother’s age over 40) with two copies of CHROMOSOME 18 instead of the and the previous CONCEPTION of a child with normal single copy (as haploid cells, gametes con- Edwards syndrome or another autosomal trisomy tain one half the complement of chromosomes). disorder are the leading risks for Edwards syn- At fertilization the ZYGOTE thus ends up with three drome. Whether done prenatally or after birth the instead of the normal two copies of chromosome karyotype, which presents photomicrographic 18, which ultimately produces multiple and life- images of the fetus’s or infant’s chromosomes, threatening congenital anomalies. provides definitive diagnosis. When all cells carry the extra chromosome 18), the anomalies are so severe that the defect often is CONGENITAL ANOMALIES lethal well before birth. Sometimes Edwards syn- CHARACTERISTIC OF EDWARDS SYNDROME drome occurs as a mosaic trisomy disorder (some facial deformities but not all cells contain the third chromosome fingers curled over one another in clenched fists 18), which tends to produce milder though heart defects nonetheless significant symptoms. Edwards syn- kidney abnormalities drome occurs in about 1 in 5,000 live births in the low, small ears United States, 80 percent of which are females. microcephaly (small head and BRAIN) Researchers do not know whether Edwards syn- small MOUTH and cleft deformities drome affects females more often or if females are spina bifida more likely to survive beyond birth. SYNDACTYLY Children born with Edwards syndrome have TALI PEDES (club foot) severe and complex physical deformities involving multiple organs and systems that require exten- See also AUTOSOME; CHROMOSOME DISORDERS; CON- sive medical care from the time of birth. Most also GENITAL ANOMALY; CONGENITAL HEART DISEASE; DOWN have profound intellectual impairment arising SYNDROME; ETHICAL ISSUES IN GENETICS AND MOLECULAR from malformations affecting the BRAIN and NERV- MEDICINE; GENETIC SCREENING; INHERITANCE PATTERNS; OUS SYSTEM. A KARYOTYPE confirms the diagnosis. MOSAICISM; PATAU’S SYNDROME; PRENATAL CARE. Fewer than 10 percent of infants born with Edwards syndrome survive the first year after ethical issues in genetics and molecular medicine birth; those who do require extensive, ongoing The questions and concerns that arise for physi- medical care and developmental support. Survival cians and individuals in regard to the information beyond five years is extremely rare. GENETIC SCREENING, GENETIC TESTING, and genetic and Doctors often can diagnose Edwards syndrome molecular therapies. Though advances in genetics and other autosomal trisomy disorders before have produced significant breakthroughs in under- birth, through prenatal screening methods such as standing, diagnosing, and sometimes treating AMNIOCENTESIS and CHORIONIC VILLI SAMPLING (CVS). health conditions that occur as a result of GENETIC 124 familial Mediterranean fever 125

DISORDERS, doctors and their patients grapple with complications of genetically based treatments. In the ethics of both research and therapeutics. The 2003 the US Food and Drug Administration (FDA), issues touch many of what have long been the which oversees clinical research and approves new sacred tenets of the practice of medicine: privacy, treatments, suspended certain GENE THERAPY meth- access to care, autonomy in decision making, and ods after people receiving apparently successful protection against discrimination. results suddenly acquired lethal leukemias. Informed consent, long the mainstay of treatment Privacy decision making, is increasingly difficult to apply. Most health conditions, with the exception of Other ethical issues arise in regard to making deci- infectious diseases, affect only the individuals who sions about genetic conditions that affect the lives have them. Matters of diagnosis, treatment, and and circumstances of children or other family prognosis remain private between physician and members. Further concerns involve legal and patient (and, some would add, third-party insur- forensic applications of genetic information. ers). Genetic issues affect families, current and prospective. Doctors, especially family practition- Discrimination ers who care for multiple members of the same As technology provides ever-expanding knowl- family, may find themselves in conflict in regard edge, concerns also grow that what people learn to genetic information about one family member about their health status could end up being used that affects the health or health prospects of other against them in settings ranging from health and family members. life insurance coverage to job offers and even medical care opportunities. Though such concerns Access to Care are not new, the inevitabilities of certain genetic Diagnostic and therapeutic applications of genetic outcomes put discrimination concerns in new per- technology are both complex and expensive. Many spective. procedures are available only in research facilities For further discussion of medical ethics within or are not covered by conventional HEALTH INSUR- the context of the structures and functions of ANCE plans. People who participate in clinical stud- genetics, please see the overview section “Genetics ies may have access to technologies that people and Molecular Medicine.” who choose not to participate in research cannot See also CLONING; LEUKEMIA; QUALITY OF LIFE. have. As well, questions arise in regard to the rela- tive value of certain applications of genetic technol- familial Mediterranean fever An inherited ogy. What purpose does genetic testing serve when genetic disorder that results in repeated episodes there is no treatment or cure for the genetic condi- of arthritis (INFLAMMATION of the joints), PERITONITIS tion? This is a particular issue for adults who may (inflammation of the membrane that lines the carry GENE mutations for genetic disorders such as abdominal cavity), pleuritis (inflammation of the HUNTINGTON’S DISEASE, for whom the disease is membrane that surrounds the LUNGS), and PERI- inevitable if they have the MUTATION but for which CARDITIS (inflammation of the membrane that con- at present there is no means to mitigate symptoms tains the HEART). FEVER accompanies the outbreaks or the disease’s unpleasant progression, although of inflammation, which occur without apparent promising therapies may be available soon. Some precipitating factors and not in any particular pat- health experts argue that resources provide greater tern. In some people the disorder also includes benefit for the larger good when they go toward AMYLOIDOSIS, in which deposits of amyloid (a wax- conditions for which prevention, treatment, or cure like substance) accumulate in organs such as the is possible. KIDNEYS. Familial Mediterranean fever, as the name Informed and Autonomous Decision Making implies, occurs predominantly among people of For as much as researchers have learned and now Mediterranean descent and is an autosomal reces- know about human genetics there remain vast sive disorder. The responsible mutated GENE is on unknowns about the potential benefits, risks, and the short arm of CHROMOSOME 16. At present there 126 Genetics and Molecular Medicine are no genetic tests or diagnostic procedures that drome more severely affects males because conclusively diagnose familial Mediterranean females have a second X chromosome that can fever; the doctor makes the diagnosis on the basis somewhat override the mutated gene on the other of family history and the pattern of symptoms. X chromosome. Most females are unaffected carri- See also AUTOSOME; GENETIC DISORDERS; INHERI- ers. Because males have one X chromosome and TANCE PATTERNS; MUTATION; RENAL FAILURE. one Y chromosome, they lack this dampening affect. A male can also be an unaffected CARRIER of family medical pedigree A comprehensive list- the mutated gene, though this is very rare, and ing of relatives and their medical conditions, will thus pass the mutation to all of his daughters including information about diseases that may though none of his sons. have genetic foundations. A family medical pedi- The symptoms of fragile X syndrome vary in gree looks somewhat like a genealogic family tree, severity though typically include with branched lineage to show family relation- ships (such as marriage, birth, half-siblings). The • developmental delays family medical pedigree should extend at least • speech impairments three generations and list each person’s age at the • intellectual impairment (sometimes profound) time of death, the cause of death, and any known • seizures history of diseases or symptoms. Many of the health conditions doctors know • behavioral problems today are genetic in origin were not known, either • AUTISM-like characteristics as diseases or as GENETIC DISORDERS, even one or • physical features that may include overly flexi- two generations ago, so documenting symptoms ble joints, flat feet, long facial configuration, can help reveal undetected genetic conditions. and oversized ears Maintaining a record of personal health symptoms and conditions, and similar information for chil- Diagnosis occurs through GENETIC TESTING, typi- dren, can further provide important clues about cally cytogenic analysis. Treatment may include genetic factors in health and in illness. supportive measures such as special education in See also GENOME; INHERITANCE PATTERNS; MUTATION; school, speech and language pathology, and med- PERSONAL HEALTH HISTORY. ications to moderate behaviors and control seizures. Children who are mildly affected may fragile X syndrome An inherited genetic disor- require little extra care and may attend regular der that results in significant intellectual impair- classes and schools; those who are severely ment. Fragile X syndrome arises from a affected may require ongoing support and institu- monogenic (single-GENE), increased repeat MUTA- tional care. TION affecting the FMR1 gene on the X CHROMO- See also DOWN SYNDROME; GENETIC COUNSELING; SOME and is the leading cause of inherited GENETIC DISORDERS; INHERITANCE PATTERNS; PHENYLKE- intellectual impairment in males. Fragile X syn- TONURIA (PKU); SEIZURE DISORDERS. G

gamete A spermatozoon (SPERM cell) or an ovum within each cell, synthesize the proteins. The pro- (egg cell). A gamete, also called a germ cell or sex tein then carries the gene’s message to its target cell, is a haploid cell; it contains half the comple- and initiates the appropriate sequence of biochem- ment of chromosomes and genetic material neces- ical events to implement the message. sary to encode (result in creating) an individual. For further discussion of genes within the con- When two gametes merge they produce a single text of the structures and functions of genetics, diploid cell, the ZYGOTE, which then contains the please see the overview section “Genetics and full complement of chromosomes needed for life. Molecular Medicine.” For further discussion of gametes within the See also CHROMOSOMAL DISORDERS; GENOME; context of the structures and functions of genetics, INHERITANCE PATTERNS; MUTATION; NUCLEOTIDE; SEX please see the overview section “Genetics and CHROMOSOME. Molecular Medicine.” See also CELL STRUCTURE AND FUNCTION; CHROMO- gene therapy Treatment methods, most of SOME; CONCEPTION; OVULATION. which remain experimental, that attempt to manipulate genetic structure or gene encoding. gene A segment of coding DNA (DNA that GENE therapy targets either germline (GAMETE) or instructs the structure and function of cells somatic cells, using vectors to deliver genes within throughout the body) composed of a specific cells. Germline gene therapy aims to prevent a sequence of nucleotides. The gene is the basic unit genetic disorder from passing to new genera- of inheritance that directs every facet of the body’s tions, while somatic gene therapy targets genetic appearance and functions. Genes align along chro- disorders that already exist in individuals. Most mosomes in pairs. Each CHROMOSOME (AUTOSOME) often the goal of gene therapy is to replace a contains thousands of genes, except the sex chro- defective gene with a healthy, functional gene. mosomes which contain only a few hundred The vectors typically used are inactivated viruses genes. into which scientists insert the replacement gene. Each gene has a specific location on the chro- The VIRUS enters the target cell and delivers the mosome, called its locus, and encodes a specific gene. function (either a protein or RNA transcription). Applications of gene therapy have not been as The HUMAN GENOME PROJECT identified 19,599 con- successful as researchers have hoped was possible, firmed genes and 2,188 probable genes at its con- however, and at present the US Food and Drug clusion in April 2003. GENETIC DISORDERS occur Administration (FDA) has not approved any gene when there are disruptions of the ALLELE pairings therapy methods for use in the United States. The or there is damage to the gene or the chromosome effects of gene therapy appear time-limited, and at or near the gene’s locus. viral vectors often initiate immune responses. Each gene has a specific task, which it carries Researchers continue to investigate safe and effec- out through a process called encoding. The gene tive mechanisms to therapeutically manipulate instructs the cells to synthesize (produce) a spe- genes with the goal of treating or curing GENETIC cific protein. Ribosomes, specialized structures DISORDERS. 127 128 Genetics and Molecular Medicine

See also ETHICAL ISSUES IN GENETICS AND MOLECU- als, couples, or families with as much information LAR MEDICINE; MOLECULARLY TARGETED THERAPIES; as possible about whatever genetic risks or situa- RECOMBINANT DNA; SOMATIC CELL. tions they are facing and the options for addressing them. genetic carrier An individual whose GENOTYPE The role of the genetic counseling team is to contains a recessive GENE MUTATION capable of caus- answer questions and provide support for the deci- ing a genetic disorder though the individual does sions individuals and couples make. Major health- not have or show symptoms of the disorder the care centers and high-risk obstetrical practice mutation causes. Typically a genetic CARRIER has groups generally have genetic counseling practi- one “good” gene and one mutated gene. A genetic tioners and services available. carrier may pass on the mutated gene to his or her See also ETHICAL ISSUES IN GENETICS AND MOLECU- biological children, though typically two mutated LAR MEDICINE; FAMILY MEDICAL PEDIGREE; GENETIC genes are necessary for the child to acquire the SCREENING; GENETIC TESTING; PREGNANCY. genetic disorder. See also CELL FUNCTION AND STRUCTURE; GENETIC genetic disorders A collective classification for DISORDERS; GENETIC SCREENING; GENETIC TESTING; syndromes, diseases, and congenital anomalies INHERITANCE PATTERNS. that result from alterations of the genes and chro- mosomes. There are four general categories of genetic code The organizations of nucleotides genetic disorders, each relating to the way in (DNA sequences) within messenger RNA into triplet which the alterations manifest. structures called trinucleotides or codons. The codons convey the order of amino acids for the Chromosomal Disorders structure of the protein for which a particular GENE The normal human GENOME contains 23 paired encodes. The process of protein synthesis takes chromosomes. CHROMOSOMAL DISORDERS occur place in the ribosomes in the cell cytoplasm; the when there are disruptions in these pairings in messenger RNA carries the encoding to the ribo- which there is an extra CHROMOSOME (trisomy) or a somes. missing chromosome (monosomy). Chromosomal See also CELL STRUCTURE AND FUNCTION; CHROMO- disorders also occur when large segments of a SOME; GENOME; GENOTYPE; NUCLEOTIDE; PHENOTYPE. chromosome are damaged or missing (deletion syndromes). Less often, a broken segment of a genetic counseling A multidisciplinary approach chromosome attaches itself to another chromo- to evaluating the risk for specific genetic diseases some (TRANSLOCATION). Common chromosomal dis- or CHROMOSOMAL DISORDERS. Doctors often recom- orders include DOWN SYNDROME, EDWARDS mend genetic counseling for people who have SYNDROME, PATAU’S SYNDROME, TURNER SYNDROME, strong family history for GENETIC DISORDERS such as and KLINEFELTER’S SYNDROME. TAY-SACHS DISEASE or HUNTINGTON’S DISEASE and older women who are or who are planning to become Single-Gene Disorders pregnant. Obstetricians also will recommend Each GENE encodes, or directs, a specific action genetic counseling for couples who receive posi- within the body. Single-gene disorders, in which a tive results from prenatal genetic tests so they may MUTATION of a gene or set of genes causes malfunc- make informed decisions and conduct appropriate tions of the proteins that carry out the gene’s planning for pregnancies in which there are instructions, cause conditions of faulty encoding, genetic or chromosomal abnormalities. either because the gene’s protein messenger is A genetic counseling team may include a clinical missing or incomplete. The disorders that result geneticist (physician specializing in genetics and often become more severe over time as the mal- molecular medicine), genetic psychologist, and a function continues to repeat itself. CYSTIC FIBROSIS, social worker. The intent of genetic counseling is to SICKLE CELL DISEASE, Duchenne’s MUSCULAR DYSTRO- evaluate family history, results of genetic tests, and PHY, HUNTINGTON’S DISEASE, and MARFAN SYNDROME current health circumstances to provide individu- are single-gene disorders. genetic predisposition 129

Multifactorial Disorders chromosomes that determine which traits are Researchers suspect many health conditions arise expressed in the PHENOTYPE. However, it is possible as a result of an interplay between genetic and for mutations to occur that result in both sets of a environmental factors. Geneticists call such condi- particular chromosome coming from the same tions multifactorial disorders because it appears a parent (uniparental disomy). Though such muta- certain combination of events must take place for tions likely occur with no noticeable effect and disease to result; doctors may refer to them as thus remain undetected, they can allow rare conditions of GENETIC PREDISPOSITION. These are the recessive abnormalities to be expressed. conditions that tend to run in families; some fam- Though rare, the CHROMOSOMAL DISORDERS ily members develop them and others do not. Prader-Willi syndrome and Angelman syndrome Health conditions in which genetics, lifestyle, and represent the most common pathology of genetic other variables participate in the development of imprinting. These syndromes reflect uniparental disease are numerous. Some of those that are disomy of CHROMOSOME 15, one of the chromo- common include CORONARY ARTERY DISEASE (CAD), somes known to incorporate genetic imprinting. HYPERTENSION (high BLOOD PRESSURE), CANCER, DIA- Chromosome 15 regulates numerous neurologic BETES, GALLBLADDER DISEASE, and NEPHROLITHIASIS and musculoskeletal structures and functions that (kidney stones), and numerous other conditions. affect intelligence, cognition (the ability to think, reason, and remember), behavior, emotion, physi- Mitochondrial Disorders cal appearance, MUSCLE tone, movement, and Mitochondria are self-replicating structures within METABOLISM as well as reproductive health and a cell (called organelles) that carry out the meta- capability. bolic functions of the cell. Mitochondria have Normal development requires one copy of their own DNA that directs their specific functions, chromosome 15 from each parent. When both and have multiple copies; MITOCHONDRIAL DNA copies of chromosome 15 are maternal (called (MTDNA) is different from the cell’s nuclear DNA. paternal deletion), genetic imprinting produces a MITOCHONDRIAL DISORDERS, which are the rarest of constellation of symptoms known as Prader-Willi the genetic disorders, occur when the genes that syndrome. When both copies of chromosome 15 encode mitochondrial activity contain mutations are paternal (called maternal deletion), genetic or when there are defects in the mtDNA. Mito- imprinting produces a constellation of symptoms chondrial disorders tend to vary widely among known as Angelman syndrome. Each syndrome individuals, causing different symptoms because presents differing manifestations of neurologic they affect different, and usually multiple, organs dysfunction, musculoskeletal and other physical or structures. Doctors define the disorder as a anomalies, and intellectual impairment. complex of symptoms. Some forms of Researchers believe genetic imprinting is a ENCEPHALOPATHY, MYOPATHY, and CARDIOMYOPATHY are mechanism intended to prevent damaging muta- mitochondrial disorders. tions from propagating (extending themselves). See also CONGENITAL ANOMALY; INHERITANCE PAT- Genetic imprinting appears to affect only certain TERNS; MOSAICISM. chromosomes and, when it causes a disease state, results in related though differing symptoms, genetic imprinting The inactivation of certain depending on the deletion. genes, determined by whether the GENE is mater- See also CELL STRUCTURE AND FUNCTION. nal (comes from the mother) or paternal (comes from the father). Genetic imprinting, also called genetic predisposition The tendency to develop genomic imprinting, appears to be another a health condition as a consequence of the inter- method of controlling genes by requiring one copy action between genetics and lifestyle factors. Doc- of each of certain chromosomes from each parent. tors believe genetic influences underlie many if INHERITANCE PATTERNS, which establish gene not all health conditions that develop over time, expression through dominance, regulate most such as HYPERTENSION (high BLOOD PRESSURE), ATHER- gene expression and normally present paired OSCLEROSIS, OSTEOARTHRITIS, RENAL FAILURE, LIVER dis- 130 Genetics and Molecular Medicine ease, and type 2 DIABETES. An individual’s GENOTYPE even when the findings of genetic screening pro- establishes genetic vulnerability through mecha- cedures appear normal. Genetic screening proce- nisms researchers do not fully understand. dures are minimally invasive and typically present These genetic elements influence the effects of no risk to the mother or the fetus in prenatal environmental factors such as cigarette smoking, screening or to the individual in screening con- physical activity and inactivity, exposure to chemi- ducted following birth or in adults. cal toxins, ALCOHOL consumption, and nutrition See also AMNIOCENTESIS; AUTOSOMAL TRISOMY; (lack of certain NUTRIENTS or excesses of other CHORIONIC VILLI SAMPLING (CVS); CHROMOSOMAL DISOR- nutrients) in the development of disease DERS; ETHICS IN GENETICS AND MOLECULAR MEDICINE; processes. Once the disease becomes established, FAMILY PLANNING; FOLIC ACID SUPPLEMENTATION; its genetic underpinnings may allow more rapid GENETIC TESTING; NEURAL TUBE DEFECTS. progression of damage or severity of symptoms. Unlike GENETIC DISORDERS that encode for specific genetic testing Methods and procedures to disturbances of structures and functions that determine the presence of a genetic disorder. The inevitably produce a disease state (such as DOWN KARYOTYPE, which uses microphotographs to exam- SYNDROME), genetic predisposition for a condition ine and depict an individual’s chromosomes, is does not make that condition certain. Many doctors one of the more common methods of genetic test- and researchers believe knowing of genetic predis- ing. Other methods include cytogenic analysis, positions gives an individual the opportunity to AMNIOCENTESIS, and CHORIONIC VILLI SAMPLING (CVS). engage in lifestyle modifications to prevent health Some genetic testing methods are highly sophisti- problems from developing. cated and require specialized equipment and See also LIFESTYLE AND HEALTH. knowledge available only in research centers. Other methods, such as CVS, have become fairly genetic screening Procedures that indicate commonplace. whether an individual has the potential to have a Diagnostic genetic testing can identify the cause genetic disorder. Among the most commonly per- of symptoms resulting from GENE mutations and formed genetic screening procedures in the United CHROMOSOMAL DISORDERS. This knowledge can be States are prenatal ULTRASOUND and maternal BLOOD helpful when there are treatments and treatment levels of multiple biomarkers, such as ALPHA FETO- choices for the resulting conditions, and in FAMILY PROTEIN (AFP), during PREGNANCY. These procedures PLANNING decisions. The matter of genetic testing to may present suspicious findings though are not screen for the presence of GENETIC DISORDERS, par- precise enough to allow diagnosis. Other genetic ticularly in people who do not have symptoms or screening procedures are those that test for condi- apparent increased risk for conditions of genetic tions that occur in the general population and origin, remains an issue of intense ethical debate. have significant consequences when undetected Some such practices, such as testing for PHENYLKE- and untreated. For example, hospitals in the TONURIA (PKU) in newborns, have become standard United States conduct routine newborn testing for in the United States. Others, such as those for the PHENYLKETONURIA (PKU), an inherited metabolic dis- so-called CANCER genes (BRCA-1, BRCA-2, CA-125, and order that results in severe intellectual impair- others), often raise more questions than answers ment without treatment at the time of birth. because the consequence of having such genes The findings of genetic screening, positive or remains uncertain. negative, can have a margin of error for false- Even when the outcome is certain, the knowl- negative as well as false-positive results. However, edge of the genetic disorder may have little thera- doctors use genetic screening when factors of peutic value yet create distress for the individual. increased risk for GENETIC DISORDERS, such as mater- This is currently a significant issue with genetic nal age in pregnancy or family history, exist. The testing for HUNTINGTON’S DISEASE, for example, a doctor may conduct further GENETIC TESTING and fatal neurodegenerative disorder for which there diagnostic testing when the overall health picture is no treatment or cure. People who carry the points to an increased risk for genetic disorders, gene MUTATION for Huntington’s disease are certain G6PD deficiency 131 to develop the disease in midlife. GENETIC COUNSEL- experiences unusual stress, such as illness, or with ING is almost always a valuable and necessary certain medications such as aspirin and sulfa component of genetic testing. antibiotics. These circumstances cause oxidants to See also ETHICAL ISSUES IN GENETICS AND MOLECU- accumulate in the blood. Without G6PD to neu- LAR MEDICINE; GENETIC PREDISPOSITION; LIFESTYLE AND tralize these oxidants, they destroy erythrocytes, HEALTH. resulting in hemolytic ANEMIA. The symptoms of hemolytic anemia resulting genome The total genetic material, including from G6PD deficiency include coding and noncoding sequences, a cell contains in its chromosomes. Each organism has a unique • dark URINE genome. Scientists define the size of a genome by • pale SKIN the number of its base pairs. The human genome • weakness contains 3.2 billion base pairs, which make up • JAUNDICE (yellowish discoloration of the skin that comprise about 23,000 genes. and sclera of the eyes) See also CELL STRUCTURE AND FUNCTION; CHROMO- SOME; GENE; GENOTYPE; HUMAN GENOME PROJECT; PHE- • HEPATOMEGALY (enlarged LIVER) and SPLENOMEGALY NOTYPE. (enlarged SPLEEN) • tachycardia (rapid HEART RATE) genotype The contents of an individual’s GENETIC • FEVER CODE. The genotype directs the structures and func- tions of the human body. A person’s genotype is to Symptoms and family history may cause the the human body what an architect’s blueprint is to doctor to suspect G6PD deficiency. Blood tests will a house: It provides the directions for the construc- reveal the hemolytic anemia. Treatment generally tion and operation of the human organism. consists of avoiding circumstances and substances See also GENOME; KARYOTYPE; PHENOTYPE. that trigger oxidative stress. Many people are able to avoid symptoms entirely through such an G6PD deficiency An inherited genetic disorder approach. Because G6PD is an inherited condition, in which the body lacks the enzyme glucose-6- there are no methods for prevention. The inheri- phosphate dehydrogenase (G6PD). Erythrocytes tance pattern for G6PD is X-linked recessive; (red BLOOD cells) normally produce G6PD, which G6PD affects twice as many males as females and aids in metabolizing carbohydrates and also helps is more prominent in people of African American to protect erythrocytes from oxidation (damage heritage and Mediterranean heritage. resulting from metabolic waste). The absence of See also ERYTHROCYTE; GENETIC DISORDERS; INHERI- G6PD causes health problems when the body TANCE PATTERNS; PHENYLKETONURIA (PKU); PORPHYRIA. H–K

Human Genome Project A collaborative under- linked and either dominant or recessive. Such taking among researchers around the world, inheritance patterns reflect statistical calculations organized under the joint auspices of the U.S. assessing the mathematical likelihood of certain Department of Energy and the National Institutes traits or mutations passing from one generation to of Health, to identify and map the human GENOME the next. Inheritance patterns consider the geno- (genetic material that defines the human being). types of each parent. Inheritance patterns vary Altogether, more than 20 research centers in the according to whether the chromosomes responsi- United States, United Kingdom, China, France, ble are autosomesal or sex-linked chromosomes. Germany, and Japan participated in the DNA Geneticists often refer to these patterns as sequencing. The Human Genome Project began in Mendelian, in reference to the foundational work 1990 and concluded with the full mapping of of botanist Gregor Mendel (1822–1884), who was the human genome in April 2003, 50 years after the first to delineate inheritance patterns. Watson and Crick unveiled their double-helix Recent research, notably through the HUMAN model of DNA. Researchers expect data analysis GENOME PROJECT, has shown that much of human and new findings to continue for the indefinite inheritance may not be quite so simple as the future. The Human Genome Project’s Web site, Mendelian model. Multiple genes and chromo- (www.ornl.gov), regularly posts updates. somes share responsibility for traits ranging from EYE color to the development of diseases, such as HUMAN GENOME PROJECT FINDINGS: HIGHLIGHTS DIABETES AND CARDIOVASCULAR DISEASE, that also • The human GENOME consists of 3,164,700,000 NUCLEOTIDE have environmental (lifestyle) components. This bases. circumstance of multiple factors makes it far more • The largest GENE (dystrophin) contains 2.4 million nucleotide difficult to statistically represent a delineated pat- bases. tern of inheritance. Multifactorial inheritance is • 99.9 percent of the nucleotide bases are identical in all peo- not clearly dominant or recessive, though is com- ple. monly autosomal (derives from autosomes rather • The human genome contains about 30,000 genes. than sex chromosomes). • CHROMOSOME 1 contains 2,968 genes and chromosome Y The least common pattern of inheritance is contains 231 genes, the most and the fewest, respectively. mitochondrial, which comes only from the Source: The Science behind the Human Genome Project, mother and involves traits and mutations affecting www.ornl.gov/hgmis; updated October 27, 2004. mitochondrial, not nuclear, DNA. This pattern is exclusively maternal because only the ovum See also CELL STRUCTURE AND FUNCTION; CLONING; (female GAMETE or egg) contains mitochondria. ETHICAL ISSUES IN GENETICS AND MOLECULAR MEDICINE; Mitochondria affect functions rather than struc- GENOTYPE; PHENOTYPE; RECOMBINANT DNA. tures of the body, and thus, mitochondrial muta- tions cause numerous, nonspecific multisystem inheritance patterns The ways in which geno- disturbances. Because mitochondria are the types pass among individuals and generations. energy generators of the cells, mitochondrial Many inherited traits are either autosomal or X- mutations affect functions that require energy 132 karyotype 133

INHERITANCE PATTERNS: AUTOSOMAL TRAITS AND MUTATIONS Autosomal Recessive Autosomal Dominant Both parents carriers One parent carrier, Both parents affected One parent affected, one parent noncarrier one parent unaffected Each child: Each child: Each child: Each child: 25% condition 50% noncarrier 25% unaffected 50% unaffected 25% noncarrier 50% carrier 25% more severely affected 50% affected 50% carrier than parents 50% affected Percentages refer to the probability of occurrence.

INHERITANCE PATTERNS: X-LINKED TRAITS AND MUTATIONS X-Linked Recessive X-Linked Dominant Mother CARRIER, Mother noncarrier, Mother affected, Mother noncarrier, father noncarrier father affected father noncarrier father affected Each daughter: Each daughter: Each daughter or son: Each daughter: 25% noncarrier 100% carrier 50% affected 100% affected 25% carrier Each son: 50% nonaffected Each son: Each son: 100% noncarrier 100% nonaffected 25% noncarrier 25% affected Percentages refer to the probability of occurrence.

rather than affect structures of the body. Though chromosomes from largest to smallest. This stan- mitochondrial mutations may be single-GENE, they dardized presentation allows the geneticist to ana- often have widespread effects across types of cells lyze an individual’s chromosomal profile. A in which energy needs are high, such as NERVE geneticist can structure a karyotype from any cells and MUSCLE cells. SOMATIC CELL (nonsex cell) in the body. The most See also AUTOSOME; CHROMOSOME; FAMILY MEDICAL common application of karyotyping is GENETIC PEDIGREE; GENOTYPE; MITOCHONDRIAL DISORDERS; MITO- SCREENING of a fetus. A geneticist constructs a kary- CHONDRIAL DNA (MTDNA); MUTATION; SEX CHROMO- otype to evaluate whether an individual has a SOME. GENETIC DISORDER. A karyotype requires DNA from a representative cell in the body, from which the karyotype A pictorial presentation of an individ- geneticist extracts and prepares the DNA for ual’s chromosomes, taken from microphotographs examination under the microscope. (photographs taken through a microscope) and See also CHROMOSOME; GENETIC COUNSELING; arranged in a numeric sequence that aligns the GENETIC DISORDERS; GENETIC TESTING. M–N

mitochondrial disorders Inherited mutations in experience for those patients looking for answers mitochondrial genes that result in functional dis- for their symptoms. There are no definitive diag- turbances in various body systems. Mitochondria nostic tests for mitochondrial disorders, though are structures within the cell that generate the muscle biopsy often can provide strong evidence energy, in the form of adenosine triphosphate supporting diagnosis once doctors rule out other (ATP), the cell requires to function. A cell may conditions and disorders. Treatment targets manag- contain dozens of mitochondria. Each mitochon- ing symptoms and preventing common complica- drion contains the specific genetic material (MITO- tions such as DEHYDRATION. Some doctors advocate CHONDRIAL DNA [MTDNA]) to encode the enzymes COENZYME Q10 supplementation for people who (specialized proteins) that regulate the biochemi- have mitochondrial disorders, which appears to cal reactions within the mitochondrion that gen- improve the efficiency of cellular METABOLISM as erate ATP. The only function of mtDNA is to well as protect cells from oxidative damage. People regulate these processes of energy production. who have mitochondrial disorders should include Each mitochondrion contains multiple copies of GENETIC COUNSELING in their FAMILY PLANNING efforts. its DNA. Mutations typically affect some but not See also CELL STRUCTURE AND FUNCTION; CHROMO- all DNA copies, so mitochondrial function contin- SOME DISORDERS; GENETIC DISORDERS; MUTATION; REPLI- ues though may be impaired whenever the CATION ERROR. mutated mitochondrial GENE sends incorrect code. Only the ovum contains mitochondria that pass mosaicism A chromosomal disorder in which on to the ZYGOTE at CONCEPTION. SPERM cells contain some cells are normal and some cells contain the few mitochondria, and these are in the sperm chromosomal abnormalities of the disorder, in cell’s tail, which breaks away as soon as the sperm contrast to a complete distribution of the abnor- penetrates the ovum. As the zygote continues to mal chromosomes throughout all cells. The distri- divide, it may perpetuate errors in mtDNA that are bution of abnormal cells in mosaicism is usually widespread or pervasive. random and unpredictable. Mosaicism most com- Mitochondrial disorders include myositis, some monly occurs in AUTOSOMAL TRISOMY, in which types of CARDIOMYOPATHY, some types of MYOPATHY, there is an additional copy of one CHROMOSOME and carnitine deficiency syndrome. Often, symp- that appears in some cells and not in others. The toms are multisystem and inconsistent with the result generally is a milder presentation of symp- conventional presentations of the health condi- toms when only some cells express the abnormal- tions they suggest. MUSCLE and NERVE cells have ity (mosaic disorder) than occurs when all cells particularly high energy needs, so mitochondrial express the abnormality (complete disorder). Peo- disorders often manifest symptoms such as weak- ple who have a mosaic expression of the autoso- ness and poor muscle tone (hypotonia). mal trisomy disorder DOWN SYNDROME, for Because mitochondrial disorders are rare and example, typically have milder symptoms than their symptoms are confusing, the diagnostic path people who have a complete expression. may lead to numerous dead ends. Though this Mosaicism may also affect genetic expressions process rules out other diagnoses, it is a frustrating other than health disorders. 134 nucleotide 135

See also CELL STRUCTURE AND FUNCTION; CHROMO- CEPTION, passing to the child. WILMS’S TUMOR and SOMAL DISORDERS; EDWARDS SYNDROME; INHERITANCE HEMOPHILIA are examples of germline mutations PATTERNS; MUTATION; PATAU’S SYNDROME; REPLICATION that cause disease. A monogenic MUTATION affects a ERROR. single gene. Duchenne’s MUSCULAR DYSTROPHY and SICKLE CELL DISEASE are among the conditions that mutation Permanent alterations in the ALLELE occur as a result of monogenic mutations. Poly- pairings, or genes, on the chromosomes that pass genic mutations involve multiple alleles of numer- on to new cells and ultimately to offspring. Muta- ous genes, often across chromosomes. Polygenic tions are the process through which genetic mutations often do not clearly result in GENETIC change takes place. Some mutations are benefi- DISORDERS though establish GENETIC PREDISPOSITION. cial, some are neutral, and some are harmful. Conditions such as CARDIOVASCULAR DISEASE (CVD), Mutations occur as changes in the GENE’s DIABETES, and some types of cancer occur as a NUCLEOTIDE sequences. These changes may take the result of polygenic mutations in combination with form of lifestyle (environmental) factors. See also AUTOSOMAL TRISOMY; CHROMOSOMAL DIS- • point mutations, also called base mutations, ORDERS; LIFESTYLE AND HEALTH. which are analogous to changing one letter in a word and occur when one nucleotide substi- nucleotide A structural component of DNA and tutes for another RNA. A DNA nucleotide contains deoxyribose and • deletion mutations, which are analogous to a nitrogen base of adenine, guanine, thymine, or removing a word from a sentence and occur cytosine, which form pairs called base pairs. An when the gene drops a nucleotide sequence RNA nucleotide contains ribose and a nitrogen • insertion mutations, which are analogous to base of paired adenine, guanine, uracil, or cyto- adding a word to a sentence and occur when sine. Each DNA or RNA molecule contains thou- the gene adds a nucleotide sequence sands of nucleotides. The order in which the • increased repeat mutations, which occur when nucleotides appear is the base sequence and con- a normally repeated nucleotide repeats extra veys the GENETIC CODE for the proteins the DNA or times RNA molecule encodes. Base sequences, arranged in triplets (trinucleotides), make up GENES. A germline mutation affects a GAMETE (ovum or See also CELL STRUCTURE AND FUNCTION; CHROMO- spermatozoon) or ZYGOTE and is present from CON- SOME; GENOME. P–R

Patau’s syndrome An AUTOSOMAL TRISOMY disor- the BRAIN and NERVOUS SYSTEM. KARYOTYPE confirms der that results from a REPLICATION ERROR during the diagnosis. It is rare for a child who has Patau’s cell division in which a GAMETE (sex cell) ends up syndrome to survive beyond early childhood; with two copies of CHROMOSOME 13 instead of the there are no documented survivals to adulthood. normal single copy (as haploid cells, gametes con- Ongoing medical care to accommodate physical tain one-half the complement of chromosomes). anomalies and developmental support to achieve At CONCEPTION the ZYGOTE thus ends up with three optimal learning potential provide the child who instead of the normal two copies of chromosome survives the best possible QUALITY OF LIFE. 13, which ultimately produces multiple and life- See also AUTOSOME; CHROMOSOME DISORDERS; CON- threatening congenital anomalies. When Patau’s GENITAL ANOMALY; CONGENITAL HEART DISEASE; DOWN syndrome occurs as a complete trisomy disorder SYNDROME; EDWARDS SYNDROME; ETHICAL ISSUES IN (all cells carry the extra chromosome), the anom- GENETICS AND MOLECULAR MEDICINE; GENETIC SCREEN- alies are so severe that the disorder often is lethal ING; INHERITANCE PATTERNS; MOSAICISM; POLYCYSTIC KID- well before birth. Occasionally Patau’s syndrome NEY DISEASE. occurs as a mosaic disorder (some but not all cells contain the extra chromosome 13), which typi- phenotype The outward presentation, or fea- cally produces milder though nonetheless signifi- tures, of an individual’s GENOTYPE (genetic compo- cant symptoms. Patau’s syndrome occurs in about sition). The phenotype is the construction and 1 in 10,000 live births in the United States. operation that results from implementation of the genotype, much as a house is the outcome of a CONGENITAL ANOMALIES building contractor’s implementation of an archi- CHARACTERISTIC OF PATAU’S SYNDROME tect’s blueprints. A phenotype consists of such atrial septal defect (ASD) CLEFT PALATE/CLEFT PALATE obvious characteristics as EYE color and HAIR pat- malformed KIDNEYS AND LIP terns as well as less apparent traits such as BLOOD malformed or absent eyes malformed KIDNEYS TYPE and proclivity for health or certain diseases. malformed or absent NOSE microcephaly (small head The genotype for lipid METABOLISM, for example, multiple hernia and BRAIN) may support effective use of lipids within the body patent ductus arteriosus polycystic kidneys (supporting health) or the tendency for high levels (PDA) POLYDACTYLY of lipids to accumulate in the BLOOD (increasing ventricular septal defect (VSD) Vextrocardia (HEART on right the risk for CARDIOVASCULAR DISEASE [CVD]). side of chest) See also ALLELE; ALOPECIA; CELL STRUCTURE AND FUNCTION; FAMILY MEDICAL PEDIGREE; VARIATION. Children born with Patau’s syndrome have severe and complex physical deformities involving phenylketonuria (PKU) An inherited genetic multiple organ systems that require extensive disorder in which the enzyme phenylalanine medical care from the time of birth. Most also hydroxylase is missing or severely deficient, pre- have severe developmental delays and intellectual venting the METABOLISM of the essential amino acid impairment arising from malformations affecting (one the body must acquire from dietary sources) 136 porphyria 137 phenylalanine. Phenylalanine is common in all pass the disorder to their children only if the father foods that contain protein (such as meats, dairy carries the mutated gene or also has PKU. products, fish, and legumes) and in artificial sweeteners such as aspartame. Avoiding foods that Risk Factors and Preventive Measures contain phenylalanine, which means following a PKU is an autosomal recessive, single-GENE muta- strict low-protein diet, prevents phenylalanine tion. Both parents must carry the PKU mutation accumulations and the resultant damage that for a child to have the disorder. However, PKU affects primarily the NERVOUS SYSTEM. The most carriers often do not know they have the mutated significant consequence of undiagnosed PKU is gene because they do not show any indications of irreversible, and usually severe, intellectual the disorder. People who know they are PKU car- impairment. riers or who have PKU should consider GENETIC COUNSELING as an element of their FAMILY PLANNING. Symptoms and Diagnostic Path See also CARRIER; GENETIC DISORDERS; INHERITANCE Early symptoms of PKU appear soon after birth and PATTERNS; NUTRITIONAL NEEDS; PORPHYRIA. include restlessness, irritability, stunted growth, and a characteristic musty smell to the breath. The porphyria The collective term for a group of eight appearance of symptoms means neurologic damage inherited GENETIC DISORDERS of METABOLISM in which is already occurring, however. Newborn screening deficiencies of certain enzymes block the produc- to identify PKU before symptoms appear is essential tion of heme and allow the accumulation of por- to prevent intellectual impairment. Hospitals in the phyrins. Heme is an iron-containing pigment United States routinely screen newborns, typically normally present in nearly all tissues in the body, within two days of birth, to detect elevated levels of notably as a component of HEMOGLOBIN in the BLOOD phenylalanine in the blood. Further testing can and of electron transport proteins called confirm the diagnosis, and immediate dietary cytochromes. The LIVER produces cytochromes, restrictions can prevent the disorder from causing which are essential for metabolizing numerous permanent damage. drugs, hormones, NUTRIENTS, and other substances. Heme synthesis occurs in a sequence of eight steps, Treatment Options and Outlook each occurring through the actions of a particular Treatment is stringent restriction of dietary pheny- enzyme. Each of the eight forms of porphyria rep- lalanine, which includes BREAST milk. Infants resents the absence of one of these enzymes. require special phenylalanine-free formulas. Dietary restrictions are lifelong. Many food prod- Symptoms and Diagnostic Path ucts contain labeling information that states their Symptoms vary with the type of porphyria and may phenylalanine content, and a number of food be neurologic (affect the NERVOUS SYSTEM), dermato- manufacturers produce low-phenylalanine ver- logic (affect the SKIN), hepatic (involve the liver), or sions of popular foods such as cereals as well as erythropoietic (involve the BONE MARROW and phenylalanine-free protein substitutes. Fruits, veg- blood). Typically symptoms are episodic, occurring etables, breads, and pastas contain very low as attacks that last for days to weeks and sometimes amounts of phenylalanine. In the United States longer. Symptoms vary widely in appearance, foods that contain aspartame must state on the severity, and duration and may include label that they contain phenylalanine. Women who have PKU can safely carry a PREG- • eruptive skin rashes (bullae) NANCY to term though must be especially diligent to • PHOTOSENSITIVITY maintain a low phenylalanine diet because exces- sive phenylalanine in the mother’s BLOOD circula- • severe ABDOMINAL PAIN tion also affects the developing FETUS and can cause • NAUSEA, VOMITING, and DIARRHEA permanent neurologic and other damage before birth. Because the inheritance pattern for PKU is • MUSCLE weakness and possibly PARALYSIS autosomal recessive, women who have PKU will • agitation and hallucinations 138 Genetics and Molecular Medicine

THE PORPHYRIAS Porphyria Deficient Enzyme Inheritance Pattern acute intermittent porphyria (AIP) porphobilinogen deaminase (PBG-D) autosomal dominant

ALAD-deficiency porphyria (ADP) aminolevulinic acid dehydratase (ALAD) autosomal recessive congenital erythropoietic porphyria (CEP) uroporphyrinogen III cosynthase autosomal recessive erythropoietic protoporphyria (EPP) ferrochelatase autosomal dominant hepatoerythropoietic porphyria (HEP) uroporphyrinogen decarboxylase autosomal recessive hereditary coproporphyria (HCP) coproporphyrinogen oxidase autosomal dominant porphyria cutanea tarda (PCT) uroporphyrinogen decarboxylase autosomal dominant variegate porphyria (VP) protoporphyrinogen oxidase autosomal dominant

• tachycardia (rapid HEART RATE) Risk Factors and Preventive Measures • URINARY RETENTION and URINARY INCONTINENCE The porphyrias are inherited genetic disorders. The risk of porphyria depends on the inheritance The diagnostic path includes blood and urine pattern. There are no measures to prevent por- tests to measure the presence of key porphyric phyria. People who have porphyria, or who have enzymes. In people who know they have por- family members who have porphyria, might con- phyria, exposure to identified precipitating factors sider GENETIC TESTING and GENETIC COUNSELING. It is —which include numerous drugs, hormones, and possible to be a CARRIER for the autosomal reces- nutrients—will bring on an attack. HYPERTENSION sive forms of porphyria. (high BLOOD PRESSURE) can develop during an See also BULLA; CYTOCHROME P450 (CYP450) attack and persist after symptoms subside. ENZYMES; GENE; HALLUCINATION; HORMONE; MUTATION; RASH. Treatment Options and Outlook Severe symptoms, particularly neurologic, require progeria A very rare genetic disorder, commonly hospitalization and aggressive treatment that may called severe premature aging, that arises from a include intravenous heme administration (the MUTATION in a single GENE on CHROMOSOME 1 called only form in which heme is available). Medica- lamin A (LMNA). The gene encodes a protein, also tions safe to take to relieve and control symptoms called lamin A, that is important for proper func- include narcotic pain relievers and phenothiazines tioning of the membrane of the cell nucleus. In to relieve nausea and vomiting or neuropsychi- progeria this protein is abnormal, resulting in atric symptoms. It is crucial to stop any substances rapid deterioration of the nuclear membrane and that may have precipitated the attack. Most symp- destruction of the cell. The diagnostic path is pri- toms subside within two to three weeks, and most marily clinical, based on symptoms. Most children people fully recover within six weeks. Some peo- who have progeria die of cardiovascular problems ple experience extended muscle weakness. such as HEART ATTACK or STROKE by the age of 12 or Attacks may occur without provocation. Many 13 years. As a consequence of research into the people who have porphyria seldom experience causes of progeria, scientists have discovered other attacks, however. mutations of the same gene that cause uncommon RNA 139 forms of MUSCULAR DYSTROPHY. At the present time DISORDERS such as AUTOSOMAL TRISOMY, in which a there is no treatment, cure, or prevention for GAMETE (also called a sex cell or germ cell) receives progeria. two copies of a CHROMOSOME instead of the normal See also CELL STRUCTURE AND FUNCTION; GENETIC single copy. Gametes, which are haploid cells, DISORDERS. each carry one-half the complement of chromo- somes so when they unite to form the ZYGOTE that recombinant DNA A biotechnology technique will become a new human being, the zygote con- that replaces DNA to alter a cell’s function. There tains the full complement of genetic material. are several methods for performing recombina- With a replication error such as an autosomal tri- tion, though all ultimately involve extracting the somy, the zygote receives an extra chromosome— native DNA from a carrier (called a vector) and two copies from one gamete and one copy from replacing it with the desired DNA. Modified BACTE- the other gamete. The result is a chromosomal dis- RIA and viruses are common vectors—bacteria order such as DOWN SYNDROME. Replication errors because they replicate rapidly, and viruses because also may have harmless consequences when they they can deliver modified DNA into the nucleus of occur in DNA sequences that do not encode struc- cells within the body (GENE THERAPY). tural or regulatory sequences of gene activity. One of the most significant uses of recombinant See also MUTATION; VARIATION. DNA technology is the production of substances such as human INSULIN supplementation to treat RNA The abbreviation for ribonucleic acid. RNA DIABETES, which recombinant technology can syn- is a single-strand molecule consisting of ribose; a thesize in vast quantities in the laboratory to meet sugar; and nucleotides made up of the nitrogen strict quality and consistency standards. Because bases adenine, uracil, guanine, and cytosine. RNA such recombinant products are biochemically exists in a number of forms, all of which serve as indistinguishable from their endogenous (natu- biochemical messengers that carry the instructions rally produced in the body) counterparts, they are of DNA to the ribosomes, structures in the cell’s an exact replacement, and the body accepts them cytoplasm. Ribosomes synthesize (manufacture) as though they were endogenous. Recombinant the proteins the genes encode. RNA also may DNA technology produces other hormones, too, function as the carrier of GENETIC CODE within the such as HUMAN GROWTH HORMONE (HGH) SUPPLEMENT. mitochondria. See also CELL STRUCTURE AND FUNCTION; CLONING; For further discussion of RNA within the con- HORMONE; VIRUS. text of the structures and functions of genetics, please see the overview section “Genetics and replication error A mistake that occurs when Molecular Medicine.” DNA sequences duplicate before cell division. Repli- See also CELL STRUCTURE AND FUNCTION; GENE; cation errors are accountable for CHROMOSOMAL NUCLEOTIDE. S

senescence The gradual and progressive slowing some carries. HEMOPHILIA and some forms of MUS- of cellular activity, including cell division, that CULAR DYSTROPHY (notably Duchenne’s and occurs with aging. Cells lose the ability to divide Becker’s) are X-linked genetic disorders. over time, a phenomenon researchers call See also AUTOSOME; GAMETE; GENE; MUTATION; Hayflick’s limit. The limit relates to the number of SOMATIC CELL. times the cell divides. During cell division, fibers of DNA called telomeres attach to the chromatids, somatic cell A cell that is not a GAMETE (sex facilitating their separation from each other to cell). More than 99 percent of the body’s trillions enter the new daughter cells. The process destroys of cells are somatic cells. Somatic cells are diploid; the segment of the TELOMERE attached to the CHRO- their nuclei contain the full complement of paired MATID, causing the telomere to shorten with each chromosomes and genetic material necessary to cell division. When the cell runs out of telomeres encode an organism. When somatic cells divide, it can no longer divide and it dies. their chromosomes replicate so the new daughter The exceptions are cancer cells, which seem to cells receive the full complement of paired chro- be nonsenescent. Cancer cells produce increased mosomes as well. levels of an enzyme called telomerase, which acts For further discussion of somatic cells within to restore the length of the telomeres and gives the context of the structures and functions of cancer cells the ability to endlessly divide. Normal genetics, please see the overview section “Genetics cells also produce telomerase but not in quantities and Molecular Medicine.” sufficient to regenerate telomeres. Researchers do See also CELL STRUCTURE AND FUNCTION; CHROMO- not know what causes cancer cells to increase the SOME; CONCEPTION; REPLICATION ERROR; ZYGOTE. amount of telomerase they produce. As well, other factors are at play in the processes of senes- stem cell An undifferentiated, primal cell that cence, which researchers continue to study. has the capability to endlessly divide and develop See also APOPTOSIS; CELL STRUCTURE AND FUNCTION; into numerous types of cells. Totipotent stem cells PROGERIA. exist primarily in the early EMBRYO (blastocyst) and can differentiate into (become) virtually any type sex chromosome The structure of GENETIC CODE of cell in the body. As the body becomes more that determines gender (male or female). The complex and develops beyond the blastocyst stage, male sex CHROMOSOME has the appearance of the stem cells become specialized to produce certain letter Y and the female sex chromosome has the kinds of cells, which they retain the ability to do appearance of the letter X. A combination of XY endlessly. These stem cells, though found in tis- results in male and a combination of XX results in sues of all kinds throughout the body, are most female. The Y chromosome contains fewer than highly concentrated in the BONE MARROW (BLOOD 100 genes, while the X chromosome carries sev- STEM CELLS). UMBILICAL CORD BLOOD is another eral hundred genes. A number of GENETIC DISOR- source of highly concentrated blood stem cells. DERS are X-linked—that is, they result from Blood stem cells can differentiate into any type of mutations that occur among genes the X chromo- blood cell. 140 stem cell therapy 141

Researchers have had some success with stimu- been successful in cultivating stem cells into SKIN lating blood stem cells, in the laboratory, to func- for skin grafting, to treat severe BURNS, and into tion as though they were other types of cells such pancreatic islet cells that produce INSULIN, to treat as NERVE cells or MUSCLE cells, and are hopeful that severe type 1 DIABETES. Though these applications stem cells will someday become a source of culti- of stem cell therapy remain experimental, they vated replacement tissues and organs. Multipotent raise the potential for stem cell therapy to become stem cells that occur in other tissues are difficult viable in treating numerous health conditions. to identify and extract from their source tissues Two significant concerns with stem cell therapy though may also hold similar potential. are the potential for cancer to develop and the For further discussion of stem cells within the rejection of the cultivated cells or tissue. A prime context of the structures and functions of genetics, value of the stem cell is its unlimited ability to please see the overview section “Genetics and divide. However, a function called APOPTOSIS limits Molecular Medicine.” most division of the cells in the body. It appears See also ETHICAL ISSUES IN GENETICS AND MOLECU- that cells can divide only a certain number of LAR MEDICINE; GAMETE; HEMATOPOIESIS; STEM CELL times, then begin to shut down. The exceptions THERAPY. are stem cells and cancer cells, and researchers are not certain what will keep stem cells from becom- stem cell therapy Implantation of STEM CELLS to ing cancer cells. Apoptosis remains a focus of become specialized cells for tissue and organ repair much research. And as is the case with organs or replacement. Though most STEM CELL therapy donated for transplantation, the body can reject applications remain experimental, BONE MARROW stem cell transplantations. When this occurs the TRANSPLANTATION (also called BLOOD stem cell trans- body’s IMMUNE SYSTEM attacks the transplanted plantation) has become a standard of treatment stem cells, killing them. for many cancers affecting the blood and the lym- See also BLOOD STEM CELLS; CELL STRUCTURE AND phatic system (leukemias and lymphomas) as well FUNCTION; GENE THERAPY; ISLETS OF LANGERHANS; as certain other cancers. Researchers have also LEUKEMIA; MOLECULARLY TARGETED THERAPY. T–Z

Tay-Sachs disease An inherited genetic disorder ocular nerve joins the RETINA. The spot represents that causes a progressive, fatal form of gangliosido- the onset of gangliosidosis in the optic nerve. sis (the accumulation of gangliosides within NERVE Other symptoms include cells). Tay-Sachs disease involves mutations of a MUSCLE pair of genes on CHROMOSOME 15 that encode for the • flaccid tone (early) enzyme hexosaminidase-A (hex-A). The mutation • loss of voluntary muscle control and movement blocks production of hex-A. The body requires hex- (late) A to metabolize GM2 ganglioside, a fatty acid that • irritability (early) nerve cells need to metabolize and produce energy. • intellectual impairment Without adequate hex-A this METABOLISM cannot take place, and the GM2 ganglioside that enters the • seizures (late) cell accumulates. GM2 ganglioside concentrations • diminishing responsiveness and awareness are highest within the nerve cells in the BRAIN as (progressive) these nerve cells have the highest energy needs • loss of vision (progressive) among nerve cells. GM2 ganglioside accumulates in other nerve cells as well. The accumulation causes The diagnostic path includes family history, the nerve cell to swell and eventually rupture. ethnic heritage, BLOOD tests to measure the level of Though the accumulation of GM2 ganglioside hex-A present in the circulation, and GENETIC TEST- begins before birth, symptoms do not become ING such as cytogenetic analysis and DNA sequenc- apparent until age four to six months. Around this ing. The genetic tests provide the definitive age the damage to brain tissue reaches a critical diagnosis. level and begins to disrupt brain activity. The child appears to regress developmentally. Brain function Treatment Options and Outlook continues to decline, affecting intellectual and There is no treatment or cure for Tay-Sachs dis- thought processes as well as voluntary and invol- ease. Nearly all children who have Tay-Sachs dis- untary functions throughout the body. Tay-Sachs ease die before the age of five years. Research disease is usually fatal before age five years. An exploring methods to replace hex-A so far have uncommon variation, late-onset Tay-Sachs dis- been unsuccessful. Currently the most effective ease, allows slight amounts of hex-A, delaying the efforts target prevention by identifying carriers, onset of symptoms until ADOLESCENCE or early who do not themselves have Tay-Sachs disease adulthood. However, the progressive loss of neu- and who may not know they carry the GENE MUTA- rological and cognitive function follows a similar TION. timeline once symptoms start. Risk Factors and Preventive Measures Symptoms and Diagnostic Path Tay-Sachs disease is an autosomal recessive disor- The earliest indication of Tay-Sachs disease is a der, meaning both parents must have the mutated characteristic round, cherry-red spot on the mac- gene for them to have a child with the disease, a ula at the back of the EYE, the point where the one in four chance with each CONCEPTION. People 142 variation 143 at highest risk for Tay-Sachs disease are those of chromosome fragments trade places with one Ashkenazi Jewish heritage. A blood test became another. Such balanced translocations are com- available in 1985 to detect carriers of Tay-Sachs mon and usually do not produce symptoms disease, who do not themselves have the disease because all the normal genetic material remains but who have lower than normal amounts of hex- within the GENOME. A in their blood. GENETIC COUNSELING can help cou- A Robertsonian translocation occurs when the ples who are carriers make informed decisions long arms of two acrocentric chromosomes, in about whether to have children. Assisted repro- which the CENTROMERE (waistlike indentation) is so ductive technologies (ARTs) such as in vitro fertil- high on the chromosome that the upper arms ization allow genetic testing before implantation appear nonexistent and the upper arms contain so the couple knows the conceived child does not almost no genetic material. Robertsonian translo- carry the mutated genes. cations occur only among the five acrocentric See also ASSISTED REPRODUCTIVE TECHNOLOGY (ART); chromosomes, which are chromosomes 13, 14, ETHICAL ISSUES IN GENETICS AND MOLECULAR MEDICINE; 15, 21 and 22. Like reciprocal translocations, GENETIC CARRIER; GENETIC DISORDERS; INHERITANCE PAT- Robertsonian translocations generally do not pro- TERNS. duce harmful consequences because the genetic material remains unadulterated despite the telomere A structure of noncoding DNA (DNA translocation. Robertsonian translocations are that does not convey genetic instruction) at each fairly common. end of a CHROMOSOME. Telomeres are essential for One reciprocal translocation that tends to pro- chromosome duplication during cell division. They duce harmful health effects is the Philadelphia function as handles to pull the chromatids (divid- chromosome, in which a segment of chromosome ing chromosomes) apart as the mother cell divides 9 and a segment of chromosome 22 exchange into the two new daughter cells. The process of places. Geneticists commonly find this transloca- cell division permanently destroys a tiny fragment tion in people who have chronic myeloid LEUKEMIA of the telomere, however. Eventually the telomere (CML). becomes too short to participate in chromosome See also CELL STRUCTURE AND FUNCTION; CHROMO- duplication, and the cell stops dividing. SOMAL DISORDERS; DNA. Researchers believe the shortening of telomeres is key to APOPTOSIS, the apparently programmed trisomy 13 See PATAU’S SYNDROME. death of cells. In cancer cells the telomeres regen- erate after cell division, which researchers believe trisomy 18 See EDWARDS SYNDROME. is one of the factors that allows cancer cells to grow uninhibited. trisomy 21 See DOWN SYNDROME. For further discussion of telomeres within the context of the structures and functions of genetics, variation The genetic differences among individ- please see the overview section “Genetics and uals. There are trillions of possible GENE combina- Molecular Medicine.” tions within the human GENOME. Except for See also CELL STRUCTURE AND FUNCTION; CEN- identical twins, no two people share exactly the TROMERE; CHROMATID; SENESCENCE. same GENOTYPE (genetic constitution). Though any two individuals may have 99.9 percent of the translocation A chromosomal disorder in which same DNA sequences and gene pairings, the 0.1 a fragment of a CHROMOSOME breaks from its origi- percent of pairings that differ accounts for the nal chromosome and attaches itself to a different endless details that make each individual unique. chromosome. The fragment may exchange with The same genotype can have multiple expres- another fragment, may add itself to another chro- sions (phenotypes) among individuals. The geno- mosome, or may become lost. Some translocations type for EYE color, for example, can express itself are random and others occur in predictable pat- as blue eyes in one person and brown eyes in terns. Translocations can be reciprocal, in which another. Such variability exists for every gene 144 Genetics and Molecular Medicine pairing, with more or less obvious results. VARIA- tain half the complement of chromosomes neces- TION also occurs through MUTATION, in which DNA sary to create an organism. When two gametes sequences change during replication. Polymor- join they form a single diploid cell that contains phisms and mutations may have positive, neutral, the full complement of chromosomes. The zygote or negative effects, which differ among individuals then divides as a haploid cell, becoming a blasto- based on circumstance, lifestyle, and other factors. cyst and eventually forming an EMBRYO. See also ALLELE; CELL STRUCTURE AND FUNCTION; For further discussion of zygotes within the GENETIC PREDISPOSITION; INHERITANCE PATTERNS; PHENO- context of the structures and functions of genetics, TYPE. please see the overview section “Genetics and Molecular Medicine.” zygote The fertilized ovum (egg) before it begins See also ASSISTED REPRODUCTIVE TECHNOLOGY (ART); to divide. The spermatozoon (SPERM cell) and the CELL STRUCTURE AND FUNCTION; CHROMOSOME; CONCEP- ovum are each haploid cells (gametes); they con- TION; GAMETE; OVULATION. DRUGS

The area of health care concerned with drugs and medicinal therapies is pharmacology. Health-care professionals who dispense prescription drugs are pharmacists, who may be registered pharmacists (RPh) or doctors of pharmacy (PharmD).

This section, “Drugs,” presents an overview dis- and form the foundation of the modern pharma- cussion of pharmacologic concepts and entries ceutical industry. As many as 5,000 medicinal about drugs and their use for the maintenance of plants grow in various regions around the world, health and the treatment of infection, injury, and many in the rain forests of South America. About disease. 25 percent of modern medicines trace their deri- vations directly or indirectly to plants. Laborato- Pharmaceutical Traditions in Medical History ries now produce synthetic forms of many drugs The earliest written medical documents reference once extracted from plants, such as the antiar- often elaborate preparations of botanicals used as rhythmia DRUG digoxin (digitalis from the foxglove medicines to treat a broad spectrum of ailments, plant), the pain reliever aspirin (salicin from the ranging from HEADACHE and itching to weak PULSE bark of the willow tree), and the antimalarial drug and infected wounds. Healers in the times of quinine (quinaquina from the bark of the chin- ancient Babylonia, Mesopotamia, Egypt, and chona tree). Other drugs, such as the anticancer China relied on extensive collections of herbs, drug paclitaxel (Taxol), which is an extract from roots, barks, and seeds from which they concocted the bark of the Pacific yew tree, still derive from tinctures, teas, poultices, and other remedies. their botanical sources. Ancient pharmacopeias outlined the formulations and uses of hundreds of plant forms for medicinal Drug Controls and Regulations purposes. The regulation of drugs—from effectiveness and ALCOHOL, too, was a major weapon in the early safety to production and availability—that is the physician’s pharmaceutical arsenal, serving as a foundation of today’s pharmaceutical industry is a topical antibacterial as well as an ingested anal- modern phenomenon. Until the early 20th cen- gesic (PAIN reliever) and quasi-anesthetic. Opium tury narcotics such as opium and HEROIN were poppies and coca leaves yielded the first freely available in the United States. Patent medi- NARCOTICS, opium and COCAINE. Coffee beans and cines (an odd assortment of liniments, elixirs, tea leaves yielded CAFFEINE, a potent stimulant. tinctures, nostrums, bitters, extracts, and com- Tobacco leaves, chewed or smoked, were the pounds) dominated the druggist’s apothecary. source of another powerful stimulant, NICOTINE. From Lydia E. Pinkham’s Vegetable Compound, Coca leaves and tobacco leaves acquired such high which contained far more alcohol than vegetable, value in some early cultures that they served as to Mrs. Winslow’s Soothing Syrup, a sedating currency. preparation of morphine, patent medicines Today medicinal herbs and botanicals remain claimed to treat just about any ailment . . . and the mainstay of TRADITIONAL CHINESE MEDICINE (TCM) many claimed to treat just about every ailment. 145 146 Drugs

The Pure Food and Drugs Act of 1906 was the Indeed, there are few health conditions for which beginning of the end for patent medicines; requir- there are not pharmaceutical treatments. ing medicine labels to list the product’s ingredients Nonetheless, significant challenges exist. Health and spawning the federal oversight agency that experts worry that the expense of drugs puts them was to become the US Food and Drug Administra- out of reach for many people who need them and tion (FDA). In 1938 the Food, Drugs, and Cosmet- that collectively people are developing habits in ics Act extended the authority of the FDA to regard to drug therapies that ultimately put health regulate the safety and therapeutic effectiveness at greater risk. (and labeling claims thereof) of drugs, requiring Drug costs and availability Pharmaceutical manufacturers to prove a drug’s safety before manufacturers spend millions of dollars every year being allowed to market the drug. The regulations to develop new drugs. Yet as many as 20 promis- arose from the sometimes deleterious adulteration ing drug concepts may die in the laboratory for of drug products, brought to the forefront of pub- every one that makes it clinical testing. For the lic outrage when the use of poisonous wood alco- length of time a drug remains under patent after hol in a sulfa preparation caused the deaths of its approval, an average of 14 years, the drug’s more than 100 people. Shortly thereafter the FDA manufacturer has an exclusive piece of a multi- established separate classifications for prescription billion-dollar market. Though few dispute a phar- drugs and OVER-THE-COUNTER (OTC) DRUGS, prescrip- maceutical company’s right to expect a financial tion drugs being those whose safe use required a return on its investment, the high cost of drugs physician’s oversight and guidance and OTC drugs still under patent makes the drugs unaffordable being those that individuals could safely use with- for many people. Older people take the hardest out the guidance of a doctor or pharmacist. hit, caught in an intersection between increasing Drug advertising remained under the jurisdic- health-care needs and a fixed income. tion of the Federal Trade Commission (FTC) until One major effort to reduce drug costs is generic the Drug Amendments of 1962, the first of several drugs, which are identical to their trade name key amendments to the Food, Drugs, and Cosmet- counterparts (innovator drugs) in terms of active ics Act. The 1962 Drug Amendments also gave the ingredients, DOSE, form, and efficacy (action in the FDA the regulatory authority to require evidence body). The Government Accountability Office of a drug’s safety as well as effectiveness before (GAO), the official expenditure watchdog of the granting approval for the drug. The Dietary Sup- federal government, estimates that generic drugs plements and Nutritional Labeling Act of 1994 save Americans more than $10 million a year. drew back some authority from the FDA, how- The high cost of drugs in the United States has ever, reclassifying herbal and botanical products as fueled interest in purchasing drugs from countries dietary supplements and removing from FDA reg- in which they are not as expensive, such as ulatory oversight. Canada and Mexico. Although US law prohibits bringing imported drugs into the country, many Challenges in Pharmaceutical Therapy people order them from Internet and mail-order Drugs have transformed health care over the past sources nonetheless to save hundreds to thou- half century, relegating to insignificance many sands of dollars each year. infections and diseases that in previous genera- Patient compliance and lifestyle choices Treat- tions meant lifelong disability or early death. ing or preventing a health condition can be as Drugs treat INFECTION, DIABETES, CARDIOVASCULAR DIS- easy as taking a few pills a day. However, though EASE (CVD), kidney disease, LIVER disease, gastroin- precise statistics are difficult to determine health testinal disease, neurologic disorders, and cancer. experts estimate that perhaps half of people for Doctors in the United States write more than 14 whom doctors prescribe regular medications do billion prescriptions a year for nearly 3,000 differ- not take them as directed. They may miss doses, ent drugs, and another 2,000 medications are combine drugs to consolidate dosages, take a available in over-the-counter (OTC) products that reduced dose to “stretch” the prescription, or take are available without a doctor’s prescription. the drug only when they feel symptoms. In some Drugs 147 situations, however, taking a drug improperly is such as hospitals and extended-care facilities. more of a health hazard than not taking the drug These bacteria have often evolved to a high level at all. The problem is significant enough to sup- of multiple-drug resistance, making the infections port a thriving secondary market that sells various they cause very difficult to treat. “medication minder” methods. Unfortunately Interactions among drugs An estimated 30 thousands of Americans require additional med- million Americans take multiple prescription med- ical care for circumstances, including uninten- ications. Though these drugs keep potentially dis- tional OVERDOSE, that develop as a consequence of abling or deadly health conditions in check, the failing to follow label instructions. risk for serious drug interactions increases expo- Health experts also worry that medications are nentially with each additional drug. Factor in OTC becoming substitutes for healthful changes in drugs and herbal remedies, and drug interactions lifestyle habits. For example, people who take become more likely than not to occur. Such inter- drugs such as lipid-lowering medications may actions can result in reduced or potentiated effec- become complacent about making lifestyle changes tiveness of any or all of the drugs the person is that would allow them to stop taking the medica- taking. Doctors and pharmacists urge people tion while reducing their risk for cardiovascular dis- always to tell each doctor who provides care, ease. Often it is easier to take the pill rather than to whether or not the doctor writes a prescription, change EATING HABITS and exercise habits, another about all drugs they are taking because sometimes method for lowering blood lipid levels. the health problems that send them to the doctor Antibiotic resistance The first antibiotics, sulfa result from interactions among their medications. and penicillin, became lifesavers during and after World War II. Antibiotics put a rapid end to the Breakthrough Research and Treatment Advances often deadly infections rampant at the time, such Pharmaceutical research began to focus on phar- as PNEUMONIA, TONSILLITIS, GONORRHEA, and TUBERCU- macogenomics—the interactions between genetics LOSIS. Within 25 years, however, infections began and medications—in the 1990s. Doctors have to appear that were resistant to penicillin, the known for quite some time that some people most commonly used antibiotic, and doctors had metabolize certain drugs more or less efficiently to prescribe newly developed alternatives. than do other people. This can result in altered ANTIBIOTIC RESISTANCE emerged as a full-blown efficacy. Researchers have been able to identify health issue in the latter decades of the 20th cen- genes, some of which regulate CYTOCHROME P450 tury with the appearance of multiple-drug-resist- (CYP450) ENZYMES, the collective of enzymes that ant infections of tuberculosis, gonorrhea, and metabolize most drugs that enter the body. Subtle pneumonia. By 2002 some strains of Staphylococcus differences in protein encoding may slow or speed aureus, a BACTERIA family accountable for a wide drug absorption, METABOLISM, or length of time in range of infection, including pneumonia and the BLOOD circulation. Particularly in areas such as wound infections, had acquired resistance even to cancer treatment, researchers are searching for the most powerful antibiotic available, van- ways to use pharmaceuticals to manipulate comycin. Of the most critical concern are NOSOCO- genetic encoding. Other research focuses on MIAL INFECTIONS, infections that result from developing “smart” drugs, which specifically and exposure to bacteria that thrive in environments narrowly target certain kinds of cells. A adverse drug reaction An undesired, negative, the ways in which the body responds to the drug and often unpleasant response to a medication. over the long term. Tardive DYSKINESIA is a known People commonly refer to adverse DRUG reactions adverse reaction to long-term use of ANTIPSYCHOTIC as side effects, which is not entirely accurate MEDICATIONS, for example. Long-term use of CORTI- because a SIDE EFFECT may have therapeutic value COSTEROID MEDICATIONS, such as taken to treat whereas an adverse drug reaction is potentially INFLAMMATORY BOWEL DISEASE (IBD) or ADDISON’S DIS- harmful. Adverse drug reactions are common, EASE, have numerous adverse effects on the body. affecting more than two million Americans each Adverse drug reactions may be localized, such year. They can occur with any drug a person takes as DERMATITIS, or systemic (involve multiple body or uses, ranging in severity from upset STOMACH or systems). Doctors generally classify adverse drug HEADACHE, which often subside after taking the reactions as immunologic (those that involve an drug for several doses, to URTICARIA (hives) or ANA- IMMUNE RESPONSE) or nonimmunologic (those that PHYLAXIS (life-threatening closure of the airways), do not involve an immune response). People who which are usually allergic reactions. RASH and are IMMUNOCOMPROMISED (such as those who have itching are also common adverse reactions. HIV/AIDS or take IMMUNOSUPPRESSIVE THERAPY), have Adverse drug reactions may also affect the compo- an autoimmune disorder such as RHEUMATOID sition of the BLOOD or the function of organs such ARTHRITIS or SYSTEMIC LUPUS ERYTHEMATOSUS (SLE), as the HEART, LIVER, and KIDNEYS. have liver or kidney disease, take multiple med- ications (often called polypharmacy), or are age 60 Intentional misuse of a DRUG, including or older have increased risk for adverse drug reac- taking more than recommended or in tions. Most drug reactions occur within several combination with other drugs, increases days to three weeks of beginning the drug, though the likelihood of adverse drug reaction. some long-term adverse reactions occur up to years after the drug’s initiation. All drugs have some identified potential adverse reactions. These are the events that usu- COMMON ADVERSE DRUG REACTIONS ally surface during the human testing phase of allergic response ANAPHYLAXIS ANEMIA clinical research studies. Some such reactions may ANGIOEDEMA ARRHYTHMIA arthralgia be inherent to the properties of the drug—that is, CANDIDIASIS DERMATITIS DIARRHEA result from the drug itself. Many ANTIBIOTIC MED- GLOMERULONEPHRITIS LYMPHADENOPATHY NEUTROPENIA ICATIONS, for example, kill BACTERIA in the intes- PRURITUS RASH on trunk tardive DYSKINESIA tines at the same time they kill bacteria that are TINNITUS URTICARIA VOMITING causing INFECTION, resulting in DIARRHEA because intestinal bacteria are essential for proper diges- It is important, when beginning treatment with tion. NAUSEA, VOMITING, and HAIR loss are known a new medication or adding a different drug to a adverse reactions with CHEMOTHERAPY drugs. Other treatment regimen, to know the expected results such reactions may result from DRUG INTERACTIONS and possible adverse reactions. People who take with other medications the person is using or from multiple drugs, including OVER-THE-COUNTER (OTC) 148 aging, effects on drug metabolism and drug response 149

DRUGS and MEDICINAL HERBS AND BOTANICALS, should relievers), the most common kinds of drugs chil- make sure the prescribing physician and the dis- dren may need, but also it makes the liver vulner- pensing pharmacist know all of them. Numerous able to damage from substances that enter the products interact with one another in ways that blood circulation. Incompletely metabolized drugs alter their effects in the body, increasing the risk increase the risk for damage to other developing for adverse drug reactions. organ systems as well, notably the CENTRAL NERV- Many countries have regulatory requirements OUS SYSTEM. These factors become of therapeutic for documenting and reporting adverse drug reac- concern when treating serious childhood diseases tions. Such requirements help oversight agencies for which medications are the primary course of and health-care professionals monitor issues with treatment, such as SEIZURE DISORDERS, CONGENITAL drugs that may not have been apparent during HEART DISEASE, and cancer. preapproval testing. In the United States the US The second issue in regard to medication ther- Food and Drug Administration (FDA) oversees apy in children is that many drugs do not undergo compliance with these requirements and works testing or evaluation for their effectiveness or with pharmaceutical manufacturers to resolve safety in pediatric use because children make up a issues that arise. very small percentage of the drug’s intended See also ALCOHOL INTERACTIONS WITH MEDICATIONS; patient population or because the potential risks of AUTOIMMUNE DISORDERS; CIRRHOSIS; DRUG INTERACTION; involving children in clinical research studies are LIVER FAILURE; OFF-LABEL USE; RENAL FAILURE; TOXIC too high. The consequence is that doctors rely on EPIDERMAL NECROLYSIS. best practices standards and OFF-LABEL USE of drugs in prescribing medications, which are safe and aging, effects on drug metabolism and drug effective in adults but untested in children, to response Many drugs have different therapeutic treat health conditions in children. effects as well as potential adverse DRUG reactions, depending on a person’s age. The very young and Drugs in the Elderly the very old often have limited LIVER function, The body undergoes significant metabolic and which affects the ways in which the liver metabo- functional changes by the seventh and eighth lizes drugs, resulting in lower thresholds for toxicity decades of life, a blend of the normal processes of and unpredictable therapeutic effects. In the infant aging and the cumulative effect of health condi- and young child, the liver has not yet fully devel- tions. The liver and KIDNEYS become less efficient, oped and lacks the structural capacity to metabolize which affects the amount of a drug that enters the certain substances. The elderly may lose liver func- blood circulation and how long the drug remains tion due to CIRRHOSIS, fatty deposits accumulating in the body. Health conditions such as ATHEROSCLE- within the liver (STEATOHEPATITIS), or the normal loss ROSIS (fatty deposits in the walls of the arteries) of cells that occurs with aging. Reduced kidney may alter the flow of blood through the body. function may further affect drug response by slow- Changes in NERVOUS SYSTEM function may alter the ing clearance of the drug from the body and thus release of neurotransmitters. These kinds of maintaining higher than expected concentrations changes in the body influence how, and how well, of the drug in the BLOOD circulation. drugs work. Often the very reasons elderly people need to Drugs in Children take therapeutic drugs (such as to treat CARDIOVAS- Two significant issues surround medication ther- CULAR DISEASE [CVD], DIABETES, kidney disease) have apy in children. The first is the continually chang- significant effects on the ways in which the body ing metabolic capability and status of the child’s can handle the drugs and how those drugs affect body as organ systems grow and mature. The liver the body. As well, older people are more likely to remains relatively unsophisticated in its function have complex or multiple health conditions and until a child reaches age 10 or 12 years. Not only take multiple medications, increasing the risk for does this limit the liver’s ability to metabolize ADVERSE DRUG REACTION, DRUG INTERACTION, and drugs such as antibiotics and analgesics (pain OVERDOSE. 150 Drugs

See also APOPTOSIS; NEUROTRANSMITTER; ORPHAN may not grow in the lab, can identify the cause of DRUG. an infection as bacterial. antibiotic resistance The adaptation of bacterial How Bacteria Acquire Resistance strains to certain of the ANTIBIOTIC MEDICATIONS doc- Bacteria reproduce rapidly, which gives them the tors prescribe to treat infections the BACTERIA opportunity to change rapidly. Over multiple gen- cause, rendering the antibiotic ineffective. Such erations the bacteria’s DNA—its GENETIC CODE— adaptation is an evolutionary mechanism that mutates to establish adaptations beneficial to the allows the strain of bacteria to survive. Though in bacterial strain’s survival. These adaptations most situations the strain of bacteria remains sen- include increased resistance to the antibiotics that sitive to other antibiotics even as it develops resist- people take to fight the infections the strain ance to a particular antibiotic, antibiotic resistance causes. Bacteria generally mutate through one of is a very serious concern in modern health care three processes: because the more common strains of bacteria are developing broad bases of resistance to multiple • Spontaneous MUTATION is when changes occur antibiotics. A few strains have mutated to resist all within the DNA alter the bacteria’s adaptive available antibiotics, presenting a worrisome chal- ability across the bacterial strain. Resistance lenge for fighting the infections they cause. due to spontaneous mutation, also called evo- lutionary mutation, develops over multiple Bacteria, Infection, and Antibiotics generations of the bacterial strain. Bacteria are single-cell microorganisms that exist • Transformation is when the DNA from resistant in broad families with numerous strains, or varia- bacteria enter another bacteria that are not yet tions, within the same family. Under supportive resistant. Also called DNA uptake, transforma- circumstances each individual strain can cause tion expedites the mutation process to allow unique and specific infections. Most bacteria that bacterial strains to become more rapidly resist- cause INFECTION in people are normally present in ant than they would through spontaneous the body and the environment. Ordinarily these mutation. bacteria are harmless or even beneficial to body • Plasmid transfer is when plasmids (molecules functions, such as the bacteria in the gastroin- that contain incomplete fragments of genetic testinal tract that aid in digestion. NORMAL FLORA material) move among different kinds of bacte- bacteria become pathogenic when there is a ria. Plasmids impart limited genetic encoding breach, such as a wound, in the body’s protective related primarily to the survivability of a bacte- mechanisms, or when something goes awry with rial strain and can result in rapid adaptation to the body’s balance of microorganisms and the produce antibiotic resistance. Because antibiotic IMMUNE SYSTEM cannot keep bacterial growth in resistance has become a key purpose of plasmid check. transfer, researchers designate such plasmids as Antibiotics kill bacteria, either by direct toxicity R plasmids. to the bacteria or by preventing the bacteria from reproducing. Antibiotics are effective for treating Resistance resulting from spontaneous, or evo- only bacterial infections; they cannot treat viral lutionary, mutation is the most common adapta- infections. Chronic conditions such as BRONCHITIS tion process and accounts for most of the resistant and OTITIS media (middle EAR infection) are often strains of GONORRHEA and Staphylococcus aureus infec- viral, yet are among the top ailments for which tions. Transformation, or DNA uptake, is a more doctors prescribe antibiotics. It is not possible to sophisticated, biologically intentional process than determine the cause of an infection by evaluating spontaneous mutation. Among the three mutation the symptoms, though certain characteristics processes plasmid transfer is the most efficient and make it more likely that an infection is bacterial. creates the greatest concern in regard to antibiotic Only a laboratory culture of cells from the infec- resistance. Plasmids can transfer among different tion, in which cells of a bacterial strain may or strains of bacteria within a bacterial family, sharing antitoxin 151 adaptive mutations for multiple resistance. Plasmid • Take antibiotics only for infections that labora- transfer accounts for resistance to entire classifica- tory tests prove are bacterial. tions of drugs such as the quinolones, a family of • Take all doses of the antibiotic for the full antibiotics that attack enzymes that facilitate DNA course of prescribed treatment. cleavage (the division of DNA in preparation for • Wash hands frequently with soap and warm cell reproduction) in bacteria. water to prevent the spread of infection-caus- Factors That Contribute to Antibiotic Resistance ing bacteria and other pathogens. Antibiotic use itself is the precipitating factor for • Limit exposure to other people who are ill. the adaptive changes that occur in bacteria to • Choose meat and poultry products that are result in antibiotic resistance, as these changes labeled antibiotic free. represent natural survival efforts. Key circum- stances that further encourage survival adapta- Health experts also are reexamining the prac- tions include the following: tice of ANTIBIOTIC PROPHYLAXIS (administering antibi- otics to prevent infection in people who are • Inappropriate prescribing of antibiotics for IMMUNOCOMPROMISED or exposed to risk for NOSOCO- infections that are viral or of uncertain cause. MIAL INFECTIONS). The US Food and Drug Adminis- The US Centers for Disease Control and Pre- tration (FDA), which oversees drug approval and vention (CDC) believes about half of the 100 prescribing practices in the United States, issued million antibiotic prescriptions US doctors write new regulations in 2003 that establish stringent each year are unnecessary because the condi- criteria for doctors to follow in prescribing antibi- tions they are treating are not bacterial. otics and is spearheading public education efforts • Failing to complete the full course of antibiotic to improve public awareness of antibiotic resist- therapy, which allows some bacteria to escape ance. eradication. It is important to take a therapeutic See also BACTEREMIA; FOOD SAFETY; HAND WASHING; antibiotic long enough to kill all the bacteria, OPPORTUNISTIC INFECTION; PATHOGEN; PERSONAL extending through their complete life cycle, HYGIENE. that are causing infection. Bacteria that are exposed to the antibiotic but do not die have antitoxin A serum product, cultivated from ani- the opportunity to undergo adaptive mutation, mal (usually horse) BLOOD, that counteracts the which results in antibiotic resistance. effects of toxins (poisons) certain strains of anaer- • Prophylactic antibiotics given to food animals obic BACTERIA produce when they enter the body. such as cattle, pigs, and chickens to prevent The antitoxin binds with the toxin that is circulat- them from getting infections that slow their ing in the bloodstream, neutralizing it. Some anti- growth. The constant exposure to the same toxins, such as those for Clostridium tetani (tetanus) antibiotics fosters adaptive mutation in bacteria and Corynebacterium diphtheriae (DIPHTHERIA), are that may then become infective agents in peo- effective prophylactically (administered to prevent ple. Humans become vulnerable to infection illness); doctors administer these as vaccines. Oth- from resistant bacteria through eating meat ers are effective therapeutically; doctors adminis- from treated animals that is not thoroughly ter them when exposure triggers illness, such as to cooked, which allows the bacteria to enter the Clostridium botulinum (BOTULISM). Antitoxins for body. Exposure to the bacteria in environmen- tetanus and diphtheria also have therapeutic tal settings also is a source of infection. action in people who develop these conditions. About 10 percent of people have allergic reactions Limiting Antibiotic Resistance to antitoxins. Giving smaller amounts of the anti- The most effective measure for reducing antibiotic toxin over a longer period of time, such as when resistance is to decrease the use of antibiotics. To treating disease, often mitigates the reaction. this end, health experts offer these recommenda- See also ANTIVENIN; CHILDHOOD DISEASES; PREVEN- tions for individuals: TIVE HEALTH CARE AND IMMUNIZATIONS; VACCINE. 152 Drugs antivenin A serum product, also called as pets, or for scientific research or display (as in antivenom, cultivated from animal BLOOD and zoos). Local and regional poison control centers given therapeutically to neutralize the effects of know what antivenin products are available and poisonous venoms such as from BITES AND STINGS. how to obtain them. Antivenin is specific to a particular venom and Most antivenins are cultivated from the blood works by activating antibodies that enable the per- of horses so it is important to know a person’s son’s IMMUNE SYSTEM to fend off the effects of the allergy history. Allergic reaction to antivenin is not venom. uncommon. Even in people who have a known ALLERGY to horses, however, the antivenin may be When possible, safely capture the snake lifesaving. Generally in such a situation the or spider that renders the bite for posi- administration of ANTIHISTAMINE MEDICATIONS and tive identification and the correct EPINEPHRINE will mitigate the allergic response to antivenin. allow the antivenin to be effective. Serum sick- ness, an immune reaction to the antigens and A person generally must receive antivenin blood proteins present in products derived from within about four to eight hours of the bite or nonhuman blood, may also occur. Serum sickness sting for the antivenin to be effective. Antivenin is generally begins one to two weeks after adminis- commonly available in the United States for the tration of the antivenin and runs its course over bites of indigenous snakes and spiders and the about three weeks. The risk for allergic reaction stings of scorpions. There are facilities in many and serum sickness increases with higher doses of parts of the United States that stock antivenin for antivenin. exotic snakes and spiders that may enter the See also ANTIBODY; ANTIGEN; HYPERSENSITIVITY country inadvertently (such as among produce), REACTION. B–D

bioavailability The amount of a DRUG’S active gastrointestinal MALABSORPTION, renal failure, or ingredient the body absorbs and the length of time LIVER FAILURE, as well as the person’s age and weight, it takes for that ingredient to cause an effect in the and metabolic disorders, also affect bioavailability. body. A common means of determining bioavail- See also EFFICACY; GENERIC DRUG; HALF-LIFE; THER- ability is to measure the concentrations of the APEUTIC EQUIVALENCE. drug in the BLOOD circulation or in the URINE at certain time intervals. Doctors know the spectrum bioequivalence A DRUG that has the same bio- of bioavailability and calculate DOSAGE to obtain logical effect in the body as a substance the body the desired therapeutic concentration of the drug. makes naturally (such as a HORMONE supplement) For most drugs the spectrum of activity pro- or two or more drugs that have the same BIOAVAIL- vides adequate therapeutic levels and tests to ABILITY and EFFICACY. Bioequivalence is a significant measure the drug’s concentrations are not neces- concern with NARROW THERAPEUTIC INDEX (NTI) sary. NARROW THERAPEUTIC INDEX (NTI) drugs such as drugs, which require precise and consistent dos- the anticoagulant warfarin, the antiarrhythmic ing, as well as with generic drugs. digoxin, and HORMONE supplements such as A GENERIC DRUG, which is a different chemical levothyroxine (thyroid hormone) require diligent formulation of equivalent active ingredients com- assessment and monitoring because the margin pared to the innovator (original) drug, is not nec- between therapeutic and toxic is very close. The essarily bioequivalent to the INNOVATOR DRUG. That doctor may also assess the drug’s bioavailability is, the same drug product from different manufac- through observation of clinical changes, such as turers may contain the same amounts of active an INFECTION that improves with antibiotic therapy ingredient though not the same inactive ingredi- or BLOOD PRESSURE that drops with antihyperten- ents or different proportions of inactive ingredi- sive medications. ents. The extent to which these differences For the most part pharmaceutically equivalent influence bioavailability (the amount of the active drugs (generic drugs) have consistent bioavailabil- ingredient that enters the body) varies among ity across manufacturers and are interchangeable classifications of drugs and is especially crucial from this perspective. The exceptions are NTI with NTI drugs. drugs, for which doctors and pharmacists recom- The US Food and Drug Administration (FDA) mend staying with the same brand name of drug establishes and regulates the parameters of bioe- for the duration of treatment. Which brand does quivalence. Drugs that are bioequivalent must fall not matter so much as that the brand remains con- within a specific range for the amount of time it sistent. This is because even minute variations in takes for each drug to enter and remain in the the manufacturing process, as is inherent in differ- BLOOD circulation. ent formulations of the same drug product, affect See also DRUG INTERACTION; ORANGE BOOK, THE; the way the body absorbs and metabolizes the drug. THERAPEUTIC EQUIVALENCE. Other factors that influence bioavailability are interactions with foods, other drugs, and MEDICINAL cytochrome P450 (CYP450) enzymes A group HERBS AND BOTANICALS. Health conditions such as of about 60 endogenous enzymes (enzymes the 153 154 Drugs body produces) that participate in the METABOLISM health conditions, and those who take numerous of drugs. The CYP450 enzymes also participate in medications. lipid (notably cholesterol) and steroid HORMONE See also AGING, EFFECTS ON DRUG METABOLISM AND synthesis. Most of the CYP450 enzymes that are DRUG RESPONSE; PEAK LEVEL; THERAPEUTIC LEVEL; active in DRUG metabolism are in the LIVER and the TROUGH LEVEL. SMALL INTESTINE. The CYP450 enzymes function as catalysts to facilitate the processes by which the dose The amount of a DRUG a person takes or drug transforms from its initial chemical structure receives at a single time. A dose falls within a rec- to the biochemical forms that have action in the ommended therapeutic range for the drug, the body. Each of the CYP450 subtypes, also called person’s condition, and the person’s personal isoforms or isoenzymes, metabolizes certain drugs health circumstances (including age and gender). or groups of drugs. An excess of this amount is an OVERDOSE, which Hormones, antibodies, and foods affect the can have serious and even fatal consequences. activity of CYP450 enzymes. Interactions among See also AGING, EFFECTS ON DRUG METABOLISM AND them may block or enhance a drug’s activities; DRUG RESPONSE; DOSAGE; PEAK LEVEL; THERAPEUTIC these effects may be beneficial or harmful. Some LEVEL; THERAPEUTIC WINDOW; TROUGH LEVEL. drug treatment regimens for complex conditions such as HIV/AIDS work by manipulating CYP450 drug Any product that, when it enters the body, enzyme activity to take advantage of beneficial changes the function of the body in some way. interactions. Harmful interactions may manifest as Drugs such as ANTIBIOTIC MEDICATIONS work by adverse drug reactions such as toxicity or unpleas- killing BACTERIA within the body, for example, and ant side effects. antiarrhythmia drugs work by altering the electri- Individuals may express CYP450 activity differ- cal activity of the HEART. As the mainstay of mod- ently—that is, known variation exists among indi- ern medicine, drugs exert therapeutic actions to viduals in the ways CYP450 enzymes function. treat numerous health conditions. These variations in CYP450 expression factor into See also ADVERSE DRUG REACTION; ALCOHOL; DRUG individual responses to medications, at least par- INTERACTION; INVESTIGATIONAL NEW DRUG (IND); OFF- tially accounting for why one drug may be more LABEL USE. or less effective than another drug in the same drug family for a particular individual. drug interaction An effect or action that occurs See also ALCOHOL INTERACTIONS WITH MEDICATIONS; in the body as a consequence of taking two or ANTIBODY; PHARMACODYNAMICS; PHARMACOKINETICS. more drugs that does not occur when taking any one of the drugs alone. Drugs may interact with dosage The therapeutic course of a DRUG, each other, OVER-THE-COUNTER (OTC) DRUGS and encompassing the drug’s DOSE (amount of the drug products, vitamin and mineral supplements, taken), the frequency of the doses, the health con- MEDICINAL HERBS AND BOTANICALS, and foods. Most dition and status of the person (including age and DRUG interactions are inadvertent, occurring when gender), and the total length of time the drug the a person takes an OTC medication with prescrip- person needs to take the drug. For many drugs tion medications, for example, or when a doctor there are standard dosages that are applicable to prescribes a new medication without knowing all most people. The doctor or pharmacist calculates of the other medications a person is taking. The dosages for people who fall outside the standard latter circumstance becomes a particular challenge range, and for NARROW THERAPEUTIC INDEX (NTI) when a person must receive urgent care in a drugs (drugs for which the margin between thera- clinic, hospital emergency department, or other peutic and toxic is very close). People who may setting in which the provider is someone other fall outside the standard range of dosage for many than the person’s regular health-care provider. drugs are the very young, the very old, those who Some drug interactions are neutral or even are extremely underweight, those who are beneficial, such as when one medication potenti- extremely overweight, those who have multiple ates (increases or enhances) or mitigates the drug interaction 155 action of another in a known and predictable way P450 (CYP450) ENZYMES, are abundant in the SMALL for a therapeutic effect. Such effect occurs, for INTESTINE and the LIVER. CYP450 enzymes in the example, with the combination of codeine (a nar- small intestine initiate the process of metabolism cotic PAIN reliever) and promethazine (Phenergan), to allow molecules of the drug’s active ingredient an antiemetic medication (reduces NAUSEA). to pass into the BLOOD circulation. The blood car- Though an effective pain reliever, codeine tends to ries the molecules to the liver, where the CYP450 cause nausea, but promethazine offsets this effect. enzymes there complete metabolism. There are And though promethazine alone has no analgesic numerous subtypes of CYP450 enzymes, each (pain-relieving) effects it does potentiate, or inten- responsible for specific metabolic activity for cer- sify, the actions of codeine on the CENTRAL NERVOUS tain drugs. Some drugs work by inducing and oth- SYSTEM as well as mitigate its tendency to cause ers by inhibiting particular CYP450 enzyme nausea. Other drug interactions can lessen or subtypes, which in turn affects the metabolism of intensify the effects of one or more of the involved other drugs. Other drug interactions may occur drugs in ways that are detrimental, either by caus- when the chemicals the drugs contain interact in ing adverse actions in the body or preventing the some fashion. Iron and calcium in foods, vitamin therapeutic effects of one or any of the drugs. Cer- supplements, and ANTACIDS bind with some antibi- tain ANTIBIOTIC MEDICATIONS, for example, diminish otics in the STOMACH, for example, preventing the the effectiveness of oral contraceptives (birth con- antibiotic from becoming absorbed and entering trol pills). the blood circulation. The potential for drug interaction is extensive. It is important for every doctor, dentist, The more medications a person takes, the higher or other health-care provider who pre- the risk for drug interaction. A useful safeguard is scribes a DRUG for an individual to know to ask the pharmacist when picking up a prescrip- all of the drugs, prescription and over- tion what other drugs and foods might interact the-counter products (including herbal with it. Even when foods do not directly interact remedies and natural products) that the with drugs, they may affect the drug’s absorption person is taking. into the body. See also ADVERSE DRUG REACTION; ALCOHOL INTER- Most drug interactions occur as the result of a ACTIONS WITH MEDICATIONS; ANTIEMETIC MEDICATIONS; family of enzymes responsible for drug CONTRACEPTION; ILLICIT DRUG ABUSE; OVERDOSE; PRE- METABOLISM. These enzymes, called CYTOCHROME SCRIPTION DRUG ABUSE.

COMMON DRUG/DRUG AND DRUG/FOOD INTERACTIONS This Drug In Combination with This Drug or Food Consequence of Interaction anticoagulant medications aspirin further decreases clotting response of the BLOOD, (heparin, warfarin) GINGKO BILOBA raising risk for bleeding antiplatelet medications (cilostazol, clopidogrel, large quantities of spinach increases ability of blood to clot, diminishing dipyridamole, ticlopidine) vitamin supplement containing VITAMIN K effectiveness of ANTICOAGULANT THERAPY

ANTIFUNGAL MEDICATIONS ALCOHOL of any kind (including in increases the risk for liver failure (fluconazole, griseofulvin, medications such as cold and flu products) itraconazole, ketoconazole) 156 Drugs

This Drug In Combination with This Drug or Food Consequence of Interaction beta blockers (acebutolol, oral antidiabetes medications decreases effectiveness of oral antidiabetes atenolol, betaxolol, medications bisoprolol, carteolol, masks presence of HYPOGLYCEMIA carvedilol, esmolol, labetalol, metoprolol, H2 blockers reduces liver’s ability to metabolize beta blocker, nadolol, penbutolol, allowing potentially toxic levels to accumulate in pindolol, propranolol, the blood circulation sotalol, timolol) MAOI antidepressants increases MAOI level; high risk for toxicity

cigarette smoking reduces effectiveness of beta blocker

H2 ANTAGONIST (BLOCKER) antifungal medications reduces absorption and effectiveness of antifungal MEDICATIONS (cimetidine, medications famotidine, ranitidine, nizatidine) oral antidiabetes medications increases effectiveness of antidiabetes medications, INSULIN raising risk for hypoglycemia

beta blockers increases effectiveness of beta blockers, raising risk for bradycardia and HYPOTENSION

tricyclic antidepressants (amitriptyline, increases antidepressant level in blood circulation, desipramine, imipramine, nortriptyline) raising risk for serotonin syndrome metronidazole (Flagyl) alcohol of any kind (including in action similar to that of disulfiram (antabuse) medications such as cold and flu products)

lithium lithium toxicity

anticoagulant and antiplatelet medications further decreases clotting response, raising the risk for bleeding monoamine oxidase beta blockers sudden, rapid, and very high surge in BLOOD inhibitor (MAOI) foods high in tyramine (beer, red wine, PRESSURE (potentially fatal) ANTIDEPRESSANT processed cheeses, smoked meats, MEDICATIONS avocados, bananas, raisins, cured foods) (isocarboxazid, phenelzine, GINSENG selegiline, tranylcypromine) CAFFEINE in beverages or medications drug interaction 157

This Drug In Combination with This Drug or Food Consequence of Interaction oral antidiabetes medications alcohol decreases effectiveness of oral antidiabetes medication

CORTICOSTEROID MEDICATIONS increases effectiveness of oral antidiabetes thiazide diuretics medication aspirin and other salicylates MAOI antidepressants NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) sulfonamide antibiotics warfarin quinolone antibiotics ANTACIDS chemical binding in stomach prevents absorption (ciprofloxacin, levofloxacin, dairy products of antibiotic ofloxacin, trovafloxacin) calcium supplements tetracycline antibiotics iron supplements (doxycycline, minocycline, tetracycline) beta-hydroxy-beta grapefruit juice decreases liver’s ability to metabolize statins methylglutaryl–coenzyme A (HMG-CoA) reductase antibiotic and antifungal medications various adverse reactions inhibitor (statin) lipid-lowering medications oral contraceptives (birth control pills) reduced effectiveness of the oral contraceptive (atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin) E–I

efficacy The ability of a DRUG to produce a pre- age of the cost for a nonformulary drug or may dictable effect in the body. Many factors influence choose not to cover (pay for) nonformulary drugs a drug’s efficacy, from foods and other drugs to at all except within the parameters of specifically health conditions and a person’s metabolic charac- defined criteria. A doctor may prescribe a drug teristics. An individual’s age, weight, gender, and that is not on the formulary even though the level of activity also may affect the rate at which a insurer may refuse to pay for it. The person may drug enters, and how long it stays in, the BLOOD still receive the drug by paying for the prescrip- circulation. Efficacy is a key factor in determining tion. Drug formularies help establish consistent a drug’s potential effectiveness to treat a particular prescribing practices as well as control costs for the condition in a specific individual. Some drugs insurer. have greater efficacy in younger people, for exam- See also GENERIC DRUG; ORANGE BOOK, THE; OVER- ple. Other factors that are also relevant include THE-COUNTER (OTC) DRUGS; PHARMACOPEIA; SIDE BIOAVAILABILITY and BIOEQUIVALENCE. EFFECT. See also CYTOCHROME P450 (CYP450) ENZYMES; THERAPEUTIC WINDOW. generic drug A DRUG that has BIOEQUIVALENCE and THERAPEUTIC EQUIVALENCE to its INNOVATOR DRUG (the formulary A list of the prescription drugs a first drug to receive approval for use). Generic health plan or insurance company, including state drugs became significant in the health-care indus- and federal health insurance programs, will cover. try in the 1970s when manufacturing require- Typically a committee of physicians and pharma- ments and procedures became standardized and cists makes the determinations about what drugs patents began to expire on innovator drugs, con- appear in the formulary and why. Factors for con- verging factors that opened the market for compe- sideration include tition within the pharmaceutical industry. Most generic drugs are significantly less expensive than • the DRUG’s EFFICACY their innovator counterparts, and most states have • whether generic products are available laws allowing pharmacies to substitute generic • similarity to other drugs that are less expensive drugs when filling prescriptions unless the pre- or have fewer side effects scribing provider specifies otherwise. The intent behind such laws is to provide consumers with • NARROW THERAPEUTIC INDEX (NTI) status cost-effective alternatives for prescription drugs. • the need for the drug within the insurer’s Generic products are also available for many OVER- patient population THE-COUNTER (OTC) DRUGS, allowing consumers to • whether over-the-counter forms of the drug are choose either generic or trade name products. available The US Food and Drug Administration (FDA), • the drug’s approved uses the federal regulatory agency that approves drugs for use in the United States, establishes the criteria Most insurers update their formularies at least for potency, purity, consistency, and efficacy all annually. An insurer may pay a smaller percent- drugs must meet. These criteria are the same for 158 investigational new drug (IND) 159 innovator and generic drugs. Generic drugs may THERAPEUTIC LEVEL; THERAPEUTIC WINDOW; TROUGH also have trade names, which manufacturers often LEVEL. use to establish brand recognition and brand loy- alty for marketing purposes. For example, Elavil imported drug A DRUG or pharmaceutical prod- and Endep are trade names for amitriptyline, a uct not manufactured in the country of purchase. commonly prescribed tricyclic antidepressant. The Countries may have differing requirements for manufacturer of an innovator drug may also pro- testing and product safety for the manufacture duce and market generic versions of the drug and distribution of drugs within their borders. In when the innovator drug’s patent expires. the United States the Food and Drug Administra- In nearly all circumstances a person may take tion (FDA) has regulatory authority over drug any manufacturer’s product, generic or innovator production and distribution and establishes the drug, and experience the same therapeutic effects. standards for bringing drugs into the country. The only exception is with NARROW THERAPEUTIC The Internet has dramatically broadened access INDEX (NTI) DRUGS, in which the margin between to foreign markets for drugs. Many Americans are the therapeutic dose and the toxic dose is exceed- drawn to Internet purchasing because of the ease ingly small. People who take NTI drugs should and convenience and because imported drugs are always take the same product, whether the inno- often less expensive than the same drugs pur- vator drug or a generic drug. Variations in the chased in the United States. However, health drug’s inactive ingredients can affect how the experts caution that drugs purchased through body absorbs the drug, which can have therapeu- locations in other countries, either by mail order tic significance with NTI drugs. or via the Internet, may not meet US quality stan- In its electronic document THE ORANGE BOOK, the dards for purity, potency, and safety and may not FDA maintains a list of newly approved generic be legal to bring into the country. drugs, updated each month, and a list of all The FDA supports the National Association of generic drugs available in the United States. The Boards of Pharmacy’s Verified Internet Pharmacies Orange Book is available at the FDA’s Web site Web site, www.nabp.net. This system provides (www.fda.gov/cder/ob). another way for consumers to verify the legiti- See also INVESTIGATIONAL NEW DRUG (IND); LEGEND macy of online pharmacies. DRUGS; OFF-LABEL USE; SCHEDULED DRUG. See also GENERIC DRUG; INVESTIGATIONAL NEW DRUG (IND). half-life The length of time it takes for the body to metabolize or eliminate from the body 50 per- innovator drug The first DRUG containing its spe- cent of the amount of a DRUG a person takes or cific active ingredients to receive approval for use receives. Drug half-life is an important factor in from the US Food and Drug Administration determining appropriate DOSAGE and for treating (FDA). An innovator drug’s patent protects the OVERDOSE. Drug half-life also helps the doctor drug from market competition, giving its manu- know when to expect to begin to see the effects of facturer exclusive right to produce and sell the the drug. The calculation of drug half-life is loga- drug. The innovator drug’s manufacturer gener- rithmic. Drug informational literature, packaged ally has invested significant time and money in with prescription drugs, provides general informa- the drug’s development, testing, and approval tion about the drug’s half-life that is generally process. Only when the patent expires may com- adequate for most clinical circumstances. A doctor peting pharmaceutical manufacturers produce and may conduct BLOOD tests to measure the levels of a market a generic version of the innovator drug. drug in an individual’s blood circulation over a See also GENERIC DRUG; INVESTIGATIONAL NEW DRUG period of time as a means of indirectly assessing (IND). half-life, though this is seldom therapeutically necessary. investigational new drug (IND) A new DRUG in See also BIOAVAILABILITY; CYTOCHROME P450 the final phases of development for which the US (CYP450) ENZYMES; EFFICACY; METABOLISM; PEAK LEVEL; Food and Drug Administration (FDA) grants 160 Drugs restricted approval for use in clinical testing, emer- • The person to receive the IND has a serious or gency treatment, or transportation across state life-threatening condition the IND is being lines. Typically the use of an IND must meet one developed to treat, and the FDA is in the of three requirements: process of reviewing the drug’s clinical research data. • The person to receive the IND enrolls in a clini- cal research study that is evaluating the drug’s The most commonly used INDs are antibiotics effectiveness, benefits, and risks among the used to treat multiple-drug-resistant infections drug’s intended patient population. and drugs to treat cancer. On its Web site the FDA • The person to receive the IND has a serious or maintains lists of current INDs by type of drug and life-threatening condition the IND is being information about how to gain access to unap- developed to treat, and there are no ongoing proved drugs (www.fda.gov). clinical research studies in which the person See also ANTIBIOTIC RESISTANCE; OFF-LABEL USE; can enroll. ORPHAN DRUG. L–N

legend drug In the United States, any DRUG that count from regular retail prices. Doctors’ offices requires a physician or other appropriately and clinics hospitals also often have drug samples licensed health-care provider (such as a dentist, that pharmaceutical representatives leave. Some optometrist, or podiatrist) to write a prescription programs offer prepaid prescription cards and and a pharmacist to dispense the medication. The other kinds of membership promotions for people federal approval and regulatory process deter- who do not have insurance to cover prescription mines which drugs are legend drugs, the labels of drugs but exceed the income levels for low-cost which must carry the admonition, “Caution: Fed- prescription plans. Whether these programs truly eral law prohibits dispensing without a prescrip- save money on prescription drugs depends on the tion.” Each state further regulates the prescribing amount and kinds of prescription drugs an indi- and dispensing of legend drugs, though practices vidual takes. are fairly consistent across states. Such regulation See also HEALTHY PEOPLE 2010; ORPHAN DRUG. includes the kind of information that must appear on the dispensing label and the manner in which narrow therapeutic index (NTI) A very close the pharmacist must discuss the drug’s intended margin between the concentration in the BLOOD benefits and potential risks with the person receiv- circulation of a DRUG that is therapeutic and the ing the medication. It is common to refer to leg- concentration that is lethal (deadly). Pharmacists end drugs simply as prescription drugs. generally express the therapeutic index as a ratio See also OFF-LABEL USE; OVER-THE-COUNTER (OTC) between the median effective DOSE (ED50) and the DRUGS; SCHEDULED DRUG. median lethal dose (LD50). A drug has a narrow therapeutic index when there is less than a low-cost prescription programs Need-based twofold difference between the ED50 and the programs, usually under the sponsorship of major LD50. With NTI drugs even very small changes in pharmaceutical manufacturers, that make certain the dose, variations in product potency, or prescription medications available to people who changes in the person’s health status can result in lack insurance coverage for prescription medica- toxic levels of the drug with harmful or fatal con- tions or who cannot otherwise afford to obtain sequences. them. Most low-cost prescription programs have The current standard of practice is to maintain income limitations for enrollees and many require the course treatment with the same drug product that a doctor refer the person and that the person rather than substituting across brand and generic receive the medications through delivery to the products as commonly and safely occurs with doctor’s office. Doctors, hospitals, and pharmacies non-NTI drugs. Some doctors prefer to use specific maintain information about current programs and brand name products when prescribing NTI drugs. their enrollment requirements. Some states mandate a nonsubstitution standard Some organizations, such as the American via law or regulatory code, requiring pharmacies Association for Retired Persons (AARP), also have to dispense the original drug product. Some clini- membership prescription programs that make cal studies support such caution though others drugs available to members at a significant dis- suggest that, at least with some NTI drugs, generic 161 162 Drugs substitution maintains therapeutically acceptable COMMONLY PRESCRIBED consistency for potency and EFFICACY. NARROW THERAPEUTIC INDEX (NTI) DRUGS The current standard of practice calls for close aminophylline carbamazepine clindamycin monitoring of blood concentrations until the drug clozapine cyclosporin digoxin reaches the desired therapeutic level, with routine disopyramide isoproterenol levothyroxine blood tests to monitor blood concentration over lithium metaproterenol phenytoin time, when the person begins taking a new drug, prazosin primidone procainamide and when there is a change in the person’s health quinidine valproic acid warfarin status (including significant change in body weight). Once the blood concentration of the drug See also BIOAVAILABILITY; BIOEQUIVALENCE; ORANGE reaches a steady state with the drug at a therapeu- BOOK, THE; PEAK LEVEL; THERAPEUTIC LEVEL; THERAPEU- tic level the NTI becomes less of a concern. TIC WINDOW; TROUGH LEVEL. O

off-label use Taking a DRUG for a purpose other See also ADVERSE DRUG REACTION; INVESTIGATIONAL than that for which it has received regulatory NEW DRUG (IND); SIDE EFFECT. approval. In the United States the Food and Drug Administration (FDA) requires pharmaceutical Orange Book, The A document the US Food and manufacturers to demonstrate the safety and effi- Drug Administration (FDA) maintains that lists all cacy of a drug before approving it for use. Once a the drugs, prescription and over-the-counter, that drug receives FDA approval, however, doctors have FDA approval for use in the United States. may legally prescribe it for uses that are consistent As of 2005 The Orange Book is available only as with current standards of care. The FDA does not an electronic document (www.fda.gov/cder/ob) regulate how doctors prescribe or individuals take on the FDA’s Web site (print editions are no longer approved drugs. obtainable). An individual may download the doc- Additional beneficial effects of a drug often ument in a printable format to produce a paper emerge after the drug has been in use for some copy, if desired. time and doctors begin to notice those effects. For The FDA updates The Orange Book daily. These some of these drugs the additional effects are so updates provide, among other kinds of informa- significant that prescribing the drug for them sub- tion, the most current information about newly sequently becomes an approved use. In other situ- approved generic products. The Orange Book lists ations the drug becomes widely known for its drugs by proprietary (trade or brand) name, active additional effects but the manufacturer does not ingredient, and patent holder. Listings identify the conduct further studies or seek FDA approval for INNOVATOR DRUG (first drug that received approval) them. and any GENERIC DRUG also approved for use as Off-label use is most common when treating well as provide information about the status of the conditions for which conventional therapies are product’s patent. limited or unsuccessful, especially when the con- See also FORMULARY; INVESTIGATIONAL NEW DRUG. dition is progressive or chronic such as MULTIPLE SCLEROSIS, PARKINSON’S DISEASE, CANCER, and CHRONIC orphan drug A DRUG to treat a rare condition. PAIN syndromes. Doctors may also turn to off-label The US Orphan Drug Act of 1983 (ODA) estab- use when prescribing medications for children lished criteria in the United States to encourage because many drugs receive approval without pharmaceutical manufacturers to investigate new having been tested for safety and EFFICACY in chil- drugs and continue to produce approved drugs to dren. A doctor’s decision to prescribe a drug off- treat conditions, such as HUNTINGTON’S DISEASE and label draws from available clinical study results, some forms of MUSCULAR DYSTROPHY, that affect clinical observations, and best practices standards. fewer than 200,000 people. The underlying prem- It is important for a person considering off-label ise of an orphan drug is that its sales will not gen- use of a drug to fully understand the potential erate enough revenue for its manufacturer to benefits and risks of such use as well as the drug’s recover the costs of its development and testing, a possible side effects and adverse reactions. circumstance that makes research and production

163 164 Drugs unappealing to pharmaceutical manufacturers. heat and humidity as a result of people bathing or The ODA establishes mechanisms of financial sup- showering. Pharmacists recommend storing drugs, port for pharmaceutical manufacturers through prescription and over-the-counter, in a cool, dry, grants and tax relief, in return for which the man- dark location unless the label specifies other stor- ufacturer agrees to produce and market the drug. age requirements, such as refrigeration. Additional grants are available to support research See also EFFICACY; OVERDOSE. about rare diseases. In 2005 there were approxi- mately 1,400 drugs with orphan drug status. The overdose Consumption of a quantity of a DRUG US Food and Drug Administration (FDA) Office of in excess of its recommended DOSE or of a combi- Orphan Products Development (OOPD) oversees nation of drugs that results in potentiated effects orphan drug research. from any or all of the drugs. Overdose may occur See also INVESTIGATIONAL NEW DRUG (IND); OFF- with prescription or OVER-THE-COUNTER (OTC) LABEL USE. DRUGS. The consequences of an overdose may range from no apparent symptoms to potentially outdated drug A DRUG that is past the manufac- life-threatening adverse effects. The severity of the turer’s listed expiration date. An outdated drug consequences depends on numerous factors, may be less effective than the unexpired product or including the person’s age, health condition, may be harmful. Drugs deteriorate over time. Some amount and kind of drug, whether the person also drugs have short effective periods, particularly consumed ALCOHOL, and to some extent whether those that require refrigeration. Other drugs main- the overdose is intentional or unintentional. tain potency for years. The US Food and Drug Administration (FDA) requires pharmaceutical Seek immediate medical help for any manufacturers to determine the length of time a suspected overdose. Call 911 or the US drug remains at full potency and to incorporate an national poison control hotline at 800- expiration date into the drug’s labeling informa- 222-1222. Do not induce vomiting tion. In general, pharmacists recommend not using unless a health professional so advises. a drug after one year from the date it was opened or Keep the package or container and any removed from its original packaging (including remaining DRUG for positive identifica- preparation or repackaging as a prescription). tion.

No matter what a DRUG’s official expira- Unintentional overdose may occur when a per- tion date, do not use or take products son that are discolored or obviously deterio- rated (such as tablets that are crum- • misreads or misunderstands the dosage instruc- bling) or when there is damage to the tions container (such as a crack in a tube or a • forgets having taken a dose and takes another broken lid). • takes one drug thinking it is another drug Factors such as exposure to heat, light, mois- • takes multiple drugs that have the same ingre- ture, and air may hasten deterioration, causing a dients drug to become less effective even before its expi- • takes a prescription drug and an over-the- ration date. It is important to store drugs in their counter (OTC) drug that have the same active original or prescription containers and in the ingredient appropriate environment. Many people keep med- ications in a bathroom medicine cabinet, which, • takes multiple drugs that interact in ways that though convenient for remembering to take med- intensify the effects of one or more of the drugs ications at the prescribed times, is a less than ideal taken environment. Most bathrooms are small and • drinks alcohol or uses illicit substances when enclosed and experience extreme variations in taking the medication overdose 165

A high risk for overdose exists among young the pill is in the person’s mouth and to aid in children who spend extended periods of time with making the pill easy to swallow. A child may older caregivers such as grandparents. Many older experience life-threatening poisoning from taking people have difficulty with child-resistant drug only a few pills, far fewer than would cause packaging or set out their medications to remem- adverse effects in an adult. Medications to treat ber to take them. Brightly colored tablets and cap- HEART conditions and iron supplements are among sules are attractive to young children who think the most hazardous drugs for overdose in chil- they are candy. The coatings on many pills contain dren. Overdose of acetaminophen and aspirin may sugar to mask unpleasant flavors during the time cause permanent LIVER FAILURE or RENAL FAILURE

COMMON DRUG OVERDOSE SYMPTOMS Type of Drug Common Symptoms acetaminophen initial: NAUSEA, VOMITING, excessive sweating later: ABDOMINAL PAIN, HEPATOMEGALY, JAUNDICE, LIVER FAILURE, RENAL FAILURE

ANTIHISTAMINE MEDICATIONS (brompheniramine, cetirizine, initial: extremely dry mucous membranes and SKIN, flushing, clemastine, diphenhydramine, doxylamine, fexofenadine, difficulty urinating, agitation, confusion loratadine, meclizine, promethazine, tripelennamine, later: seizures, extreme HYPERTENSION, ARRHYTHMIA, COMA triprolidine) aspirin, salicylates, and NONSTEROIDAL ANTI-INFLAMATORY initial: TINNITUS, vomiting, FEVER, rapid HEART RATE, rapid BREATHING, DRUGS (NSAIDS) confusion, HALLUCINATION later: kidney failure, HEART FAILURE, coma, gastrointestinal bleeding

BARBITURATE (pentobarbital, phenobarbital, secobarbital) initial: drowsiness, lack of coordination, slurred speech, depressed breathing, slow heart rate later: coma, RESPIRATORY FAILURE

BENZODIAZEPINES (alprazolam, chlordiazepoxide, initial: drowsiness, blurred vision, agitation, confusion, clorazepate, diazepam, flurazepam, lorazepam, hallucinations, depressed breathing, HYPOTENSION oxazepam, prazepam, temazepam, triazolam) later: loss of CONSCIOUSNESS, coma digoxin initial: nausea, confusion, blurred vision later: irregular heart beat, CARDIAC ARREST iron (ferrous gluconate, ferrous fumarate, ferrous sulfate, initial: nausea, vomiting, metallic taste in MOUTH, chills, HEADACHE, multiple vitamin and mineral supplement products dizziness, flushing containing iron) later: rapid heart rate, hypotension, coma

NARCOTICS (codeine, fentanyl, hydrocodone, initial: drowsiness, hypotension, depressed breathing, pinpoint hydromorphone, meperidine, methadone, morphine, pupils oxycodone) later: respiratory failure tricyclic ANTIDEPRESSANT MEDICATIONS (amitriptyline, initial: irregular heart rate, nausea, vomiting, DIARRHEA, hypotension desipramine, doxepin, imipramine, nortriptyline, later: seizures, psychotic behavior, arrhythmias, extreme protriptyline, trimipramine) HYPERTENSION, cardiac arrest 166 Drugs requiring LIVER TRANSPLANTATION or KIDNEY TRANS- • physostigmine, which counteracts some antihis- PLANTATION. tamines • flumazenil, which counteracts BENZODIAZEPINES Symptoms and Diagnostic Path The symptoms of drug overdose vary according to Other treatment targets symptoms and provides the drug or drugs involved and may range from supportive care until the body can metabolize agitation to lethargy to loss of CONSCIOUSNESS. enough of the drug for blood concentrations to Some symptoms are immediate, such as slowed drop below toxic levels. Such support might BREATHING and HEART RATE with narcotic overdose, include MECHANICAL VENTILATION when breathing is and others develop over time, such as JAUNDICE, impaired or dialysis for kidney failure. The extent resulting from liver damage. Prompt medical treat- of permanent damage or the likelihood of death ment is essential whenever there is cause to sus- depends on the drug and the amount as well as pect overdose. The kinds of symptoms a person how quickly the person receives treatment. has can suggest the general nature of the toxicity (narcotic, cholinergic, hepatotoxic) though it is Risk Factors and Preventive Measures important to identify as quickly as possible what Child-resistant containers and storing medications drug or drugs the person has taken. in locked cabinets or drawers out of the reach of children are important measures for preventing Treatment Options and Outlook accidental overdose in children. Adults should Treatment focuses on removing or neutralizing the store drugs in their original containers and check drug, when health-care providers are reasonably the container before taking a dose of the drug. certain what drug or drugs the person has taken. Particularly with prescription drugs repackaged in Gastric lavage (“STOMACH pumping”) is the com- pharmacy containers, it is easy to grab the wrong mon method for attempting to remove ingested bottle and take one drug thinking it is another. (swallowed) drugs. It is effective only within 30 to Contact the pharmacist or doctor if there are 60 minutes of ingestion; after this time any swal- unusual symptoms after taking any drug. It is also lowed substances have passed from the stomach crucial for the prescribing doctor and the dispens- into the SMALL INTESTINE. Gastric lavage involves ing pharmacist to know all of the drugs a person is inserting a nasogastric tube through the NOSE and taking, prescription and OTC (including MEDICINAL down the back of the THROAT into the stomach to HERBS AND BOTANICALS). withdraw the stomach’s contents and flush the See also ADVERSE DRUG REACTION; AGING, EFFECTS stomach with liquid. Sometimes the doctor will ON DRUG METABOLISM AND DRUG RESPONSE; ALCOHOL infuse a solution of activated charcoal, which is INTERACTIONS WITH MEDICATIONS; CYTOCHROME P450 highly absorbent, to help prevent more of the (CYP450) ENZYMES; HEPATOTOXINS; POISON PREVENTION. drug from entering the BLOOD circulation. Doctors do not agree about the effectiveness of gastric over-the-counter (OTC) drug In the United lavage for improving the person’s risk for compli- States, a DRUG that is available for purchase with- cations of overdose, and gastric lavage itself carries out a prescription and that does not require a risks for esophageal perforation (damage to the pharmacist to dispense. However, US laws do wall of the ESOPHAGUS) and aspiration of stomach require OTC product labels to list the product’s fluids into the LUNGS. active ingredients, main inactive ingredients, Antagonists, also called antidotes, are available strength, recommended DOSAGE, significant side to reverse the effects of some kinds of drugs. They effects (such as drowsiness), and any health con- include ditions a person might have in which the person should not take the drug. Furthermore these • naloxone, which counteracts NARCOTICS drugs must meet drug purity, consistency, and • N-acetylcysteine, which counteracts acetamino- safety standards. OTC drugs are available in a wide phen variety of retail locations. Most OTC products over-the-counter (OTC) drug 167 come in child-resistant packaging. Tablets and cap- act with each other or with prescription drugs the sules may come in bulk or single-dose packaging. person is also taking. Unintentional OVERDOSE may The US Food and Drug Administration (FDA) occur when taking a prescription drug and an OTC oversees the approval of new OTC drugs, which drug or when taking multiple OTC drugs that con- must meet the general criteria that: tain the same ingredients. This is a particular haz- ard when taking cold and flu products with • The drug’s benefits outweigh its risks. ALLERGY relief products, when taking PAIN relief • A person can take the drug to treat a self-diag- products with cold and flu products, and when nosed condition (such as HEADACHE or seasonal taking prescription drugs to treat OSTEOARTHRITIS allergies). with pain relievers or cold and flu products. Many • The drug has a low risk for abuse. cold and flu products contain an antihistamine and an ingredient to relieve pain and FEVER, such Many OTC drugs are lower-dose versions of as acetaminophen or ibuprofen. Prescription med- approved prescription drugs and thus have exten- ications for osteoarthritis are often NONSTEROIDAL sive clinical history that demonstrates their relative ANTI-INFLAMMATORY DRUGS (NSAIDS), the same classi- effectiveness and safety. Though OTC drugs are fication of drug as OTC pain relievers such as generally safe to take without a doctor’s oversight ibuprofen, ketoprofen, and naproxen. It is impor- of either the drug’s use or the condition the person tant to read product labels carefully and ask the is taking the drug to treat, people who regularly pharmacist about any possible interactions with take prescribed or doctor-recommended medica- other medications. tions should ask the doctor or pharmacist about See also ADVERSE DRUG REACTION; ALCOHOL INTER- possible problems or interactions. ACTIONS WITH MEDICATIONS; GENERIC DRUG; LEGEND All drugs have potential side effects, adverse DRUG; ORANGE BOOK, THE; SCHEDULED DRUG; SIDE reactions, and interactions. OTC drugs may inter- EFFECT. P–S

peak level The maximum concentration of a teins are the basic components of the body’s bio- DRUG in the BLOOD circulation. The peak level cor- chemical messengers, hormones and neurotrans- responds in part to the drug’s route of administra- mitters. The interactions they initiate are often tion, chemical composition, and rate of intricate cascades that influence numerous bio- METABOLISM. A drug’s peak level may occur within chemical processes (such as ion passage for cell minutes to several hours of taking or receiving it. communication) as well as DNA encoding and tran- Injectable drugs enter the blood circulation rap- scription (cell function and replication). Numer- idly; oral medications (taken by MOUTH) take ous factors influence the unfolding of these longer to reach the blood as they must first go cascades, from a person’s general health status and through digestion. Foods and liquids also con- existing health conditions to other drugs the per- sumed affect the rate of digestion and absorption, son is taking. For example, INSULIN RESISTANCE and as do other factors such as the person’s activity DIABETES affect the energy accessible to cells to level, age, body weight, and any health condi- carry out the functions of cellular METABOLISM, tions. altering the processes and outcomes of receptor A drug’s peak level establishes the upper limit binding. Through different mechanisms HYPOTHY- of the drug’s therapeutic range. For most drugs it ROIDISM slows and HYPERTHYROIDISM accelerates cel- is not necessary for the doctor to determine peak lular metabolism, also affecting receptor binding. level and TROUGH LEVEL (lowest concentration) as Pharmacodynamics gives doctors and pharmacists the drug’s informational literature provides the the ability to assess how individuals may react to expected levels. Improvement in the person’s specific drugs, depending on their unique health symptoms or condition is clinical evidence that the profiles. drug DOSAGE is therapeutically appropriate. The See also ALCOHOL INTERACTIONS WITH MEDICATIONS; doctor may more closely monitor blood concen- BIOAVAILABILITY; CYTOCHROME P450 (CYP450) ENZYMES; trations for NARROW THERAPEUTIC INDEX (NTI) drugs, HORMONE; NEURON; NEUROTRANSMITTER; PHARMACOKI- for which the peak and trough levels are critical. NETICS. Because the goal of most medication therapy is to achieve a fairly constant level of the drug in the pharmacokinetics The timing of a DRUG’s blood circulation, peak and trough levels are pri- absorption, METABOLISM, action, and excretion. marily significant at the onset of treatment. Pharmacokinetics is an element of DOSAGE deter- See also HALF-LIFE; ROUTES OF ADMINISTRATION; mination and the EFFICACY of a drug. Many vari- THERAPEUTIC LEVEL. ables unique to an individual influence the rate of a drug’s entry into, stay within, and passage from pharmacodynamics The actions of drugs within the body. Mathematical calculations that integrate the body. Drugs enter and act within the body by the drug’s characteristics (such as form and binding with cell receptors, specialized fragments strength) with an individual’s health circum- of proteins that instruct the cell to take or not take stances allow doctors and pharmacists to tailor specific actions. This binding process, called selec- medication therapy regimens specific to the indi- tivity, limits and directs the effects of drugs. Pro- vidual’s needs. 168 route of administration 169

See also ALCOHOL INTERACTIONS WITH MEDICATIONS; taken with the intent of producing a therapeutic BIOAVAILABILITY; BIOEQUIVALENCE; CYTOCHROME P450 effect. The placebo effect refers to the sense of (CYP450) ENZYMES; PHARMACODYNAMICS. improvement of symptoms an individual may experience when taking or using a product that pharmacopeia A professional and regulatory has no active ingredients. Researchers often use compendium of information about drugs, includ- placebo products when testing new drugs, particu- ing their formulations, dosages, and therapeutic larly medications such as PAIN relievers (ANALGESIC uses, that establishes manufacturing, safety, EFFI- MEDICATIONS), in which the assessment of effective- CACY, and prescribing standards. The US Pharma- ness has a subjective component. copeia (USP) is a formal and official document as See also INVESTIGATIONAL NEW DRUG (IND); MIND- well as a process for maintaining quality standards BODY CONNECTION. across the spectrum of pharmaceutical manufac- turers, pharmacies, and health-care organizations route of administration The method by which a (such as practices, clinics, care facilities, and hospi- person takes or receives a DRUG. The common tals) after a drug receives approval from the US routes administration are oral (by MOUTH), sublin- Food and Drug Administration (FDA). Drugs and gual (beneath the tongue), injection, topical, products such as dietary supplements that bear the transdermal, and rectal. Women may use some indication “USP-verified” or include “USP” with drugs intravaginally. Some drugs are available the product name meet USP standards. Other only in certain forms, such as injectable. Many countries have similar pharmacopeia (commonly drugs are available in numerous forms. Factors spelled “pharmacopoeia” outside the United that influence the selected route of administration States) structures. include the drug’s formulation and the person’s See also FORMULARY; ORANGE BOOK, THE. ability to take or receive a particular form of the drug. For example, a young child or person who placebo An inert substance that has no biologi- has difficulty swallowing or is experiencing NAUSEA cal, chemical, or other action within the body, and VOMITING may better handle a drug adminis-

ROUTE OF DRUG ADMINISTRATION Route Forms Entry Mechanism injection intravenous (IV), intramuscular (IM), IV: into a VEIN, direct entry to the BLOOD circulation subcutaneous (SC) IM: into a MUSCLE; rapid absorption into the blood circulation SC: into the fatty tissue beneath the skin; slow absorption into the blood circulation oral (per os or PO) tablet, capsule, liquid digestion breaks down the product, with absorption usually in the SMALL INTESTINE rectal suppository Soft carrier wax melts, drug becomes absorbed into the blood circulation through the wall of the RECTUM sublingual (SL) tablet, liquid dissolves under the tongue, becoming absorbed into the blood circulation through the mucosa of the MOUTH topical cream, ointment, gel, lotion, spray intended to remain within the layers of the SKIN transdermal patch, cream, ointment intended to be absorbed through the skin into the blood circulation 170 Drugs tered by transdermal patch, injection, or rectal destroying the scheduled drugs within its defini- suppository. Injection allows the most rapid deliv- tion; in general the distribution system is a closed ery; other forms allow slower entry of the drug one in that every individual who handles a sched- into the BLOOD circulation. uled drug must account for that drug’s passage See also BIOAVAILABILITY; PHARMACOKINETICS. through his or her contact. The US Drug Enforce- ment Agency (DEA) oversees compliance with scheduled drug In the United States a DRUG that UCSA regulations. Though state provider licensing has strict prescribing and availability criteria regulations designate prescribing authority for because of its potential for ADDICTION or abuse, as scheduled drugs, a provider must have a DEA the federal Uniform Controlled Substance Act license to prescribe scheduled drugs. (UCSA) of 1970 specifies and regulates. Some sub- Schedule I drugs are available only to stances are scheduled drugs (also called controlled researchers. Schedule II drugs require a written substances) because they have no medicinal or prescription for each quantity of drug received. therapeutic value yet may cause considerable harm Schedule III and schedule IV drugs require a writ- or death when used, such as HEROIN and lysergic ten or oral prescription and are refillable from the acid diethylamide (LSD). The UCSA establishes five original prescription up to five times within six levels of control for such drugs, indicated by a months if the provider authorizes refills. Under Roman numeral on the drug package’s label. federal law schedule V drugs do not require a pre- Each level of control has specific requirements scription though states may otherwise regulate for ordering, storing, prescribing, dispensing, and their availability.

SCHEDULED DRUGS Schedule Common Drugs Definition schedule I HEROIN, LSD, mescaline, methylenedioxymethamphetamine no accepted medical use (MDMA), methaqualone, racemoramide, tilidine, high risk for abuse trimeperidine unsafe for use schedule II amobarbital, AMPHETAMINE, COCAINE, codeine, glutethimide, limited medical use hydrocodone, hydromorphone, levorphanol, meperidine, high risk for abuse METHADONE, methylphenidate, morphine, oxycodone, high risk for physical or oxymorphone, pentobarbital psychological dependence schedule III amobarbital, amphetamine, anabolic steroids, BUPRENORPHINE, accepted medical use chlorphentermine, codeine compounds, GLUTETHIMIDE, moderate risk for abuse hydrocodone compounds, phenmetrazine moderate risk for physical or psychological dependence schedule IV BENZODIAZEPINES, CHLORAL HYDRATE, meprobamate, paraldehyde, accepted medical use pemoline, pentazocine, phenobarbital, propoxyphene low risk for abuse compounds, zolpidem low risk for physical or psychological dependence schedule V codeine COUGH preparations, dihydrocodeine, diphenoxylate accepted medical use negligible risk for abuse negligible risk for physical dependence, low risk for psychological dependence side effect 171

See also ILLICIT DRUG USE; LEGEND DRUG; OVER-THE- tions of the CENTRAL NERVOUS SYSTEM) and NAUSEA at COUNTER (OTC) DRUGS; PRESCRIPTION DRUG ABUSE. the onset of therapy with antihypertensive med- ications (which affect the autonomic NERVOUS SYS- side effect An action other than the intended TEM). A harmful side effect (one that has serious therapeutic effect of a DRUG. Side effects may be or long-term health consequences) is an ADVERSE neutral, beneficial, or harmful. Many side effects DRUG REACTION. It is important to know what side are so common as to be expected, such as DIAR- effects can occur with all medications a person is RHEA with certain ANTIBIOTIC MEDICATIONS (which taking, for each individual drug as well as for the occurs because antibiotics kill BACTERIA, including drugs in combination with each other. In the the bacteria that normally reside in the gastroin- United States federal and state laws require prod- testinal tract to aid in digestion). Some side effects uct package inserts or label information to contain are temporary, such as drowsiness when first brief information about possible side effects. beginning treatment with ANTIDEPRESSANT MEDICA- See also ALCOHOL INTERACTIONS WITH MEDICATIONS; TIONS (which affect neurotransmitters and func- DRUG INTERACTION; NEUROTRANSMITTER; OFF-LABEL USE. T therapeutic equivalence In pharmacology, drugs usually a steady state with little variation between that have the same active ingredients in the same the drug’s PEAK LEVEL and TROUGH LEVEL. Doctors forms and have the same actions within the body. calculate dosages to achieve a therapeutic level, The US Food and Drug Administration (FDA), factoring the person’s age, body weight, and other which oversees DRUG approval in the United medications with which interactions are possible. States, refers to such drugs as bioequivalent with For most drugs, blood drawn at any time provides matching EFFICACY and safety profiles. Therapeuti- the needed information about the drug’s concen- cally equivalent drugs may have superficial differ- tration in the blood. At the onset of medication ences such as in appearance (shape or color) and therapy or when taking a drug that has a NARROW the inactive ingredients that serve as the vehicle to THERAPEUTIC INDEX (NTI), blood tests taken to meas- contain the active ingredient. However, they must ure both peak and trough levels may provide have the same BIOAVAILABILITY and efficacy. more useful information to assess whether the The FDA has adopted a BIOEQUIVALENCE standard drug is at therapeutic level. It often is valuable to based on a statistical methodology in which the tell the doctor or the lab the time of the last DOSE time it takes for each drug to reach its maximum of the medication, which may help to determine concentration in the BLOOD circulation and the whether doses are spaced appropriately. amount of time the drug remains at a THERAPEUTIC See also CYTOCHROME P450 (CYP450) ENZYMES; LEVEL in the blood circulation differ by no more DOSAGE; EFFICACY; THERAPEUTIC WINDOW. than 20 percent. In its official listing of approved drugs, The Orange Book, the FDA identifies all therapeutic window The DOSAGE range within drugs with alternate products as “A” drugs (thera- which most of a DRUG’s likely population will peutically equivalent) or “B” drugs (not therapeu- experience the expected EFFICACY and therapeutic tically equivalent). value of the drug. The therapeutic window is Health-care providers other than pharmacists important to doctors when they calculate dosages, sometimes use the term therapeutic equivalence providing a clinically valid starting point for most in the context of different drugs within the same people. Individual characteristics such as other classification that have similar effects—for exam- health conditions, other medications being taken, ple the drugs fluoxetine and sertraline, both of body weight, and activity level help the doctor which are selective serotonin reuptake inhibitors determine where within the therapeutic window (SSRIs) to treat DEPRESSION. Though these drugs act is the most appropriate point to choose the start- in similar ways to achieve a similar therapeutic ing dosage. effect, they do not have the same active ingredi- See also PEAK LEVEL; THERAPEUTIC LEVEL; TROUGH ents. LEVEL. See also; GENERIC DRUG; INNOVATOR DRUG. trough level The amount of a DRUG in the BLOOD therapeutic level The amount of a DRUG in the circulation at the drug’s lowest therapeutic con- BLOOD circulation that is necessary to achieve and centration. Generally the trough level occurs sustain the desired effect for treatment, which is immediately before the person is due to take the 172 trough level 173 next DOSE of the drug. The trough level helps the Trough level is an especially important measure doctor determine if the dosage is appropriate to for NARROW THERAPEUTIC INDEX (NTI) drugs (drugs for achieve the desired therapeutic effect and is useful which the margin between therapeutic and toxic information primarily at the onset of treatment. is very close) such as theophylline (to treat The goal of most medication therapy is a steady ASTHMA), certain ANTIBIOTIC MEDICATIONS, state of the drug’s concentration in the body, at cyclosporine for IMMUNOSUPPRESSIVE THERAPY, some which there is little difference between the drug’s antiseizure medications, and many antiarrhythmia PEAK LEVEL (highest concentration in the blood cir- medications. culation) and trough level. See also HALF-LIFE; THERAPEUTIC LEVEL. NUTRITION AND DIET

The science of nutrition concerns itself with the ways in which foods influence health and disease. A health-care prac- titioner who specializes in nutrition may be a registered dietitian (RD), registered nurse (RN), physician (MD or DO), naturopathic physician (ND), pharmacist (RPh or PharmD), or chiropractor (DC). The general term nutritionist is in common use to identify a health-care professional who specializes in matters of nutrition but does not consistently des- ignate specific education, training, qualifications, or credentials.

This section, “Nutrition and Diet,” presents an Among the most famous names in medical overview discussion of nutritional concepts as nutrition is John Harvey Kellogg (1852–1943), a they relate to health, health risk factors, and pre- late-19th-century American physician and sur- ventive health measures. The entries in this sec- geon whose belief that diet was the foundation of tion focus on the broad picture of how nutrition good health launched what would become one of and diet influence health and disease. The section, the world’s largest and most successful cereal “Lifestyle: Obesity and Smoking,” provides discus- companies. Kellogg came up with a recipe for a sion and content of nutritional topics that relate simple, nutritious breakfast food to serve at the to WEIGHT LOSS AND WEIGHT MANAGEMENT. sanitarium where he was at the time the director: cornflakes. The product based on the recipe Making the Connection between Diet and Health became itself an American institution. Kellogg Though the mechanisms of nutrition remained implemented many practices based on nutrition unknown until the early 20th century, doctors during his tenure at the sanitarium, gaining were quite familiar with the diseases of nutri- prominence for them in a time when other med- tional deficiencies. Ancient Egyptian physicians ical alternatives were fairly nonexistent. identified the disease now called SCURVY, which for In the flood of transforming discoveries sweep- centuries was the bane of sailors who spent ing the practice of medicine, diet was not espe- months to years at sea on ships with no fruits or cially exciting and its connections to health vegetables to supply needed vitamins and miner- unproven. Researchers discovered aspirin, INSULIN, als. Biscuits and salt pork sustained life but they antibiotics, immunizations, and ANESTHESIA. Sur- did not support nutrition. Not until the middle of geons invaded the belly, chest, and cranium. Kel- the 18th century did ships’ surgeons recognize logg, himself a talented surgeon, developed a that citrus fruits (namely lemons, limes, and number of surgical techniques and the instru- oranges) could cure as well as prevent scurvy ments to carry them out. Though Kellogg’s corn- among sailors. flakes became a national phenomenon, doctors did not pay much attention to the role of diet— the kinds and amounts of foods people eat—in HEALTH CONDITIONS RESULTING health unless they were treating conditions result- FROM NUTRITIONAL DEFICIENCIES ing from or that caused NUTRITIONAL DEFICIENCY or BERIBERI MALNUTRITION toxicity. NIGHT BLINDNESS OSTEOPOROSIS About the time John F. Kennedy became US PELLAGRA pernicious ANEMIA president, researchers established the first diet– RICKETS SCURVY disease correlation, that between cholesterol and 174 Nutrition and Diet 175

CARDIOVASCULAR DISEASE (CVD). Following shortly Current Challenges and Future Directions was the first official recommendation to limit con- A key challenge today is the rapidly changing sumption of a particular food, eggs, as an effort to understanding of the relationships between nutri- prevent disease. In the decades since, research has tion and health and between nutrition and dis- confirmed a tight and intricate relationship ease. Though a general range of nutrient intake is between DIET AND HEALTH, and diet-related health adequate for most healthy adults, it is becoming conditions became the focus of renewed effort to increasingly clear that individual variations in identify nutritious, healthful foods. NUTRITIONAL NEEDS and nutrient intake can make the difference between health and disease. The HEALTH CONDITIONS LINKED TO DIETARY FACTORS medical community is in transition in regard to ATHEROSCLEROSIS BREAST CANCER nutritional recommendations, shifting from the cervical dysplasia CERVICAL CANCER system in place since the early 1940s to methods COLORECTAL CANCER CORONARY ARTERY DISEASE (CAD) of NUTRITIONAL ASSESSMENT that take individual vari- DENTAL CARIES HYPERLIPIDEMIA ations more into consideration. Current research HYPERTENSION OBESITY is exploring the ways in which NUTRIENTS may PERIPHERAL VASCULAR DISEASE (PVD) PROSTATE CANCER serve to lower health risk factors, such as for CVD STOMACH CANCER type 2 DIABETES and diabetes, over the length of the lifespan. A aging, nutrition and dietary changes that occur food intake restricted without precise instructions with Nutritional needs and dietary choices from a doctor or nutritionist. change across the spectrum of age. Diet and nutri- tion also influence the processes of aging and the Health Changes and Nutrition status of health. Beginning in middle age people start to experience physical changes that alter their ability to digest Food Choices and Lifelong Health foods and absorb NUTRIENTS. The STOMACH produces Health experts recommend BREASTFEEDING for less acid, and foods may stay in the stomach infants, in most circumstances, from birth through longer before being digested enough to progress to at least six months of age if possible. Breast milk the SMALL INTESTINE. The stomach also produces fulfills 100 percent of an infant’s NUTRITIONAL NEEDS, less intrinsic factor, a biochemical essential for the provided the mother is meeting her own nutri- absorption of vitamin B12 (cyanocobalamin). Den- tional needs, and provides the infant with extended tal conditions and changes to the gums (such as immune coverage until his or her own IMMUNE SYS- PERIODONTAL DISEASE) may result in lost TEETH and TEM develops enough to become protective. Infants difficulty chewing. Perceptions of taste and smell for whom breastfeeding is not practical or appropri- may change, altering the desire for certain foods. ate should receive fortified formulas that meet their Other changes include a generalized slowing of nutritional needs. Cow’s milk does not provide ade- the metabolic rate, which affects digestion and quate nutritional value and contains higher nutrient absorption, and a decreased need for amounts of sugars than infant formulas. nutrients (fewer calories). The nutritional needs of the toddler and older Health conditions with metabolic conse- child focus on supporting proper growth and quences, such as diabetes and GALLBLADDER DISEASE, development. Children who learn to make nutri- become more prevalent with advancing age. tious food choices, including portion size, early in Health conditions for which nutrition plays a role, life are likely to make such choices the mainstay such as CARDIOVASCULAR DISEASE (CVD), also become of diet throughout life. Healthy children do not more prevalent. Other chronic health conditions require vitamin or mineral supplements and may accelerate the body’s use of certain nutrients. should take them only when a doctor recom- Both men and women begin to experience mends them. changes in BONE DENSITY and BONE mass in middle A critical health problem among children is OBE- age, women in an especially pronounced manner SITY, which sets the stage for a plethora of health after MENOPAUSE. Without proper vitamin D and challenges that can have lifelong consequences. calcium intake, OSTEOMALACIA and OSTEOPOROSIS are Researchers are identifying in children, especially significant threats to bone health. teens, diseases formerly the exclusive territory of The very old (80 and older) may have mobility, middle age such as type 2 DIABETES, OSTEOARTHRITIS, independence, and economic issues that prevent and ATHEROSCLEROSIS. Nutritious EATING HABITS are an them from eating appropriately. Debilitating con- important component of weight management. ditions such as ALZHEIMER’S DISEASE, DEMENTIA, and However, children should not go on “diets” or have PARKINSON’S DISEASE are more common among the 176 appetite 177 elderly. NUTRITIONAL DEFICIENCY and MALNUTRITION Research suggests antioxidants play a vital role in can develop rather quickly, initiating a cascade of stopping cancers before they gain any momentum health consequences that can be difficult to as well as in slowing the progression and damage reverse. It is important for caregivers and health- of chronic conditions such as ATHEROSCLEROSIS and care providers to monitor dietary intake and nutri- DIABETES. tion in the elderly, to make sure food and nutrient Though many NUTRITIONAL SUPPLEMENTS contain consumption is adequate. Basic NUTRITIONAL ASSESS- antioxidants, food-based antioxidants appear to MENT should be a component of most visits to the have more potent effects through their numerous doctor and of every ROUTINE MEDICAL EXAMINATION. though little-understood interactions with one another. One exception is coenzyme Q10, which Maintaining Healthy Nutrition does not come from dietary sources but rather Across the Age Spectrum through processes within the body. Coenzyme Healthy eating habits support the body in main- Q10 supplements boost coenzyme Q10 levels in taining optimal health at any age. In combination the body to have apparently the same effects as with appropriate daily physical exercise, adequate endogenous coenzyme Q10. Minerals such as cop- nutrition often is the difference between full per and zinc help the body use antioxidants more recovery and prolonged or incomplete recovery effectively. from health conditions that arise. These lifestyle See also NUTRITIONAL THERAPY; PHYTOESTROGENS; factors also lower the risk for numerous health SUN’S SOUP; VITAMIN AND MINERAL THERAPY. conditions. See also CARDIOVASCULAR DISEASE PREVENTION; DIET appetite The sensation of feeling the desire to AND HEALTH; LIFESTYLE AND HEALTH; NUTRIENTS; OBESITY eat. Appetite represents complex hormonal, neu- AND HEALTH; PREVENTIVE HEALTH CARE AND IMMUNIZA- rologic, and environmental interactions that cor- TIONS. relate in varying proportions both to HUNGER, the body’s physiologic signal that it needs food, and to antioxidant A biochemical substance that learned behaviors for eating. Seeing, smelling, and attracts free radicals, unmatched molecules thinking about food often trigger appetite. Many remaining as the waste byproducts of oxidation people also feel the desire to eat at conventional functions (energy conversion and release) within meal times, regardless of whether their bodies the body. Free radicals are associated with numer- actually need food. Emotional circumstances may ous health conditions, especially chronic diseases, trigger appetite as well, particularly when there is though researchers do not yet fully understand an emotional or habitual connection between eat- their roles. Free radicals bind with other mole- ing and feeling comforted. cules, hijacking them from their intended destina- tions. The resulting rogue molecules do not have The Mechanisms of Appetite legitimate functions within the body and disrupt Three regions of the BRAIN work in collaboration normal cellular functions. When an antioxidant and counterbalance to regulate appetite: the molecule binds with a free radical, the resulting appetite center, the SATIETY center, and the hunger structure becomes a readily identifiable waste center. The appetite center resides within the molecule that the body’s natural processes then brainstem, the most rudimentary structure of the eliminate from the body. brain that regulates functions necessary for sur- Antioxidants are abundant in fruits and vegeta- vival. It responds to external sensory NERVE signals bles. The body also synthesizes some antioxidants from the body that travel to the brain via the CRA- such as COENZYME Q10. Carotenoids (components of NIAL NERVES as well as to nerve signals that come vitamin A), vitamins C and E, the mineral sele- from the cerebral cortex. Because signals from the nium, and phytochemicals such as flavonoids and cerebral cortex arise from activities of cognitive plant sterols are among the common dietary function (such as thought, memory, and emo- antioxidants. SOY, GREEN TEA, and GINKGO BILOBA are tion), their influence on the appetite center is particularly high in such phytochemicals. within conscious control. 178 Nutrition and Diet

The hunger center resides within the HYPOTHAL- of digestive hormones begins to shift, further sig- AMUS, a structure of the midbrain that integrates naling the satiety center as well as slowing the sig- neurologic and hormonal activity to maintain nals going to the appetite center. essential body functions. The hunger center responds primarily to the level of GLUCOSE (the Appetite Response form of sugar that is the primary fuel for the Appetite is a powerful mechanism intended to body’s cells) in the BLOOD, activating the appetite bring food (energy) into the body. Though aspects center when the blood glucose level drops. The of appetite represent areas of conscious control, hunger center’s activation triggers a cascade of appetite response is not simply an issue of response from the hypothalamus that includes willpower or of survival. Some people eat a small sending nerve signals to the appetite center and amount, feel satisfied, and stop eating. Other peo- the cerebral cortex to stimulate the desire to eat, ple eat large amounts of food and do not feel satis- hormonal signals to the gastrointestinal tract to fied, even when they begin to feel physically begin releasing DIGESTIVE HORMONES (such as gas- uncomfortable because they have eaten more trin, secretin, cholecystokinin, and pepsin), and than enough to fill their gastrointestinal tracts. neurohormonal signals that result in an increase Appetite appears to be a short-term feature of of acetylcholine, a NEUROTRANSMITTER that facili- energy management designed to meet the body’s tates smooth MUSCLE contraction, in the gastroin- daily energy needs; how appetite correlates with testinal tract. These events establish a cycle that the body’s available stores of surplus energy (in continues until blood glucose levels rise. Because the form of body fat) remains a mystery. the hunger center responds to neurohormonal sig- There is some evidence that continued expo- nals related to basic survival, neither it nor its sure to the smells of food without eating may sig- influence on the appetite center is within con- nal both the satiety center and the appetite center scious control. that the body is consuming enough food, even The satiety center also resides in the hypothala- when a person is only smelling, not eating, food. mus near the hunger center. It responds to nerve However, manipulating the appetite is not so easy. signals from the hunger center and from the Establishing EATING HABITS that provide adequate appetite center. As food enters the SMALL INTESTINE CALORIE and nutrition intake helps maintain bal- for the main phase of digestion, the small intestine ance among the appetite, hunger, and satiety cen- releases peptide YY, a HORMONE that signals the ters. This is particularly important for WEIGHT LOSS satiety center. The satiety center in turn sends AND WEIGHT MANAGEMENT as well as for overall nerve messages to the hunger center and to the health maintenance. appetite center, signaling that the body no longer See also DIGESTIVE ENZYMES; METABOLISM; OBESITY needs to consume food. Concurrently the balance AND HEALTH; STARVATION. B–C beriberi A health condition resulting from long- • abdominal tenderness term deficiency of thiamine (vitamin B1). Beriberi affects neurologic, musculoskeletal, cardiovascu- As the condition progresses symptoms become lar, and gastrointestinal structures and functions. specific for the body system affected. Neurologic Though common in developing parts of the world, and musculoskeletal (dry beriberi) symptoms beriberi occurs primarily in people who have gas- include trointestinal disorders that interfere with thiamine • peripheral NEURITIS (INFLAMMATION of the nerves) absorption and in long-term, chronic ALCOHOLISM. or peripheral NEUROPATHY A BREASTFEEDING infant whose mother is thiamine deficient may also develop beriberi. Beriberi is also • PARESTHESIA (disturbances of sensation such as common among people whose primary food is tingling and numbness) white rice. Thiamine is necessary for cells in the • cramps in the lower legs body to convert GLUCOSE to energy and to convert • PAIN and weakness in muscles throughout the glucose to energy storage forms (fat). body There are two main forms of beriberi: dry and wet. Dry beriberi is more common and affects pri- • difficulty walking and rising from a sitting or marily the NERVOUS SYSTEM and the musculoskeletal squatting position system. Wet beriberi affects primarily the cardio- Cardiovascular (wet beriberi) symptoms are vascular system; its most apparent symptom is those of congestive HEART FAILURE and include edema (swelling due to fluid accumulation), which accounts for the “wet” designation. People • tachycardia (rapid HEART RATE) who have mild to moderate beriberi typically have distinctly one form or the other; people who have • diaphoresis (“cold sweats”) moderate to severe disease generally have both • edema forms as the deficiency is severe enough to affect • shortness of breath (DYSPNEA) all body functions. The diagnostic path begins with a careful Symptoms and Diagnostic Path assessment of the PERSONAL HEALTH HISTORY with an The early symptoms of beriberi are the same for emphasis on EATING HABITS. BLOOD tests can meas- either the wet or the dry form and include ure the amount of thiamine in the blood as well as enzyme levels related to thiamine activity in the • fatigue body. When symptoms are cardiovascular, the • difficulty concentrating and cognitive dysfunc- doctor is likely to conduct an ELECTROCARDIOGRAM tion (ECG) and an ECHOCARDIOGRAM. • irritability Treatment Options and Outlook • loss of APPETITE Treatment is injections of thiamine until blood • NAUSEA, VOMITING, and CONSTIPATION levels return to normal and symptoms begin to 179 180 Nutrition and Diet subside. Cardiovascular symptoms generally represent energy the body expends. Recom- improve within 24 hours, though underlying mended daily calorie intake guidelines represent damage to the HEART may be permanent and the amount of energy a typical adult requires to require subsequent treatment. Neurologic and carry out the activities of normal living. Taking in musculoskeletal symptoms may take several more calories than one expends results in weight months to completely resolve. Dry beriberi gener- gain (the body stores extra calories as fat), and ally resolves without residual complications except expending more calories than one consumes in the most severe cases, in which there may be results in weight loss (the body draws from stored permanent peripheral neuropathy (damage to the energy to meet its needs). The steady state of PERIPHERAL NERVES). Untreated beriberi is fatal, usu- weight maintenance occurs when there is a rela- ally a result of cardiovascular collapse. tive balance between the calories that enter the Maintenance therapy with vitamin B supple- body and the calories the body uses. mentation helps prevent RECURRENCE, especially See also METABOLIC EQUIVALENT (MET); NUTRIENTS; in people who are not likely to receive adequate NUTRITIONAL NEEDS. B vitamins from dietary sources. Most people who have thiamine deficiency are also deficient carbohydrate intolerance An enzyme deficiency in other B vitamins and should take a vitamin that results in the body’s inability to metabolize B complex supplement product. People who one or more forms of carbohydrate. The most have gastrointestinal disorders that interfere with common form of carbohydrate intolerance is LAC- their ability to absorb thiamine, such as PEPTIC TOSE INTOLERANCE, which affects up to 50 million ULCER DISEASE, may require ongoing thiamine Americans and results from a deficiency of the injections. enzyme lactase. Other forms of carbohydrate intolerance are much less common though may Risk Factors and Preventive Measures result from deficiencies of maltase (necessary to The sole risk factor for beriberi is inadequate con- metabolize maltose) and sucrase (also called iso- sumption of dietary thiamine. Accordingly, main- maltase, necessary to metabolize sucrose). taining adequate dietary consumption of foods The enzyme deficiencies responsible for carbo- that contain B vitamins prevents beriberi in most hydrate intolerance may be congenital (absent people. Food sources of thiamine include lean from birth), acquired through a natural decline in meats (notably pork), legumes, watermelon, acorn DIGESTIVE ENZYMES through aging, or as a conse- squash, and whole grains and whole grain prod- quence of gastrointestinal disorders such as CELIAC ucts. Grain products such as breads and cereals DISEASE. RADIATION THERAPY and CHEMOTHERAPY treat- produced in the United States are fortified with B ments for cancer also can affect the cells that pro- vitamins, including thiamine. Highly refined and duce the various enzymes, resulting in enzyme processed foods, especially white rice and white depletion and intolerance of the corresponding bread, contain minimal amounts of B vitamins, carbohydrate. including thiamine, unless they are fortified. B The symptoms of carbohydrate intolerance complex vitamin supplements help ensure ade- often include abdominal cramping, flatulence quate intake. B vitamins are water-soluble so (gas), and DIARRHEA. Children may fail to gain there is no risk for OVERDOSE. weight or grow appropriately. The diagnostic path See also ANEMIA; MALNUTRITION; NUTRITIONAL DEFI- may include an oral carbohydrate challenge, in CIENCY; NUTRITIONAL NEEDS; PELLAGRA; RICKETS; which the person drinks a solution containing the SCURVY; VITAMINS AND HEALTH. suspect carbohydrate. BLOOD samples taken at cer- tain intervals measure the amount of the sugar calorie A unit of measure that denotes heat form present in the blood circulation. Because lac- consumption. In nutrition and exercise, calories tose intolerance results IN excessive hydrogen gas represent a measure of energy exchange. The production, breath tests to measure hydrogen con- calories in foods represent energy the body takes centrations in the lungs are often diagnostic for in, and the calories assigned to physical exertion lactose intolerance. cholesterol, dietary 181

Many people can tolerate small amounts of production, has the consistency of a waxy liquid substances that contain the sugars for which they and does not dissolve in water or blood. Carrier are lacking enzymes. Avoiding larger amounts proteins called lipoproteins, which the liver also keeps symptoms in check. It is important for peo- produces, bind with cholesterol molecules so they ple who have carbohydrate intolerance to make can travel through the bloodstream. The more sure they receive adequate intake of other NUTRI- cholesterol molecules in the blood circulation, the ENTS in foods for which they have intolerance or to more lipoproteins required to transport them take supplements that supply them. through the blood. When there are high levels of See also AGING, NUTRITION AND DIETARY CHANGES lipoproteins in the blood some tend to “fall out” THAT OCCUR WITH. against the sides of the arteries, eventually form- ing plaques (hardened patches) that narrow and cholesterol, dietary A sterol substance found in stiffen the arteries. These plaques are the early animal-based foods such as meats and dairy prod- stages of ATHEROSCLEROSIS, the foundation of CAD. ucts. Dietary cholesterol under scrutiny in the There is very little correlation between the cho- 1970s when research connected high BLOOD cho- lesterol in foods and the cholesterol in the blood lesterol levels with increased risk for CARDIOVASCU- circulation. Rather, the amounts of saturated fats LAR DISEASE (CVD), notably ATHEROSCLEROSIS and and trans fats in the diet determine blood levels of CORONARY ARTERY DISEASE (CAD). However, subse- cholesterol in most people. Cholesterol and satu- quent research has determined the true culprit is rated fats co-exist in many animal-based foods, endogenous cholesterol—the cholesterol the LIVER however, so a diet heavy in these foods con- synthesizes from the components of dietary satu- tributes to higher-than-healthy cholesterol and rated fats and trans fats. The liver makes about 80 lipoprotein levels in the blood. Health experts rec- percent of the cholesterol in the blood circulation, ommend limiting dietary cholesterol to 200 mil- and it continues to make cholesterol as long as it ligrams a day for people who have no increased receives the source materials (dietary fats) to do risk for CVD. Doctors may recommend a lower so. Dietary cholesterol has almost no role in this limit for people who have, or have increased risk process. for, CVD. Furthermore, researchers recognized it is not See also CARDIOVASCULAR DISEASE PREVENTION; the cholesterol itself that is the problem. Choles- CHOLESTEROL BLOOD LEVELS; DIET AND HEALTH; HYPER- terol, which is important to health because it is LIPIDEMIA; LIFESTYLE AND HEALTH; NUTRIENTS; TRIGLYC- essential for cell membrane repair and HORMONE ERIDE BLOOD LEVEL; TRIGLYCERIDES, DIETARY. D–H

diet and health The effects foods and EATING Correlations between diet and disease are HABITS have on health and HEALTH RISK FACTORS. As sometimes difficult for researchers to quantify. For diet is the primary means by which the external example, people who eat a diet high in meats and environment enters the internal environment of saturated fats have a higher incidence of COLON the body, much research focuses on how diet cancer than people who eat a diet that is primarily affects health in general as well as the risk for vegetarian and low in fat. The reasons for this are numerous health conditions. The obvious correla- imprecise, however, and likely represent an inte- tions are those between specific nutrient deficien- gration of factors of which diet is only one consid- cies, conditions such as BERIBERI and SCURVY. Other eration. Other correlations are more precise, such health conditions that have major dietary connec- as those that link high dietary saturated fat, high tions are the diseases that claim the most lives and CHOLESTEROL BLOOD LEVELS, and ATHEROSCLEROSIS. cause the most disability among Americans: can- Foods also appear to influence mood and behav- cer, CARDIOVASCULAR DISEASE (CVD), DIABETES, OBE- ior, though again the precise mechanisms of these SITY, and OSTEOPOROSIS. Diet—what foods and how interactions remain unknown. much of them a person eats—has emerged as a Diet can bolster health as well. Supplying the significant risk factor for these conditions. body with the nutrients it needs allows it to func- On the whole, the body has a remarkable abil- tion with optimal efficiency. In such a state the ity to use the substances it receives through diet to body’s own systems are fully active to resist dam- conduct the functions of living. This ability in part age and respond promptly when injury or illness stems from the processes of METABOLISM that occurs. Health experts believe lifestyle factors such reduce all NUTRIENTS to their absolute basic compo- as diet and exercise have the ability to eliminate as nents, amino acids and sugars that eventually much as 85 percent of HEART disease, obesity, and become GLUCOSE. The body’s numerous systems type 2 DIABETES, and reduce the risk for COLORECTAL then reassemble those components into the sub- CANCER, STOMACH CANCER, and possibly BREAST CAN- stances they require. In large part the body can CER and PROSTATE CANCER. subsist in reasonable health on a marginal diet. See also ANTIOXIDANT; CANCER PREVENTION; CARDIO- Eventually, however, the shortcomings become VASCULAR DISEASE PREVENTION; DIABETES PREVENTION; problematic and begin contributing to health con- FOOD SAFETY; HEALTHY PEOPLE 2010; LIFESTYLE AND ditions. For example, a diet low in fruits, vegeta- HEALTH; OBESITY AND HEALTH. bles, and whole grains lacks a consistent supply of the vitamins and minerals the body needs to enteral nutrition Nutritional supplementation or manage its energy needs, maintain immune replacement when a person cannot acquire the functions, and regulate body activities. The necessary NUTRIENTS by eating, typically adminis- consequences of inefficient metabolism range tered via a nasogastric tube or surgically inserted from molecular, which may include the accumula- tube, commonly called a feeding tube. Long-term tion of free radicals or disruptions in protein enteral nutrition may become a QUALITY OF LIFE sequencing of GENETIC CODE, to overt disease such issue or an end-of-life concern, especially for as CVD. those who become unable to make and express 182 hunger 183 their desires. An advance directive allows a person a PEG or other gastric tube. Because the small to establish in writing his or her desires about intestine accepts limited volume, enteral nutrition such matters, mitigating family conflict about via J tube is a continuous infusion. making the decision on behalf of the person. Conscientious PERSONAL HYGIENE is essential with either kind of tube to prevent skin irritation Types of Feeding Tubes for Enteral Nutrition (around the nostrils with a nasogastric tube and at A nasogastric tube is a thin, flexible catheter the the stoma site with a surgically placed tube) and doctor inserts through the NOSE, down the back of INFECTION (more of a concern with a surgically the THROAT, through the ESOPHAGUS, and into the placed tubes). STOMACH. The insertion process is somewhat uncomfortable but does not require anesthetic, Enteral Nutrition Feeding though the doctor generally sprays a topical anes- Enteral feeding may be continuous or intermit- thetic on the back of the throat to numb the gag tent, depending on the person’s health status and REFLEX. A nasogastric tube is for short-term use, NUTRITIONAL NEEDS. Enteral nutrition administered usually no longer than a few weeks. The nasogas- via surgically inserted tubes can provide adequate tric tube blocks the nostril through which it sustenance for years. Commercially prepared enters, and becomes irritating to the nasal mucosa enteral nutrition solutions, most of which require as well as the SKIN around the nostril. a doctor’s prescription, are of appropriate viscosity Surgically inserted tubes are for long-term use to avoid clogging the tube. They have high nutri- and are generally somewhat sturdier though still tional density and are available in various formu- narrow and flexible. They enter the stomach or lations to meet individual nutritional needs. The SMALL INTESTINE through an opening in the abdomi- formula and the person’s requirements determine nal wall. The most common type is the percuta- the frequency and rate of infusions. neous endoscopic gastrostomy (PEG) tube, also In some situations doctors may recommend called a gastrostomy tube or G tube, for long-term enteral nutrition formulas that are palatable use. With the person under general ANESTHESIA, enough to take by MOUTH, typically in situations in the doctor makes a small incision through the which a person has difficulty chewing or swallow- abdominal wall for the insertion of the tube. An ing and does not want a feeding tube, or who gen- endoscope passed into the stomach via the throat erally gets adequate nutrition from eating but and esophagus guides the doctor in placing the would benefit from the nutritional boost of an tube. A small balloon at the tip of the tube, enteral nutrition formula. Some products are inflated with saline solution, lodges the tube in available over the counter (OTC) without a doc- the stomach. The surgical wound, called a stoma, tor’s prescription. Because excesses of some nutri- heals in 7 to 10 days. ents can cause health problems or interfere with A gastric button is an alternative to a PEG tube. prescribed medications, people who are consider- After the stoma is completely healed, the person ing such OTC products should discuss the can remove the tube and replace it with a gastric approach with their doctors first. button, a pluglike device that fits into the stoma to See also ENDOSCOPY; NUTRITIONAL ASSESSMENT; block the opening. At feeding times the person (or PARENTAL NUTRITION. caregiver) removes the button, reinserts the tube, and administers the enteral nutrition solution. feeding tube See ENTERAL NUTRITION. Some people find a gastric button more discreet and less intrusive. A third surgical alternative is a food–drug interactions See DRUG INTERACTION. tube placed into the JEJUNUM, the middle segment of the small intestine. A jejunostomy tube, or J hunger The body’s physiologic indication that it tube, may be necessary for a person who has had needs energy (food). Hunger occurs when the a GASTRECTOMY (surgical removal of the stomach) STOMACH and SMALL INTESTINE are empty and mani- such as to treat STOMACH CANCER, or has severe GAS- fests as physical sensations of discomfort and even TROESOPHAGEAL REFLUX DISORDER (GERD) that negates PAIN that result from contractions of the stomach. 184 Nutrition and Diet

Hunger sends HORMONE and NERVE signals to the particular risk for dehydration during competition, APPETITE and hunger centers in the BRAIN, each of the former because their efforts are so intense that which responds with other neurohormonal mes- it is difficult to drink enough water often enough sages that intensify the physical and psychological to keep up with water loss and the latter because urges to eat. Hunger subsides only when the body they often do not realize the intensity of their receives food (in contrast to appetite, which abates efforts and fail to properly hydrate before and dur- after time even when the person does not eat). ing competitive activities including swimming and See also DIGESTIVE ENZYMES; DIGESTIVE HORMONES; other water sports. Dehydration leads to elec- METABOLISM; STARVATION. trolyte imbalances as the salts in the body become more concentrated, resulting in numerous physio- hydration Maintenance of the body’s fluid level. logic consequences including mental confusion About 60 percent of the body’s weight is water. and impaired cognitive function, irregular HEART The typical adult requires three quarts (two liters) RATE, fluctuations in BLOOD PRESSURE, and MUSCLE of water daily to remain adequately hydrated. cramps. Health experts recommend drinking six to eight cups of water each day to meet this need, though WATER CONSUMPTION FOR most people acquire much of the water they need HYDRATION DURING PHYSICAL ACTIVITY through the foods they eat. Many foods, notably 90 minutes before activity: 12 ounces of cold water fruits and vegetables, have high water content 15 minutes before activity: 12 ounces of cold water that helps supply the body with water. Soups, During activity: 4 ounces of cold water every 15 minutes sauces, fruit and vegetable juices, and pastas and 15 minutes after activity: 16 ounces of cold water rice cooked in water also supply fluid to the diet. Health experts consider water a vital nutrient Fluids that contain sugar or CAFFEINE actually because the body cannot live without it. Though draw water from the body. Excess sugar pulls water contains no calories, it does contain trace water into the gastrointestinal tract as it makes its minerals that are necessary for metabolic func- way through the digestive process. Caffeine is a tions. A person can survive only about five to mild diuretic, acting on the KIDNEYS to cause them seven days without water. to extract more water from the BLOOD. Beverages such as sodas (soft drinks) also contain high quan- Thirst is not a good indication of proper tities of electrolytes, which are minerals in the hydration. By the time a person feels form of salts. These, too, may act on the kidneys thirsty, the body is experiencing signifi- to increase the water the kidneys pull from the cant fluid depletion. In DEHYDRATION, blood to pass with the URINE. many people do not feel thirsty. In a clinical context hydration may refer to the long-term infusion of fluids via PARENTERAL NUTRI- DEHYDRATION is a serious condition that results TION or ENTERAL NUTRITION (feeding tube) into a per- from inadequate water consumption, and can son who is in a PERSISTENT VEGETATIVE STATE as a occur much more rapidly than expected during means of preserving life. intense physical exercise and in hot temperatures See also COGNITIVE FUNCTION AND DYSFUNCTION; as the body loses significant water through sweat. CONDITIONING; END OF LIFE CONCERNS; HEAT EXHAUS- Distance athletes and WEEKEND WARRIORS are at TION; HEAT STROKE. L–M

lactose intolerance The inability to digest lac- nutrients through alternative foods or via supple- tose, a disaccharide sugar in milk and other dairy ments. products. Lactose intolerance occurs because of a See also AGING, NUTRITION AND DIETARY CHANGES deficiency of the enzyme lactase, which is neces- THAT OCCUR WITH. sary to break down lactose into simpler sugar mol- ecules. It is the most common form of malnutrition A state of multiple nutrient deple- CARBOHYDRATE INTOLERANCE, affecting an estimated tion that alters body functions. Infants, the elderly, 50 million Americans. Lactose intolerance may be and people who have active cancer, ALCOHOLISM, congenital (present at birth), occur as a conse- OBESITY, or chronic health conditions are most sus- quence of a disease process that affects the cells ceptible to malnutrition. Malnutrition may that produce lactase (such as CELIAC DISEASE), or develop when a person does not eat enough food, develop with aging as the number of lactase-pro- eats a very narrow selection of foods, or eats too ducing cells naturally declines. much food. Malnutrition is possible with extended Congenital lactose intolerance becomes appar- adherence to fad diets that limit food types and ent when a young child begins drinking cow’s when the diet primarily contains foods that have milk, which is high in lactose. The doctor can usu- low NUTRIENT DENSITY such as “junk” foods. The ally confirm the diagnosis with a lactose challenge most severe presentations of malnutrition are the test in which the child drinks a solution that con- polar extremes of STARVATION and obesity. tains lactose. Breath samples taken at certain In the United States malnutrition resulting intervals allow measurement of hydrogen, which from inadequate food or nutrient consumption increases when lactose remains undigested in the occurs most often in the chronically ill, the very gastrointestinal tract. young, and the very old. Most people who have Switching to a fortified SOY formula nearly significant obesity have some degree of nutrient always eliminates symptoms when the child is imbalance, not only among the energy NUTRIENTS young. As the child grows older, trial and error but also of vitamins, minerals, and other micronu- will tell whether he or she can eat small amounts trients. People who have alcoholism, serious of other dairy products such as cheese and ice chronic health conditions such as HIV/AIDS, or gas- cream. Many people who have lactose intolerance trointestinal MALABSORPTION disorders including produce enough lactase to digest small amounts of INFLAMMATORY BOWEL DISEASE (IBD) and CELIAC DIS- lactose. Lactase enzymes are available without a EASE or are also vulnerable to malnutrition. doctor’s prescription; added to milk, they act on the lactose to split it into its composite sugars. Symptoms and Diagnostic Path Within 24 hours the milk will be 70 to 90 percent Early malnutrition can be difficult to detect lactose-free. This approach allows the child to though initial indications may include dry SKIN, benefit from the numerous NUTRIENTS milk and pallor, swollen or bleeding gums, PETECHIAE (pin- dairy products provide. Lactose intolerance gener- point hemorrhages under the skin), MUSCLE weak- ally does not affect an individual’s overall general ness and atrophy, and disturbances of sensory health, as long as the person acquires necessary perception (PARESTHESIA) in both inadequate and 185 186 Nutrition and Diet excessive nutrient consumption. The diagnostic TIVE PULMONARY DISEASE (COPD). Untreated disorders path includes a comprehensive medical examina- of specific NUTRIENT DEFICIENCY such as BERIBERI and tion, height and weight measurements, careful SCURVY lead to generalized malnutrition. assessment of EATING HABITS, body composition It is important to eat or provide a variety of assessment, and a complete BLOOD count (CBC) as foods in the appropriate quantities, as the USDA well as other blood tests to measure nutrient lev- food pyramid recommends, especially for young els. A BODY MASS INDEX (BMI) below 17 kilograms children and the very elderly, for whom caregivers per meter squared (kg/m 2) is generally diagnostic sometimes assume intake is nutritionally ade- of inadequate consumption; a BMI greater than quate. Though most healthy children and adults 30 kg/m 2 is generally diagnostic of obesity. who can feed themselves can acquire the nutri- ents they need through diet, nutritional supple- Treatment Options and Outlook ments can provide a steady and certain source of Treatment for malnutrition focuses on correcting necessary nutrients for people who have chronic the nutritional deficiencies that exist, which usu- health conditions or who do not eat adequately. ally means generalized nutritional supplementa- See also AGING, NUTRITION AND DIETARY CHANGES tion until symptoms resolve, along with dietary THAT OCCUR WITH; ANEMIA; MINERALS AND HEALTH; OBE- changes to improve overall nutrition. People who SITY AND HEALTH; OSTEOPOROSIS; PELLAGRA; VITAMIN have obesity often have significant nutritional AND MINERAL THERAPY; VITAMINS AND HEALTH. deficiencies even though their food consumption may be excessive. The US Department of Agricul- minerals and health Minerals are inorganic ture (USDA) publishes a food pyramid with rec- micronutrients essential for health and the body’s ommendations for food consumption to meet proper development and function. Minerals are NUTRITIONAL NEEDS. Daily physical activity, such as abundant in nature and in most foods, and facili- walking, improves the body’s ability to digest, tate numerous actions in the body. Six major min- absorb, and metabolize nutrients and also is key to erals (also called macrominerals) and nine trace weight management. minerals (also called microminerals) are essential The success of treatment depends on the sever- for health and the body’s proper growth and ity of the malnutrition at the time of diagnosis, the development; the body cannot survive without status of underlying or contributing causes (such them. Numerous other trace minerals are present as gastrointestinal or metabolic disorders), the per- in the body and presumably important for the son’s age, the availability of nutritious foods, and body’s functions but researchers do not under- the ability to feed oneself. Many of the symptoms stand their roles. Minerals within the body are of malnutrition resolve without residual complica- also called electrolytes or ions because they are tions, though severe symptoms may result in per- polarized (carry a positive or negative charge). manent damage. Major Minerals Risk Factors and Preventive Measures The body requires substantial amounts of the The most significant risks for malnutrition are major minerals, which are essential for the daily inadequate food consumption and malabsorption activities that keep the body alive and functional. disorders that keep the body from extracting The body of a person who weighs 160 pounds 1 needed nutrients during digestion. Those who contains 3 pounds of calcium, 1 ⁄2 pounds of phos- 1 1 cannot easily feed themselves are most susceptible phate, ⁄2 pound of potassium, ⁄4 pound each of to inadequate consumption. People who diet fre- sodium and chloride, and a little over 1 ounce of quently or follow restrictive eating habits (such as magnesium. those who follow a vegan diet) are at risk for defi- The major minerals work closely with each ciency in key nutrients normally in the foods they other and with the vitamins. For example, cal- are not eating. APPETITE loss contributes to cium, phosphate, and magnesium are essential for decreased food consumption in serious chronic BONE mineralization though their passage into the conditions such as HIV/AIDS and CHRONIC OBSTRUC- bone requires the presence of vitamin D in the minerals and health 187

BLOOD circulation. As well, 85 percent of the mines how much of these minerals the kidneys body’s phosphate is bound to calcium, most of it will reabsorb which in turn determines how much in the bones. Sodium, chloride, and potassium water the kidneys hold for circulation in the regulate the contraction of MUSCLE cells (including blood. Diuretic medications act on the molecular those in the HEART) and the balance of fluid in the sensors in the glomeruli to limit their ability to body. reabsorb these minerals. Deficiencies of the major minerals can signifi- cantly affect the functioning of the heart, KIDNEYS, TABLE SALT neurologic system, bones, and muscles. The most Table salt is sodium chloride, about 40 percent common deficiencies of the major minerals are of sodium and 60 percent chloride. One teaspoon calcium, which can result in OSTEOPOROSIS and of table salt contains two grams of sodium and heart ARRHYTHMIA, and potassium, which occurs three grams of chloride. most commonly in people who take diuretic med- ications to treat conditions such as congestive Potassium Potassium is a positively charged HEART FAILURE and kidney disease. ion that is abundant in the fluid within the cells Mineral toxicities of the major minerals are (intracellular fluid). It is a key player in fluid bal- uncommon though can occur in people who take ance within the body, and also in the transmission diuretic medications (when the kidneys keep of nerve impulses across neurons. The kidneys more of the mineral in the blood circulation, also regulate the amount of potassium in the allowing its level to accumulate) and in circum- blood circulation. Long-term diuretic therapy can stances of OVERDOSE such as from taking excessive deplete potassium because potassium passes from mineral supplements. Overdose of magnesium can the blood along with sodium and chloride though disrupt the functions of the neurologic and cardio- its levels in the circulation are much lower. vascular systems severely enough to be fatal. Chronic VOMITING and DIARRHEA also result in losses Some people develop HYPERTENSION (high BLOOD of potassium. Chronically low potassium levels PRESSURE) with long-term dietary excesses of cause hypertension, though researchers do not sodium and chloride, though most doctors do not understand the mechanisms of this. consider this toxicity. Phosphate This mineral is integral to nucleic Calcium The hormones PARATHYROID HORMONE acid formation (DNA and RNA) and cell reproduc- and calcitonin, along with the HORMONE form of tion. It also is a component of numerous enzymes, vitamin D, calcitriol, regulate the amounts of cal- is necessary for activation of the B vitamins, and cium in the blood. Calcium is essential for bone participates in energy conversion. Various forms of STRENGTH and BONE DENSITY. It is also a key ion phosphate bind with lipids to form the primary (electronically charged particle) with roles in structure of the cell membrane for every nucle- NERVE signals and muscle contraction. Calcium ated cell in the body. channel blockers are drugs that regulate HEART Magnesium Magnesium is essential for cellular RATE and function by blocking the passage of cal- METABOLISM and energy conversion, influencing cium ions in the heart muscle (MYOCARDIUM). the efficiency with which cells use GLUCOSE and Sodium and chloride Sodium and chloride are serving as a component of numerous enzymes. present in chemical combination with each other. Magnesium is also essential for initiating the con- Sodium is a positively charged ion that is abun- traction of muscle cells, facilitating nerve signals, dant in the fluid outside the cells (extracellular integrating certain IMMUNE SYSTEM functions, and fluid) and regulates fluid balance in the body. regulating blood pressure. Chloride is a negatively charged ion that occurs primarily in equilibrium with sodium in the extra- Trace Minerals cellular fluid, assisting with fluid balance. Special Trace minerals are present in the body in barely molecular sensors in the glomeruli of the kidneys measurable amounts, though their absence can continually monitor the levels of sodium and have far-reaching consequences for overall health. chloride in the blood circulation, which deter- Zinc and copper are essential for HEALING and the 188 Nutrition and Diet

ESSENTIAL MINERALS Mineral Dietary Sources Major Minerals (Macrominerals) calcium dairy products fortified orange juice and SOY milk spinach, broccoli, green beans legumes, nuts, tofu canned sardines, salmon, herring (with bones) molasses sweet potatoes (with skin) oranges, raisins, watermelon chloride table salt processed foods (as a preservative) pork, ham, beef, chicken, turkey, fish magnesium all foods highest in meats, poultry, fish, legumes phosphate all foods potassium all foods sodium table salt processed foods (as a preservative) pork, ham, beef, chicken, turkey, fish

Trace Minerals (Microminerals) chromium pork, ham, beef, chicken, turkey, fish, shrimp raw fruits, vegetables, whole grains copper whole grains and whole grain products finfish, shellfish, crab, lobster legumes, tofu nuts, seeds

fluorine fluoridated drinking water salt water seafood (finfish, shellfish, crab, lobster, kelp) iodine iodized table salt salt water seafood (finfish, shellfish, crab, lobster, kelp) iron canned clams fortified breads and cereals whole grains spinach, broccoli, peas, green beans, potatoes (with skin), artichokes parsley legumes, tofu minerals and health 189

Mineral Dietary Sources Trace Minerals (Microminerals) iron (continued) pork, ham, beef, chicken, turkey, fish, shrimp raisins manganese whole grains and whole grain products legumes, nuts, seeds finfish, shellfish, crab, lobster molybdenum legumes, nuts, seeds liver whole grains and whole grain products fortified breads and cereals selenium whole grains and vegetables grown in selenium-rich soil salt water finfish, shellfish, crab, lobster pork, ham, beef, lamb from animals who graze on selenium-rich land zinc oysters, clams, crab, shrimp, lobster legumes, nuts, seeds, tofu dairy products, especially cheeses peas, spinach, broccoli, corn, potatoes (with skin)

formation of new tissues (including growth) and LIVER, such as occurs with HEMOCHROMATOSIS, even- are crucial for oxidative reactions in the cells. The tually causing failure of those organs. Acute iron body requires iron to synthesize HEMOGLOBIN, the overdose is often fatal. protein that transports oxygen through the blood WILSON’S DISEASE is a genetic disorder in which circulation. Fluorine strengthens TEETH and bones the body cannot metabolize copper, allowing cop- and increases the resistance of the teeth to bacter- per to accumulate in the heart, liver, PANCREAS, ial invasion resulting in DENTAL CARIES (cavities). and BRAIN. Unchecked, this accumulation is fatal; The THYROID GLAND requires iodine to synthesize treatment is curtailed intake of foods containing thyroid hormones, which regulate metabolism. copper. High intake of zinc blocks copper metabo- Selenium is a potent ANTIOXIDANT that may be a lism, which is therapeutic in Wilson’s disease but key player in CANCER PREVENTION. Manganese and hazardous otherwise. Iodine deficiency causes molybdenum are essential cofactors for numerous HYPOTHYROIDISM, and iodine excess causes GOITER. enzymes vital to metabolic functions. Chromium Untreated hypothyroidism in a pregnant woman aids metabolism of carbohydrates and fats. or an infant causes irreversible brain damage. In Deficiencies or toxicities of some trace minerals the United States table salt includes iodine to help can have significant and potentially fatal conse- ensure adequate iodine intake. quences for health. Iron deficiency causes ANEMIA, See also CELL STRUCTURE AND FUNCTION; HEALTHY reducing the amount of oxygen that reaches the PEOPLE 2010; NUTRITIONAL NEEDS; NUTRITIONAL SUPPLE- tissues through the blood circulation. Excessive MENTS; NUTRITIONAL THERAPY; POISON PREVENTION; VITA- iron accumulates in organs such as the heart and MINS AND HEALTH. N nutrient density The nutritional value of a par- tial because the body can synthesize them from ticular food, generally presented as an assessment substances within it. of the quantity and quality of NUTRIENTS the food delivers per CALORIE. Foods that contain multiple Macronutrients minerals and vitamins per calorie have high nutri- The macronutrients—carbohydrates, fats, and pro- ent density; those that do not have low nutrient teins—are the body’s energy sources. The amounts density. Generally the less processed a food is, the and ratios of them that an individual needs vary higher its nutrient density. Fruits, vegetables, according to age, gender, activity level, and health legumes, seeds, whole grains, and nuts have high status. Metabolism reduces all macronutrients nutrient density. Prepared dinners, cookies, crack- ultimately to GLUCOSE. The body stores any ers, chips, candy, and other such food products excesses (amounts the body does not immediately have comparatively low nutrient density. Some use for energy) as glycogen and fat, regardless of prepared foods, such as cakes and pastries, have the source macronutrient. Per gram carbohydrates relatively little nutritional value beyond the and proteins yield four calories of energy; fats, energy forms (carbohydrate and fat) they deliver. which represent stored energy, yield nine calories Though many prepared foods are not devoid of per gram. nutrients, they deliver significantly more calories The body must use in some way all of the energy for comparable nutrient levels. Foods with higher that enters it in the form of food, either through nutrient density also tend to be more filling. immediate consumption or storage. Glycogen, See also EATING HABITS; METABOLISM; NUTRITIONAL which the LIVER produces and stores, is an interme- NEEDS; WEIGHT LOSS AND WEIGHT MANAGEMENT. diate storage form that can supply about 12 hours of energy. The liver also produces fat, which adi- nutrients Substances that participate in METABO- pose cells throughout the body store (body fat). The LISM. Macronutrients deliver energy. The three body in healthy balance warehouses enough body macronutrient groups are carbohydrate, fat, and fat to supply energy for six to eight weeks. protein. Micronutrients facilitate the biochemical In 2005 dietary recommendations shifted from actions that convert macronutrients into energy. a percentage allocation for macronutrient con- The main groups of micronutrients are vitamins sumption to a stance of moderation in choice with and minerals. Supportive nutrients include phyto- a focus on managing overall CALORIE intake across chemicals (plant-based biochemicals such as the spectrum of energy nutrients. Health experts flavonoids and plant sterols) and the numerous concur that people need a wide variety of nutri- trace minerals and other chemicals that are pres- ents and individual needs vary. Focusing on the ent in the body and have roles in metabolism, quality of foods within each macronutrient group though researchers do not fully understand those allows people to make choices that meet their per- roles. The final nutrient is water. Essential nutri- sonal needs and tastes, yet still meet the nutri- ents are those the body must acquire from sources tional needs of their bodies in healthful ways. outside itself, such as foods. Other nutrients, Carbohydrates Carbohydrates are chemical though no less important to health, are nonessen- structures consisting of oxygen, carbon, and 190 nutrients 191 hydrogen. Nutritionists further classify carbohy- SMALL INTESTINE. The enzymes lactase, maltase, and drates as monosaccharides (single molecule), dis- sucrase break down lactose, maltose, and sucrose, accharides (two molecules), and polysaccharides respectively. Lactose and sucrose each produce (multiple molecules). Monosaccharides and disac- one molecule of glucose; maltose produces two. charides are simple carbohydrates; polysaccharides From the small intestine the monosaccharides are complex carbohydrates. Nearly all foods con- enter the BLOOD circulation. Fructose and galactose tain or deliver as a product of metabolism some travel to the liver where chemical processes con- form of carbohydrate. Monosaccharides and disac- vert them to glucose. Depending on the body’s charides convert to energy fairly quickly after con- needs, the liver may further convert glucose to sumption; the sugars from fruits and fruit juices glycogen for storage. and from candies and sodas (soft drinks) can enter Fats (lipids) Dietary fats are chemical combi- the blood circulation within 10 minutes. Polysac- nations of carbon and hydrogen atoms that form charides such as pastas take longer for the body to structures called fatty acids. The number of hydro- digest and metabolize, up to several hours. gen atoms in a fatty acid determines whether the Polysaccharides are starches and fibers. fat is saturated or unsaturated, which is one of the Starches are storage forms of glucose the LIVER most important features of the fat from a health converts to glycogen. Fibers are structural compo- perspective. A fatty acid’s saturation determines nents of plants that the body cannot digest. Some how the fat behaves in the body. forms of fiber, such as pectin, are soluble (dissolve Saturated fats, which come primarily from ani- in water). These fibers acquire a gel-like consis- mal-based foods such as meats and dairy, con- tency in the intestines that bind with lipids tribute to elevated CHOLESTEROL BLOOD LEVELS, a risk (including cholesterol), BILE, and other substances. factor for CARDIOVASCULAR DISEASE (CVD). Saturated The primary dietary sources of soluble fibers are fats are the primary source material for the liver’s fruits, oats, and legumes. Nonsoluble fibers absorb production of cholesterol and the carriers that water but do not change consistency. These fibers transport them through the blood, lipoproteins. add bulk to digestive waste in the large intestine, Palm oil and coconut oil are also saturated fats. aiding the COLON in moving the waste through and Saturated fats are solid at room temperature. out of the body. Though not itself a nutrient, fiber is essential for the healthy function of the gas- TRANSFORMED THINKING ABOUT TRANS FATS trointestinal tract. In the 1980s and 1990s researchers and doctors believed trans fats, created through a manufac- CARBOHYDRATES turing process called hydrogenation that adds Monosaccharides hydrogen atoms to unsaturated fatty acid struc- GLUCOSE fructose galactose tures to make them more stable in food products, were less harmful for health than the saturated Disaccharides fats they were marketed to replace. However, lactose maltose sucrose further research demonstrated that trans fats are Polysaccharides instead considerably more harmful to health, cellulose fiber glycogen causing a rapid and significant rise in blood cho- lesterol levels and thus dramatically raising the Enzymes carry out the chemical actions that risk for CARDIOVASCULAR DISEASE (CVD). Health metabolize carbohydrates to the end form of glu- experts now recommend avoiding trans fats; and cose. Carbohydrate digestion begins in the MOUTH in 2006, US regulations began requiring food with the aid of amylase, an enzyme in the saliva. labels to list trans fat content. Amylase breaks down dietary carbohydrates into smaller polysaccharides and disaccharides. Unsaturated fats come from plant-based foods. Because the STOMACH does not contain any Commonly called oils, unsaturated fats are liquid enzymes that metabolize carbohydrates, the next at room temperature. They are monounsaturated stage of carbohydrate digestion takes place in the or polyunsaturated, depending on their chemical 192 Nutrition and Diet configurations. Unsaturated fats, in moderation, disproportionately deliver linoleic acid (saturated appear to help lower blood cholesterol levels. fats such as in meats) appear to correlate with Polyunsaturated fats include safflower, corn, and increased risk for CVD (notably HYPERTENSION) and sunflower oils. Monounsaturated fats, which some types of cancer (notably hormone induced). many health experts believe offer the greatest Proteins Dietary proteins, also called peptides, health benefits among the fatty acids, include are chains of amino acids; amino acids are chemical olive, canola, and peanut oils as well as olives, structures (molecules) of carbon, hydrogen, oxy- avocados, almonds, pecans, cashews, and peanuts. gen, and nitrogen. Of the hundreds of amino acids Many “vegetable oil” products blend oils from dif- in the body, 20 combine in various forms to create ferent sources. the majority of the body’s proteins. Nine are essen- Trans fatty acids, or trans fats, are processed fats tial, meaning they must enter the body from out- that contain extra hydrogen atoms to make them side sources such as foods. Using these nine amino more solid at room temperature and more resist- acids and other substances within the body, the ant to oxidative degradation than the base fatty body synthesizes all the other amino acids it needs acids are in their natural forms. Sometimes called and combines the amino acids to create proteins. hydrogenated fats, trans fats raise blood choles- Proteins are key messenger substances in the body. terol levels higher and faster than do saturated DNA (deoxyribonucleic acid), the GENETIC CODE each fats. The most common dietary sources of trans nucleated cell contains, is a protein strand. Other fats are margarines, shortening, and partially proteins carry its instructions to molecules hydrogenated cooking oils. Processed baked goods, throughout the body, giving the directions for the snack foods, fried foods, and fast foods are com- amino acid sequences that are the foundation of mon dietary sources of trans fats. the body’s structure and function. Dietary proteins are also chains of amino acids OMEGA-3 FATTY ACIDS AND HEALTH RISK REDUCTION and are complete or incomplete, according to Research suggests that tipping the balance to whether the protein chain contains all nine essen- favor consumption of omega-3 fatty acids can tial amino acids (complete) or not (incomplete). significantly lower the risk for HEART disease and Animal-based foods (meats, poultry, fish, and cancer (especially PROSTATE CANCER and BREAST dairy) and soybeans provide complete dietary pro- CANCER) in some people. Eicosapentaenoic acid teins. Plant-based foods provide incomplete pro- (EPA) and docosahexaenoic acid (DHA) are two teins, though combining consumption of different omega-3 fatty acids found in high concentrations plant-based foods can deliver a combination of in mackerel, salmon, lake trout, herring, sar- proteins that are complete. Dietary variety is the dines, and anchovies. The American Heart Asso- most effective way to ensure the body receives ciation recommends two servings weekly of any adequate amounts of all the essential amino acids. of these fish. AMINO ACIDS The body requires fatty acids for numerous Essential Amino Acids Nonessential Amino Acids functions beyond energy, including HORMONE syn- histidine isoleucine alanine argine thesis and cell membrane integrity. Nearly all fatty leucine lysine asparagine aspartic acid acids, in foods and in the body, take the form of methionine phenylalanine cysteine glutamic acid triglycerides. The essential fatty acids are linoleic threonine tryptophan glutamine glycine acid and linolenic acid, from which the body can valine proline serine synthesize other fatty acids. Linoleic acid is an taurine tyrosine omega-6 fatty acid; its primary dietary sources are meats, dairy products, and vegetable oils. After consumption dietary proteins undergo Linolenic acid is an omega-3 fatty acid; soybeans, digestion and metabolism, processes that break flaxseed and soybean oils, nuts, and seeds are its them down to their amino acid structures. The primary dietary sources. The body requires these body then reassembles the amino acids into struc- fatty acids in relative balance. EATING HABITS that tures it requires for its functions. The body even- nutritional assessment 193 tually metabolizes excess amino acids to glucose, synthesizes from glucose. Sulfur is present in many glycogen, and fat. Though muscles in the body are animal-based foods and occurs in the body as an primarily protein structures, eating large quanti- ingredient of proteins, some B vitamins, and some ties of protein does not build MUSCLE mass; the hormones. Carnitine, choline, inositol, and numer- body uses dietary protein only to supply the com- ous similar substances act somewhat like vitamins ponents it needs to craft its own proteins. Protein in the body, though the body synthesizes them. deficiency can be a health concern for vegans, See also AGING, NUTRITION AND DIETARY CHANGES who must take extra care to eat a wide variety of THAT OCCUR WITH; ANTIOXIDANT; BODY FAT PERCENTAGE; protein-rich plant-based foods to meet their pro- CARBOHYDRATE LOADING; CELL STRUCTURE AND FUNC- tein needs. TION; DIET AND HEALTH; MINERALS AND HEALTH; PHENYLKETONURIA (PKU); STARVATION; TRIGLYCERIDE Micronutrients BLOOD LEVEL; TRIGLYCERIDES, DIETARY; VITAMINS AND The key groups of micronutrients are vitamins and HEALTH. minerals, both of which facilitate the processes of energy conversion within the body and are essen- nutritional assessment A clinical evaluation of tial for life. Vitamins are organic substances useful an individual’s nutritional status, typically as part to the body only in their whole forms; cooking of a ROUTINE MEDICAL EXAMINATION or as a direction and processing easily destroy many vitamins. Vita- of the diagnostic path when evaluating symptoms mins are also the source of many antioxidants, that suggest NUTRITIONAL DEFICIENCY, MALNUTRITION, biochemicals that remove free radicals (rogue gastrointestinal disorders, and systemic (body- molecules that are the waste byproducts of metab- wide) disease. Routine nutritional assessment is olism) from the body. Researchers believe the particularly important for the very young and the cumulative damage free radicals cause contributes very old. to many health conditions, including CVD and A nutritional assessment begins with measure- cancer. Minerals are inorganic substances abun- ment of height and body weight; physical exami- dant in the environment that enter food sources nation to detect any signs or indications of directly (from the soil and water, as with plants) nutritional deficiency; and a discussion of the per- or indirectly (from the plants that animals eat). son’s EATING HABITS, including the kinds and Minerals remain chemically unchanged from amounts of food consumed over the course of a sources to their uses in the body, even when they day or a week. Basic BLOOD tests can measure the bind with each other or with other substances. levels of key NUTRIENTS in the blood circulation or nutrients the doctor suspects are deficient (such as Supportive Nutrients iron). The doctor may conduct further tests, Foods contain numerous substances that provide depending on the person’s health circumstances. supportive action for nutrients. Key among them The doctor may also measure UPPER ARM CIR- is the group called phytochemicals. Among the CUMFERENCE, TRICEPS SKINFOLD, WAIST CIRCUMFERENCE, most prominent of these are the carotenoids, and hip circumference, factors that allow the doc- flavonoids, lignans, phenolic acids, phytosterols, tor to quantifiably assess BODY FAT PERCENTAGE as PHYTOESTROGENS, and protease inhibitors. Though a well as loss of MUSCLE tissue in suspected nutri- number of phytochemicals have achieved recogni- tional disorders. From these measurements the tion for their individual effects on health, the doctor or nutritionist can calculate BODY MASS strongest health benefits appear to come from INDEX (BMI), basal metabolic rate (BMR), resting phytochemicals collectively. Health experts recom- metabolic rate (RMR), and anticipated daily CALO- mend going straight to the source for supportive RIE requirements based on the person’s lifestyle, nutrients, acquiring them through fresh fruits and weight management needs, and unique health cir- vegetables, legumes, and whole grains. cumstances. Other supportive nutrients include minerals See also AGING, NUTRITION AND DIETARY CHANGES such as sulfur; amino acid derivatives such as carni- THAT OCCUR WITH; DIET AND HEALTH; EXERCISE AND tine and choline; and inositol, a substance the body HEALTH; METABOLISM. 194 Nutrition and Diet nutritional deficiency Inadequate consumption Deficiencies are most likely to occur with of one or more key NUTRIENTS. Gastrointestinal dis- water-soluble nutrients as the body’s stores of orders of MALABSORPTION, such as CELIAC DISEASE these are short-term. Though prompt intervention and INFLAMMATORY BOWEL DISEASE (IBD), also cause through dietary changes and nutritional supple- nutritional deficiencies. Long-term, chronic health mentation can easily reverse most nutritional defi- conditions or their treatments place extended ciencies, unresolved or untreated nutritional demands on the body’s nutrient base. Certain deficiencies can result in serious health conditions medications may interfere with how the body such as SCURVY (vitamin C deficiency) and OSTEO- absorbs or maintains nutrients, such as diuretics POROSIS (calcium deficiency). (“water pills”) which alter the body’s mechanisms See also DIET AND HEALTH; HEMOCHROMATOSIS; for retaining magnesium, sodium, potassium, and MALNUTRITION; NUTRITIONAL SUPPLEMENTS; WILSON’S calcium. DISEASE. Other treatments such as RENAL DIALYSIS for RENAL FAILURE may remove nutrients from the nutritional needs The kinds and amounts of body. As well, people who have chronic health NUTRIENTS the body needs to maintain itself in good conditions are not always able to eat properly and health. Research has established minimum levels thus do not consume adequate nutrients. Vitamin of many nutrients, and health experts make rec- and mineral (micronutrient) deficiencies may ommendations for others based on the best avail- develop in people who voluntarily limit their food able information. The roles of some nutrients intake to certain kinds of foods, such as those who remain poorly understood, though the body follow strict vegan (no animal protein) diets. Fad appears to require the nutrients for proper func- diets may lead to deficiencies of macronutrients, tioning. A person’s nutritional needs change with most commonly protein. life stage, lifestyle, PREGNANCY, and health circum- stances. Acknowledging the individualized nature of HEALTH CONDITIONS AND CIRCUMSTANCES THAT CAN nutritional needs, the US Department of Agricul- CAUSE NUTRITIONAL DEFICIENCIES ture (UDSA), the government agency responsible ALCOHOLISM anorexia nervosa for establishing guidelines and standards for nutri- BARIATRIC SURGERY CELIAC DISEASE tion and diet, in 2005 revised its gold standard COMA CYCLIC VOMITING SYNDROME food guide pyramid to present 12 models of rec- GASTRECTOMY INFLAMMATORY BOWEL DISEASE (IBD) ommendations. The different models allow indi- MALABSORPTION PEPTIC ULCER DISEASE viduals to customize food choices to meet their PERSISTENT VEGETATIVE STATE RENAL DIALYSIS physical needs and health circumstances, empha- SHORT BOWEL SYNDROME STARVATION size variety, and incorporate recommendations for

NUTRIENT DEFICIENCIES AND THEIR POTENTIAL HEALTH PROBLEMS Deficient Nutrient Health Conditions calcium OSTEOMALACIA, OSTEOPOROSIS, RICKETS MUSCLE cramps HEART ARRHYTHMIA HYPERTENSION (high BLOOD PRESSURE) insomnia chromium GLUCOSE intolerance peripheral NEUROPATHY copper slow HEALING nutritional needs 195

Deficient Nutrient Health Conditions fluorine (fluoride) DENTAL CARIES (cavities) iodine GOITER HYPOTHYROIDISM iron iron-deficiency ANEMIA delayed growth and development in children GLOSSITIS (reddened, swollen, painful tongue) phosphate BONE DENSITY loss, osteoporosis selenium may contribute to hypothyroidism increased susceptibility to certain viral infections vitamin A NIGHT BLINDNESS hardening (keratinization) of tissue within the internal organs reduced resistance to INFECTION vitamin B complex BERIBERI PELLAGRA pernicious anemia, megaloblastic anemia PARESTHESIA (disturbances of sensory perception) DEPRESSION cognitive dysfunction fatigue, weakness vitamin C SCURVY slow healing gum disease, tooth loss vitamin D RICKETS, osteomalacia, osteoporosis vitamin E hemolytic anemia RETINOPATHY of prematurity ATAXIA, coordination difficulties, muscle weakness, paresthesia

VITAMIN K easy bruising and bleeding COAGULATION disorders deficits of CLOTTING FACTORS zinc ALOPECIA (HAIR loss) HYPOGONADISM night blindness slow healing, lowered resistance to infection loss of APPETITE, altered sense of taste chronic DERMATITIS 196 Nutrition and Diet physical exercise. Interactive food guide pyramid In the United States federal law classifies vita- models are accessible at the USDA’s Web site min and mineral supplements and most MEDICINAL (www.mypyramid.gov). The USDA publication HERBS AND BOTANICALS as dietary supplements. This Dietary Guidelines for Americans 2005 includes dis- removes these products from the jurisdiction of cussion of the food guide pyramids and other the US agency charged with oversight of DRUG nutritional information. safety and EFFICACY, the US Food and Drug Admin- Since the 1940s the standard of appropriate istration (FDA). Though various federal laws regu- nutritional intake for individual nutrients has late matters of safety and efficacy as well as been the recommended dietary allowance (RDA), advertising claims of health benefits, testing of which quantifies how much of a nutrient a person supplement products shows wide variation of should consume to prevent deficiency of that quality standards across manufacturers and prod- nutrient. Through the decades since, new knowl- ucts. This can result in inconsistent doses and edge and understanding have resulted in the effectiveness. emergence of additional standards that attempt to The intent of nutritional supplements should be quantify the normal levels of nutrients necessary to augment, not replace, dietary nutrients. Vita- for health as well as the lower and upper limits mins, minerals, and botanicals do not deliver beyond which health problems arise. These now energy nutrients, though other kinds of nutri- fall collectively under the umbrella term dietary tional supplements (such as protein supplements) reference intake (DRI). Because most people do not do. Health experts disagree on whether the effect consume the “daily” amount of a nutrient every of supplements, especially vitamins and minerals, day the DRI system also takes into consideration in the body is the same as that when the same variations in eating patterns and nutrient con- nutrients enter the body from food sources. Some sumption, using formulas that look at nutritional research studies investigating antioxidants, for needs over the long term and establishing aver- example, show much higher levels of activity from ages that meet them. consumed foods compared to supplements. Other For further discussion of nutritional needs, studies show no measurable difference. A com- please see the overview section “Nutrition and mon philosophy among nutritionists is “stay close Diet.” to the earth” because the highest concentrations See also AGING, NUTRITION AND DIETARY CHANGES of nutrients come from fresh fruits, vegetables, THAT OCCUR WITH; ANTIOXIDANT; LIFESTYLE AND HEALTH; and whole grains. MINERALS AND HEALTH; VITAMINS AND HEALTH. People who have chronic health conditions or take regular prescription medications should nutritional supplements Products that provide check with the doctor or pharmacist before taking additional NUTRIENTS and dietary substances nutritional supplements of any kind, as the risk beyond those that enter the body via food con- for DRUG INTERACTION is high. As well, some chronic sumption. The most commonly taken nutritional health conditions or the medications taken to treat supplements, also called dietary supplements, are them have specific effects on how the body vitamins and minerals, which are available in absorbs and metabolizes nutrients, increasing or combination formulas (multivitamin supplements, decreasing the need for those nutrients. For such multimineral supplements, and multivitamin with people, doctors may recommend therapeutic mineral supplements) as well as products that nutritional supplementation. For others, most contain single nutrients. Some products combine health experts recommend obtaining nutrients vitamins and minerals with herbal and botanical from the diet to the extent possible and using substances, for example vitamin C with ECHINACEA. nutritional supplements, including vitamins and The choices among products are nearly endless; minerals, only when there are clear and specific the nutritional supplement industry remains a key reasons to supplement dietary intake. However, player in the American economy, with annual research continues to generate new knowledge sales exceeding $19 billion. and understanding of how nutrients affect health nutritional supplements 197 and disease, and recommendations continue to See also ANTIOXIDANT; MINERALS AND HEALTH; evolve. Many people integrate specific nutritional NUTRITIONAL DEFICIENCY; NUTRITIONAL THERAPY; VITAMIN supplements with healthy EATING HABITS. AND MINERAL THERAPY; VITAMINS AND HEALTH. P–R

parenteral nutrition The intravenous adminis- RIA to enter the body and partly because the con- tration of NUTRIENTS as a method of supplying tent of parenteral nutrition solutions is very high appropriate sustenance to a person who cannot in GLUCOSE, which attracts and feeds bacteria. meet his or her NUTRITIONAL NEEDS by eating, such See also END OF LIFE CONCERNS; QUALITY OF LIFE; as someone who is in a COMA or has a severe swal- SWALLOWING DISORDERS. lowing disorder. Parenteral nutrition, called total parenteral nutrition (TPN) when it is a person’s pellagra A health condition resulting from long- sole source of nutrition, is helpful for short-term, term deficiency of niacin (vitamin B3). Pellagra is intense feeding when ENTERAL NUTRITION is not a uncommon in the United States, occurring pri- viable option. Parenteral nutrition is most success- marily in people who have chronic ALCOHOLISM or ful as temporary supportive treatment such as gastrointestinal disorders that prevent absorption after extensive surgery or during recovery from of dietary niacin (also called niacinamide, nicoti- major trauma, though sometimes is necessary for namide, nicotinic acid, or niacinic acid) or of the longer therapy such as in severe gastrointestinal essential amino acid tryptophan. The body disease or cancer. In the long term, however, par- requires niacin for cellular METABOLISM. Trypto- enteral nutrition cannot deliver all of the nutrients phan is a niacin precursor from which the body the body needs and, in particular, is lacking in its can synthesize niacin. Niacin is necessary for the ability to supply lipids (fats), which the body energy conversions that take place during cellular requires for cell maintenance and energy. metabolism. Parenteral nutrition solutions are very irritating to the veins so must be infused into the larger Symptoms and Diagnostic Path veins deep in the chest. This requires the doctor to Early symptoms of pellagra are those of nonspe- insert a percutaneous intravenous catheter (PIC cific gastrointestinal upset: NAUSEA, VOMITING, and line) into a VEIN in the arm and thread it through DIARRHEA. Burning in the MOUTH and especially of the smaller vein to a large vein. An alternative is a the tongue is common, with a characteristic gray Hickman line, in which the intravenous catheter membranous tissue coating on the gums that con- enters the jugular vein at the base of the neck and tinually sloughs or peels. As pellagra worsens, extends into the superior VENA CAVA, the largest additional symptoms that appear include GLOSSITIS vein in the upper body. Fluids run continuously (inflamed tongue) and SKIN RASH that intensifies into either line with the aid of an infusion pump with sun exposure after which the skin becomes to maintain delivery of the solution at constant rough, thick, and discolored. A characteristic pat- rate and pressure. tern of this damage often develops around the Some of the complications of extended par- neck. enteral nutrition include LIVER FAILURE, RENAL FAIL- At the same time, the lack of niacin causes the URE, NUTRITIONAL DEFICIENCY (notably of trace mucosa (mucous membrane lining) of the gas- minerals and lipids), and MALNUTRITION. INFECTION is trointestinal tract to deteriorate, progressively also a significant risk, partly because the reducing the ability of the intestines to absorb indwelling catheter provides a pathway for BACTE- nutrients; MALNUTRITION results. Niacin deficiency 198 rickets 199 also affects neurons (NERVE cells) and the function- spinach, peanuts and peanut butter, and legumes ing of the CENTRAL NERVOUS SYSTEM, resulting in contain high amounts of niacin. behavioral disturbances, delusions, confusion, and People who eat large quantities of corn and DEMENTIA. Disturbances of neuromuscular function foods made with corn flour and who do not eat include rigidity and involuntary activation of other kinds of foods, are at high risk for pellagra. reflexes. The diagnostic path includes BLOOD tests The niacin in corn is not available through diges- to measure the levels of niacin and tryptophan in tion. Other people at high risk for pellagra are the blood circulation. The diagnosis is primarily those taking long-term treatment with isoniazid clinical, however, based on the presenting symp- for TUBERCULOSIS or who have chronic CIRRHOSIS toms and their response to treatment with niacin (the LIVER is fundamental in converting trypto- supplementation. phan to niacinamide). See also ANEMIA; BERIBERI; DELUSION; NEURON; Treatment Options and Outlook NUTRITIONAL DEFICIENCY; NUTRITIONAL NEEDS; RICKETS; Treatment is immediate supplementation with SCURVY; VITAMINS AND HEALTH. niacin, usually in the form of niacinamide, and correction of EATING HABITS to restore foods to the rickets A health condition that results from diet that provide niacin. At therapeutic doses long-term deficiency of vitamin D, also called cal- niacin often causes uncomfortable symptoms such ciferol or ergocalciferol, in which the bones can- as SKIN flushing and tingling; the niacinamide not absorb calcium or build new BONE tissue. The form, a slightly different chemical structure, does body makes most of the vitamin D it requires from not. Both chemical forms provide the body with cholesterol and sunlight. Dietary sources of vita- the niacin the cells need for energy conversion. min D are primarily those that contain added sup- Though many of pellagra’s symptoms are plements such as dairy products, orange juice, and reversible, those affecting the skin often result in some SOY-based food products. Cod liver oil natu- permanent changes that are sometimes disfigur- rally contains ergosterol, a form of vitamin D ing. Untreated pellagra results in multisystem called D2, as do oily fish such as salmon and sar- organ failure that is usually fatal. dines (though not in as high a concentration as cod liver oil). Supplemental vitamin D also inter- Risk Factors and Preventive Measures acts with cholesterol to form calcitriol. Pellagra develops as a consequence of niacin defi- The LIVER manufactures cholesterol, the base for ciency; thus adequate niacin intake prevents pella- vitamin D, and sends a certain amount for stor- gra. Most people can obtain sufficient niacin age in the cells of the SKIN. Exposure to the sun’s supplies through the foods they eat. Meats, poul- ultraviolet B (UVB) rays activates a series of try, and other animal-based proteins contain high chemical changes that convert the stored choles- amounts of tryptophan, which the body converts terol molecules to a HORMONE form of vitamin D to niacinamide. Asparagus, mushrooms, potatoes, called calcitriol. The liver and the KIDNEYS also par-

PELLAGRA SYMPTOMS Gastrointestinal Dermatologic Neurologic DIARRHEA bullae (blisters) anxiety GASTROINTESTINAL BLEEDING erythema DEMENTIA GLOSSITIS hyperpigmentation DEPRESSION loss of APPETITE PHOTOSENSITIVITY disorientation MALABSORPTION thickened SKIN ENCEPHALOPATHY NAUSEA HALLUCINATION stomatitis irritability VOMITING PARANOIA 200 Nutrition and Diet ticipate in these chemical changes. In combination Risk Factors and Preventive Measures with PARATHYROID HORMONE, calcitriol maintains a Most people will synthesize (make) all the vitamin steady level of calcium in the BLOOD circulation. D their bodies require with regular modest sun This balance allows the gastrointestinal tract to exposure, about 20 minutes to the face and arms absorb calcium from dietary sources and the bones four or five days a week. The farther from the to accept calcium from the supply circulating in equator a person lives, the longer sun exposure is the blood. necessary because the intensity of the sun’s ultra- Rickets develops when a long-term deficiency violet radiation diminishes. The ideal exposure is of vitamin D results in decreased dietary absorp- that which is just less than what results in mild tion of calcium. To meet its extensive needs for SUNBURN. Doctors recommend multiple short expo- calcium, an important ion for numerous cellular sures (5 to 15 minutes several times a day) to functions, including proper contraction of the reduce the risk for sunburn. Applying sunscreen MUSCLE cells of the HEART, the body draws calcium before going in the sun, though a prudent and from the bones. The bones demineralize and recommended measure to prevent sun-related weaken. The long bones, notably those in the legs, skin damage when engaging outdoor activities, bow. Doctors generally use the term rickets to refer prevents ultraviolet rays from penetrating the to this disease process in children and the term skin. People who have dark skin require longer OSTEOMALACIA to refer to this disease process in periods of sun exposure. adults. Some health experts recommend that people who live in regions where the hours of sunlight Symptoms and Diagnostic Path drop below 12 hours a day (such as above 40 The primary symptoms of rickets are bowed legs degrees latitude in the Northern Hemisphere, and a protruding belly (the result of weakened which includes locations north of the US cities San abdominal muscles). Deformities may develop at Francisco, Denver, St. Louis, Indianapolis, the epiphyses, or growth plates, of the bones, Philadelphia, and New York City) take vitamin D forming characteristic knobs and bumps. The diag- supplement. It is important to remain within the nostic path includes X-rays to assess the density recommended dosage guidelines, however, and mineralization of the bones and blood tests to because vitamin D is a fat-soluble vitamin that can measure the levels of calcium, phosphorus, and accumulate in the body to reach toxic levels. parathyroid hormone in the blood circulation. The The antiseizure medication phenytoin increases doctor will also take a thorough PERSONAL HEALTH the body’s METABOLISM of calcidiol, one of the HISTORY including EATING HABITS. intermediary vitamin D forms. People who take this medication may need therapeutic vitamin D Treatment Options and Outlook supplementation, particularly if they do not spend Prompt vitamin D supplementation generally much time outdoors. Young children who live in reverses most circumstances of mild to moderate inner city areas where smog is a problem have rickets with little residual damage. Moderate to increased risk for rickets even when they spend severe rickets, which is fairly uncommon in the time outdoors because the smog acts to filter the United States, may result in consequential defor- sun’s ultraviolet rays. mities of the pelvis, rib joints, and knee and ankle See also ANEMIA; BERIBERI; FANCONI’S SYNDROME; joints. Proper nutrition usually maintains ade- MALNUTRITION; NUTRITIONAL DEFICIENCY; NUTRITIONAL quate vitamin D intake. NEEDS; PELLAGRA; SCURVY; VITAMINS AND HEALTH. S–T satiety The sensation of fullness and satisfaction scurvy A health condition that results from after eating a meal. Satiety represents a conver- long-term deficiency of vitamin C (also called gence of physical, physiologic, and emotional fac- ascorbic acid). Vitamin C is essential for the forma- tors. The physical sensation of fullness occurs tion of collagen, a fibrous protein that is the foun- when enough food fills the STOMACH to stretch its dation for connective tissue throughout the body walls. The stretching activates NERVE and HORMONE and the framework for BONE tissue. Collagen is sensors that then send physiologic signals to the integral to the walls of BLOOD vessels. Collagen also APPETITE and satiety centers in the BRAIN and to is an essential component of SCAR tissue, necessary receptors in the SMALL INTESTINE and the HUNGER for wound HEALING. Without vitamin C, a water- center in the HYPOTHALAMUS. These signals slow or soluble vitamin the diet must provide on a rela- stop the release of hormones and neurotransmit- tively daily basis, the body cannot produce ters necessary for digestion and initiate the release collagen. of other hormones and biochemicals that have roles in absorbing NUTRIENTS into the BLOOD circula- Symptoms and Diagnostic Path tion and further METABOLISM of those nutrients. The most common symptoms of scurvy are bleed- Research indicates that foods high in protein ing gums and loose TEETH. Other symptoms result in reaching physical satiety the most rapidly. include low grade FEVER, extended or lack of Foods high in fat take much longer to trigger wound healing, PETECHIAE (pinpoint hemorrhages physical satiety. These findings imply that eating beneath the SKIN), and internal hemorrhage. ANE- the proteins in a meal first, such as meats or MIA is often the indication that there is bleeding legumes, may curb the appetite, whereas eating somewhere in the body. The diagnostic path the fats or carbohydrates in a meal first may includes blood tests to measure the amount of extend appetite. Each circumstance has advan- ascorbic acid in the blood circulation as well as in tages, depending on an individual’s health and the white blood cells (leukocytes) along with a weight management situation. careful PERSONAL HEALTH HISTORY that includes infor- The emotional component of satiety comes mation about EATING HABITS. when the meal has satisfied desires for certain characteristics of food such as textures, flavors, Treatment Options and Outlook and quantity. Emotional satiety results in nerve Treatment for scurvy is vitamin C supplementa- signals to pleasure receptors in the cerebral cortex tion, which generally restores vitamin C levels and as well as to the brain’s appetite and satiety cen- eliminates symptoms after about a week of treat- ters. This is the most variable factor of satiety, ment. In all but the most severe cases, scurvy is influencing whether a person eats not enough or completely curable. Doctors generally recommend too much. Emotional eating is a significant dimen- continued vitamin C supplementation to prevent sion of WEIGHT LOSS AND WEIGHT MANAGEMENT. RECURRENCE. Because vitamin C is water-soluble, See also EATING HABITS; FOOD CRAVINGS; NEURO- there is no risk of toxicity with such prophylaxis. TRANSMITTER. Increasing dietary consumption of foods that con-

201 202 Nutrition and Diet tain vitamin C, notably raw fruits and vegetables, OUS SYSTEM, breaking them down into chemical helps maintain adequate intake. products that it can use as NUTRIENTS. Conse- quently emaciation, in which the body looks FOODS HIGH IN VITAMIN C gaunt and wasted, is a key characteristic of starva- bell peppers (especially red) broccoli tion. brussels sprouts cabbage Treatment for starvation is aggressive nutri- cantaloupe grapefruit tional supplementation to restore the body to a kiwi lemons state such that organ systems begin to function. It limes mango can take several weeks for the gastrointestinal sys- oranges spinach tem to be able to manage solid foods, during strawberries sweet potatoes which time PARENTERAL NUTRITION can provide sus- watermelon tenance. ENTERAL NUTRITION can deliver concen- trated nutrients to address emerging NUTRITIONAL Risk Factors and Preventive Measures DEFICIENCY disorders. Full recovery may take six Scurvy occurs only as a deficiency of vitamin C, months or longer, depending on what underlying thus adequate vitamin C consumption prevents health conditions exist. scurvy. People who have increased risk for scurvy See also EATING DISORDERS; NUTRITIONAL SUPPLE- are those who have chronic ALCOHOLISM, chronic MENTS. health conditions that interfere with the digestion or absorption of NUTRIENTS, and the very elderly triglycerides, dietary Chemical structures that who may not receive adequate nutrition through contain three fatty acids in combination with glyc- diet because they cannot or do not eat properly. erol. Triglycerides are the most common forms of Fruit and vegetable juices are easy substitutions fat in foods and in the body. The body uses triglyc- for whole fruits and vegetables. Many juices are erides primarily for energy. Dietary triglycerides fortified with additional vitamin C and other circulate in the BLOOD along with triglycerides the nutrients. LIVER synthesizes from carbohydrates and fats the See also BERIBERI; FANCONI’S SYNDROME; LEUKO- body does not use for immediate energy. Some CYTE; MALNUTRITION; NUTRITIONAL DEFICIENCY; NUTRI- triglycerides then go to cells for use as energy and TIONAL NEEDS; PELLAGRA; RICKETS; VITAMINS AND others go to adipose (fat) cells for storage. HEALTH. The liver also uses dietary triglycerides to syn- thesize (make) lipoproteins, the carrier proteins starvation The most severe state of MALNUTRITION that transport cholesterol and fats through the resulting from extended lack of food and nutri- bloodstream to cells throughout the body. Low- tion. An otherwise healthy adult may lose up to density lipoproteins (LDLs) and very low-density 50 percent of body weight before organ systems lipoproteins (VLDLs) have higher levels of triglyc- fail and death occurs. Total starvation that persists erides than high-density lipoproteins (HDLs). Ele- beyond about 10 to 12 weeks is usually fatal. In vated levels of LDLs and VLDLs in the blood the United States starvation most commonly circulation correlate to increased risk for CARDIO- occurs as a consequence of severe illness, severe VASCULAR DISEASE (CVD), HEART ATTACK, and STROKE. gastrointestinal disease, prolonged COMA, and Triglycerides are present in a wide range of anorexia nervosa. In parts of the world where foods, notably animal-based foods and oils and fats. food supplies are limited, starvation results from Reducing overall food consumption so the calories famine and causes millions of deaths every year. in balance with the calories out and reducing the The body attempts to survive starvation by dra- amount of refined carbohydrates (sugars) in the matically slowing METABOLISM. HEART RATE and diet are the most effective way to reduce blood BREATHING rate slow, BLOOD PRESSURE and body tem- triglyceride levels. Daily physical exercise helps the perature drop, and BLOOD flow to nonvital struc- body more efficiently metabolize nutrients and tures diminishes. The body turns to tissues such as increases the consumption of triglycerides as an MUSCLE and most organs outside the CENTRAL NERV- energy source. A small percentage of people have a triglycerides, dietary 203 genetic disorder of lipid METABOLISM that causes See also CARDIOVASCULAR DISEASE PREVENTION; them to have high amounts of triglycerides in their CHOLESTEROL, DIETARY; CHOLESTEROL BLOOD LEVELS; blood circulation. Lipid-lowering medications may GENETIC DISORDERS; HYPERLIPIDEMIA; TRIGLYCERIDE then be necessary to bring triglycerides levels down. BLOOD LEVEL. V vitamins and health Vitamins are organic with the fat-soluble vitamins because they accu- micronutrients essential for health and the body’s mulate in the body. Vitamin toxicity also is possi- proper growth, development, and function. They ble with extreme overconsumption of interact with each other or with other biochemi- water-soluble vitamins, usually the result of cals in the body, functioning as cofactors or coen- higher levels in the blood circulation than the zymes to carry out activities of energy conversion body can excrete. (METABOLISM) though do not themselves provide energy to the body. With the exception of vitamin Vitamin toxicity is more likely to occur D, dietary sources provide the vitamins the body when taking a multiple vitamin supple- requires. ment and individual supplements that There are 12 vitamins that are essential for supply significantly greater than the health. The 8 B vitamins and vitamin C are water needed amounts of certain vitamins. soluble; the body cannot stockpile stores of them Vitamins A; E; and the B vitamins (except in limited accumulations within the BLOOD niacin (B3), pantothenic acid (B5), pyri- circulation and the LIVER) and thus requires regu- doxine (B6), and folic acid (B9) present lar consumption to maintain levels adequate to the greatest risk for toxicity. support health. Most healthy people can obtain the vitamins their bodies need for normal func- tioning through dietary sources. Vitamins A, E, D, Vitamin A (Retinol) and K are fat soluble; the body stores excess Vitamin A is essential for proper functioning of the amounts of these vitamins in adipose (fatty) tissue photoreceptor cells (rods and cones) of the RETINA, and draws from these supplies when dietary maintains the health of the SKIN, and appears to intake does not meet needs. have some antiviral capabilities. It is also crucial Vitamin deficiency may develop when dietary for growth and development in children. The liver consumption is inadequate, as a result of gastroin- stores vitamin A, a fat-soluble vitamin, and testinal disorders that interfere with nutrient releases it into the blood circulation as the body absorption or owing to interactions with medica- needs it. The primary dietary sources for vitamin tions. Chronic health conditions may drain the A are foods that supply beta-carotene, which the body of important NUTRIENTS, including vitamins. body converts to retinol. Such foods include yel- Untreated vitamin deficiency can cause potentially low vegetables and fruits, green leafy vegetables, serious health conditions such as SCURVY, RICKETS, egg yolks, and fish liver oil. and NIGHT BLINDNESS. Vitamin A deficiency results in disturbances of Vitamin toxicity occurs most commonly as a vision, including impaired dark adaptation (slow- consequence of excessive vitamin supplementa- ing of the ability of the eyes to adjust to changes tion and can have serious or permanent conse- in lighting) and night blindness. In children, vita- quences. Metabolic disorders and medications that min A deficiency can stunt growth and impair interfere with vitamin metabolism are also com- cognitive development. These developmental dis- mon culprits. Vitamin toxicity is more common ruptions can have permanent consequences, 204 vitamins and health 205 although vitamin A deficiency severe enough to likely to develop with niacin (B3), pantothenic cause such disruptions is rare. Other consequences acid (B5), pyridoxine (B6), and folic acid (B9). of vitamin A deficiency generally improve when Though most symptoms resolve when vitamin B levels of vitamin A return to normal. intake returns to normal, vitamin B toxicities can Vitamin A toxicity nearly always results from result in permanent neurologic and skin damage. taking high doses of vitamin A supplement and can Vitamin B1 (thiamine) Thiamine converts car- occur as acute OVERDOSE (taking an extremely large bohydrates into GLUCOSE and is a coenzyme in the dose at one time) or chronic overdose (excess that synthesis of acetylcholine, a NEUROTRANSMITTER accumulates over time), usually the result of over- important for cognitive functions in the cerebral supplementation. Treatment with retinol medica- cortex and MUSCLE coordination throughout the tions, such as for severe ACNE, also can result in body. Prolonged thiamine deficiency causes vitamin A toxicity. In adults the effects and symp- beriberi. toms of vitamin A toxicity are reversible and gener- Vitamin B2 (riboflavin) Riboflavin is a key ally resolve within a few weeks of stopping player in macronutrient metabolism (fats, carbo- supplementation or therapeutic retinol. hydrate, and proteins) as well as in energy con- version at the cellular level (cellular oxidation). It Vitamin B Complex is essential for growth and development in chil- The eight B vitamins, called the vitamin B com- dren, facilitates erythropoiesis (formation of new plex, work in close synchronization with one red blood cells), and helps support the health of another and have key roles in many functions in the retina. the body. Each B vitamin further has specific func- Vitamin B3 (niacin) Niacin exists in two forms: tions, dietary sources, deficiency level, and toxic- nicotinic acid and niacinamide (also called nico- ity level. In general the B vitamins are essential tinamide). In either form it facilitates the metabo- for energy conversion (metabolism of carbohy- lism of carbohydrates (glycolysis) and functions of drates and fats) and other functions of cellular cellular energy conversion. Niacin also helps metabolism, erythropoiesis (making new red maintain the structure of the epithelium (skin and blood cells), and maintaining the epithelium (skin mucous membranes). The body synthesizes some and mucous membranes). The liver stores some of niacin from the essential amino acid tryptophan. the B vitamins for a short time. Food sources of Prolonged niacin deficiency causes pellagra. Niacin the B vitamins include meats, poultry, fish, eggs, has emerged as an effective therapy for mild to leafy green vegetables, fruits, whole grains, brown moderate HYPERLIPIDEMIA, reducing CHOLESTEROL rice, and fortified grain products such as cereals BLOOD LEVELS as effectively as some lipid-lowering and breads (regulations in the United States medications. require such fortification). Vitamin B5 (pantothenic acid) Pantothenic Deficiencies of B vitamins affect many func- acid is essential for metabolizing amino acids and tions of the body. Most often deficiencies of the B fats to carbohydrates, and works in collaboration vitamins occur collectively, though specific defi- with folic acid and biotin for various functions ciency disorders are BERIBERI (thiamine deficiency), related to cellular energy conversion. The liver PELLAGRA (niacin deficiency), and pernicious ANE- uses pantothenic acid in the synthesis of hor- MIA (cyanocobalamin deficiency). In the United mones and cholesterol. Canning and freezing States vitamin B deficiencies generally result from destroy pantothenic acid. chronic health disorders, ALCOHOLISM, and MALAB- Vitamin B6 (pyridoxine) Pyridoxine facilitates SORPTION disorders. In such circumstances it often HEMOGLOBIN production, conversion of tryptophan is necessary for the person to take therapeutic to niacin, and carbohydrate metabolism. Other vitamin B supplements, either B complex or spe- forms of vitamin B6 are pyridoxal and pyridox- cific B vitamins, to compensate. amine; all forms of vitamin B6 convert to the Toxicity of B vitamins is uncommon though coenzyme pyridoxal-5'-phosphate (PLP) in the can occur when taking excessive vitamin supple- body. Health conditions that increase the body’s ments and in some metabolic disorders; it is most specific use of and need for pyridoxine include 206 Nutrition and Diet alcoholism, END-STAGE RENAL DISEASE (ESRD) with tion via vitamin B12 injections. The ability to pro- RENAL DIALYSIS, serious BURNS, major surgery, GAS- duce intrinsic factor diminishes with age, increas- TRECTOMY or BARIATRIC SURGERY, and chronic CIRRHO- ing the risk of deficiency. SIS. People who smoke and women who take oral contraceptives (birth control pills) are at high risk Vitamin C (Ascorbic Acid) for pyridoxine deficiency. The body requires vitamin C to create collagen, a Vitamin B7 (biotin) Biotin works in close protein critical for the formation of connective tis- alliance with folic acid and pantothenic acid, and sue and in healing (the formation of scar tissue). is important in metabolizing macronutrients, espe- Collagen forms the foundation of the SKELETON over cially carbohydrates and fats, from food during which the bones develop. Vitamin C is also neces- digestion. Sulfa-based ANTIBIOTIC MEDICATIONS can sary for production of serotonin, a vital neurotrans- prevent the body from absorbing biotin from foods mitter, and aids in the dismantling of cholesterol for during digestion. excretion in the BILE. The body absorbs significantly Vitamin B9 (folic acid) Folic acid, also called more iron in combination with vitamin C; health folate, is essential for the formation of new blood experts recommend eating combinations of foods cells (HEMATOPOIESIS) and works in conjunction that contain these substances and taking iron sup- with cyanocobalamin to repair DNA. Folic acid is plements with a glass of orange juice. Citrus fruits crucial for normal development of the neurologic are the primary dietary source of vitamin C. system in the early EMBRYO; prophylactic folic acid decreases NEURAL TUBE DEFECTS by up to 80 percent. LIMEYS Folic acid also participates in cellular energy con- British sailors of the 19th century acquired the version cycles. nickname “limey” when the British Navy began including limes in sailors’ rations while at sea. FOLIC ACID PREVENTS NEURAL TUBE DEFECTS Citrus fruits are high in vitamin C, which pre- Folic acid is so effective at preventing NEURAL vents SCURVY. Limes hold up better in storage TUBE DEFECTS that doctors urge all women who than other citrus fruits. Before this practice, half could become pregnant, regardless of whether or more of a ship’s crew often died before return- they are planning PREGNANCY and especially if ing home from a long sea voyage. they are taking oral contraceptives (which deplete folic acid), to take a folic acid supple- Long-term vitamin C deficiency results in ment that delivers 400 micrograms daily. Folic scurvy, a condition of collagen depletion with acid is crucial for the closure of the neural tube, symptoms that affect the musculoskeletal, neuro- the rudimentary CENTRAL NERVOUS SYSTEM that logic, and immune systems. Vitamin C deficiency develops in the EMBRYO about 14 days after CON- is rare in modern times. Increasing dietary con- CEPTION. sumption of foods high in vitamin C is usually adequate to restore vitamin C levels and reverse Vitamin B12 (cyanocobalamin) Cyanocobal- symptoms. Though vitamin C is a water-soluble amin, also called cobalamin, is essential for the vitamin, it can accumulate to toxic levels with formation of myelin, the protein coating that pro- excessive supplementation. The symptoms of vita- tects NERVE fibers. It also participates in DNA repair min C toxicity (NAUSEA, DIARRHEA, and sometimes (nucleic acid synthesis), erythropoiesis (formation anemia) improve immediately when vitamin C of new red blood cells), and folic acid metabolism. consumption returns to normal. Intrinsic factor, which the stomach produces, is Vitamin C is also a powerful ANTIOXIDANT with essential for absorption of cyanocobalamin. Health roles in healing and preventing diseases. Much conditions that diminish intrinsic factor produc- research has explored these roles in recent tion, such as PEPTIC ULCER DISEASE, and circum- decades, and numerous studies support vitamin stances such as bariatric surgery or gastrectomy, C’s ability to expedite recovery from viral infec- significantly reduce the body’s ability to absorb tions such as COLDS (though vitamin C cannot pre- cyanocobalamin and often require supplementa- vent such infections). Doctors may recommend vitamins and health 207 vitamin C supplementation for people recovering some metabolism of fatty acids. Vitamin E also from major surgery, serious burns, and significant maintains the integrity of erythrocytes (red blood dental procedures. cells), which are vulnerable to damage, in the blood circulation. Though vitamin E has a reputa- Vitamin D (Calciferol) tion for a wide range of actions in the body to pre- Without vitamin D, the body cannot use calcium. vent diseases such as cancer and CARDIOVASCULAR Vitamin D is unique among vitamins in that the DISEASE (CVD); to treat conditions such as FIBROCYS- body can manufacture it as a process of photosyn- TIC BREAST DISEASE; and to enhance physical thesis (exposure to sunlight) that converts a form ENDURANCE, LIBIDO, and reproduction, research has of cholesterol stored in the cells of the skin into thus far failed to support these claims. Some vitamin D. Only a small portion of vitamin D research suggests that excessive amounts of vita- enters the body from dietary sources (namely, for- min E may in fact contribute to the development tified dairy products) in the form of vitamin D2 of certain cancers. Much research remains under (ergocalciferol) or vitamin D3 (cholecalciferol). way to better understand the roles of vitamin E in The circulating, active form of vitamin D is cal- health and in disease. citriol, which functions as a HORMONE. Calcitriol, in Vitamin E deficiency may occur in disorders of tandem with PARATHYROID HORMONE, regulates the fat absorption or metabolism though is quite rare. amount of calcium in the blood. This regulation When present vitamin E deficiency may result in determines the availability of calcium to the hemolytic anemia. Vitamin E toxicity is also bones. Vitamin D also influences IMMUNE SYSTEM uncommon and nearly always occurs in people functions important for fighting tumors. who take excessive amounts of vitamin E supple- Vitamin D deficiency affects bone structure, ments. Vitamin E toxicity can have deleterious preventing bone tissue from accepting new cal- effects on the mechanisms of COAGULATION, leading cium and allowing calcium to leave the bones to to hemorrhage. enter the blood circulation. Vitamin D deficiency can cause rickets in children and OSTEOMALACIA in Vitamin K (Quinone) adults. Both are conditions of demineralization BACTERIA in the SMALL INTESTINE synthesize 80 per- that are reversible with vitamin D supplementa- cent or more of the VITAMIN K the body needs and tion, though severe rickets may result in residual uses. The other 20 percent comes from plant-based deformity particularly of the pelvis. Sustained foods, notably spinach, broccoli, and other dark vitamin D deficiency in adults leads to OSTEOPORO- green vegetables. The bacterial form of vitamin K is SIS, an irreversible loss of bone tissue. menaquinone; the plant form of vitamin K is phyl- Vitamin D toxicity may develop with excessive loquinone. Vitamin K is essential for the activation consumption from vitamin supplements, which of several CLOTTING FACTORS (VII, IC, X) and pro- can be supplementation within normal limits in thrombin, which regulate the blood’s ability to clot. healthy people who get adequate vitamin D from Vitamin K deficiency may occur in disorders dietary sources and is a particular risk among peo- that interfere with the absorption of fats into the ple who take megavitamins. The toxic level is fairly body, such as GALLBLADDER DISEASE and gastroin- low. Vitamin D toxicity is also a risk in people who testinal malabsorption disorders. Long-term are receiving treatment for HYPOPARATHYROIDISM. antibiotic therapy can significantly reduce the bac- Excessive levels of vitamin D affect calcium reab- teria count in the small intestine, restricting the sorption in the kidney (HYPERCALCEMIA) and often body’s ability to synthesize vitamin K. Anticoagu- cause kidney stones (NEPHROLITHIASIS) that can lant medications such as warfarin work by block- result in permanent damage to the KIDNEYS. ing the action of vitamin K. Untreated vitamin K deficiency can result in life-threatening hemor- Vitamin E (Tocopherol) rhage. Vitamin K toxicity is rare and occurs nearly A fat-soluble vitamin, vitamin E’s most important always when taking vitamin K supplements. It can function is as an antioxidant. It blocks the reaction cause JAUNDICE and, when severe, permanent of free radicals to produce more free radicals and BRAIN damage. Some multivitamin supplements 208 Nutrition and Diet

ESSENTIAL VITAMINS AND THEIR DIETARY SOURCES Vitamin Dietary Sources A (retinol) carrots butternut squash, acorn squash, pumpkin spinach, turnip greens, chard broccoli mangos beef liver

B1 (thiamine) fortified breads and cereals pork, beef, ham, chicken, turkey, fish, eggs brewer’s yeast dairy products legumes peas, corn, green beans, potatoes (with skins)

B2 (riboflavin) fortified breads and cereals dairy products pork, beef, ham, chicken, turkey, liver, fish, eggs oysters, clams, shrimp mushrooms

B3 (niacin) fortified breads and cereals dairy products pork, beef, ham, chicken, turkey, liver, eggs tuna, cod, halibut, bluefish, shrimp peas, corn, sweet potatoes, potatoes (with skins), spinach, broccoli peanuts

B5 (pantothenic acid ) fortified breads and cereals mushrooms broccoli avocados

B6 (pyridoxine) fortified breads and cereals potatoes (with skin) bananas, apples, oranges, watermelon, grapefruit and grapefruit juice, avocados, prunes and prune juice legumes pork, beef, ham, chicken, turkey, liver, fish (especially tuna), eggs seeds, nuts, peanut butter

B7 (biotin) fortified breads and cereals brown rice, barley, oatmeal, whole wheat SOY products cauliflower egg yolks, liver tuna, finfish vitamins and health 209 contain vitamin K; unless a doctor specifically rec- See also CONTRACEPTION; MINERALS AND HEALTH; ommends vitamin K supplementation, however, NUTRITIONAL SUPPLEMENTS; NUTRITIONAL THERAPY; VITA- most people should not take supplements that MIN AND MINERAL THERAPY. contain vitamin K.

Vitamin Dietary Sources

B9 (folic acid) fortified breads and cereals spinach, okra, greens asparagus, broccoli, corn, green beans, sweet potatoes, potatoes (with skins) tomatoes and tomato juice legumes tofu seeds, nuts, peanut butter eggs

B12 (cyanocobalamin) fortified breads and cereals pork, beef, ham, chicken, turkey, liver, fish, eggs shrimp, oysters, clams dairy products

C (ascorbic acid) citrus fruits and juices: oranges and orange juice, lemons, limes, grapefruit and grapefruit juice watermelon, strawberries, cantaloupe papaya, mangos, tangerines, guava broccoli, kohlrabi, cabbage, cauliflower spinach, greens bell peppers

D (calciferol) sunlight fortified dairy products, orange juice, and soy milk

E (tocopherol) polyunsaturated oils egg yolks spinach, greens almonds, walnuts, pecans, cashews peanuts and peanut butter seeds (sunflower, flax) whole grains and whole grain products wheat germ

K (quinone) spinach, lettuce other than iceberg broccoli, cabbage, kale, kohlrabi alfalfa (especially sprouts), oats, rye, whole wheat and whole wheat products FITNESS: EXERCISE AND HEALTH

Exercise has emerged as a significant factor in nearly all facets of health, both in terms of maintaining overall health and in reducing risk for health conditions and injuries. A health-care practitioner who specializes in fitness-related care may be a doctor (MD or DO), certified physician assistant (PA-C), registered physical therapist (RPT), chiroprac- tor (DC), or exercise physiologist. Doctors who specialize in treating injuries and conditions related to physical activity may be board-certified in sports medicine, family practice, orthopedics, or physiatry (rehabilitation medicine). Educa- tion, certification, and credentialing are less consistent for other fitness practitioners such as fitness trainers and athletic trainers who primarily work outside the health-care delivery system to help individuals develop exercise regimens for preventive or therapeutic purposes.

This section, “Fitness: Exercise and Health,” pre- • physical activity for a total of 30 minutes a day sents an overview discussion of physical activity at moderate intensity at least 5 days a week as it relates to health maintenance, health risk and preferably every day factors, health conditions, and preventive health • physical activity for 20 minutes at a time at vig- measures. The entries in this section focus on the orous intensity on 3 or more days of the week broad picture of how physical activity and inactiv- ity influence health and disease. The section Research has continued to strengthen the evi- “Lifestyle: Obesity and Smoking” features discus- dence for these recommendations. However, most sion and entries about fitness and exercise topics Americans fall short of meeting them. The 1996 that relate to WEIGHT LOSS AND WEIGHT MANAGEMENT. US Surgeon General’s report Physical Activity and The section “The Musculoskeletal System” con- Health found that 25 percent of Americans do not tains discussion and comprehensive entries about participate in any physical activity beyond the the structure, function, health, and health condi- requirements of daily living, and 60 percent exer- tions of the bones, muscles, and joints. cise less than the minimum recommendations for health. Among youth between the ages of 12 and Making the Connection 21, about 25 percent engage in physical activity at between Physical Activity and Health a level that meets minimum recommendations for Researchers provided the first substantive correla- health, 50 percent participate in regular physical tion between physical inactivity and health in the activity at vigorous intensity, and 25 percent are 1970s when clinical and epidemiologic studies physically inactive. linked sedentary lifestyle with premature death Many adults start exercise programs and then due to health conditions such as CORONARY ARTERY do not continue them, most commonly because DISEASE (CAD) and HYPERTENSION (high BLOOD PRES- they begin with activities that support the FITNESS SURE). Health experts subsequently issued the first LEVEL they want to achieve rather than those formal recommendations for incorporating regular geared to their current fitness level. Such an physical exercise into daily lifestyle as a means of approach often results in discomforts; minor preventing the development of CARDIOVASCULAR injuries such as blisters, sore muscles, and aching DISEASE (CVD). These recommendations were much joints; and discouragement because the body is the same as current recommendations for mini- not ready for such activity. It is important to start mal physical activity for adults, which are at the current fitness level and steadily work up to 210 Fitness: Exercise and Health 211 the desired fitness level. The health benefits of mainstay of recuperation, reduced PULMONARY exercise become apparent within two weeks of EMBOLISM (PE) and DEEP VEIN THROMBOSIS (DVT)— starting an exercise regimen and progress as phys- BLOOD clots in the LUNGS and the inner veins of the ical activity continues. Conversely, the health ben- legs, respectively—which are risks with surgery efits of physical activity diminish significantly two and major injury. weeks after stopping an exercise regimen and are By the mid-1980s supervised and graduated gone after two months of physical inactivity. physical activity was the core of structured cardiac Though the overall health benefits of exercise rehabilitation programs, and today exercise is a far outweigh the risks, a few health risk factors do component of treatment regimens for numerous increase with physical activity, notably those for health conditions. Structured physical rehabilita- exercise-related injuries and REPETITIVE MOTION tion programs are now also the standard of care INJURIES. However, most such injuries are prevent- for people who have musculoskeletal injuries, able through proper WARMUP, preparation, protec- operations, and conditions. The typical multidisci- tive items, and technique during activity. plinary health-care team includes professionals Furthermore, maintaining a high fitness level who specialize in returning the body to optimal reduces the risk for many other kinds of injuries function. because regular exercise increases BONE DENSITY, MUSCLE STRENGTH, FLEXIBILITY, and balance. HEALTH CONDITIONS INFLUENCED BY PHYSICAL ACTIVITY AND INACTIVITY HEALTH RISKS ASSOCIATED WITH EXERCISE ASTHMA ATHEROSCLEROSIS ACHILLES TENDON INJURY ANKLE INJURIES ATHLETIC INJURIES BREAST CANCER (certain forms) BLISTER CHAFING CARDIOVASCULAR DISEASE (CVD) CHRONIC FATIGUE SYNDROME CHARLEYHORSE EPICONDYLITIS CHRONIC PULMONARY COLORECTAL CANCER FRACTURE KNEE INJURIES OBSTRUCTIVE DISEASE (COPD) CONSTIPATION MUSCLE and JOINT soreness ROTATOR CUFF CORONARY ARTERY DISEASE (CAD) DEPRESSION SHIN SPLINTS IMPINGEMENT SYNDROME DIABETES FIBROMYALGIA SPRAINS AND STRAINS SYNOVITIS HYPERLIPIDEMIA HYPERTENSION TENDONITIS INSULIN RESISTANCE INTERMITTENT CLAUDICATION OBESITY OSTEOARTHRITIS Prescription: Exercise OSTEOPOROSIS PERIPHERAL VASCULAR DISEASE Until the 1970s bedrest was the standard prescrip- PROSTATE CANCER (PVD) tion for convalescence after significant health con- ditions ranging from herniated disk (HERNIATED Fitness for Health: Public Health Goals NUCLEUS PULPOSUS) and KNEE INJURIES to HEART The US federal government adopted formal inter- ATTACK and major surgical operations. Rest, est in and support for physical fitness in the 1950s, according to prevailing medical wisdom, allowed when President Dwight D. Eisenhower the body to heal itself. With the collection of evi- (1890–1969) formed the President’s Council on dence of physical inactivity’s harmful effects on Youth Fitness in response to published scientific health in general growing in the late 1960s, doc- data that America’s youth were significantly less tors began to question the value of the “rest to physically fit compared to European youth. Each recover” approach and to implement gradual US president after Eisenhower strengthened and physical activity as part of a person’s recuperation broadened the role of government agencies to plan. Doctors observed that people who engaged study exercise and educate the public about the in limited physical active early in the course of relationship between EXERCISE AND HEALTH. their recovery, such as sitting in a chair or walking Through the 1970s and 1980s these initiatives to the bathroom, in the days immediately after an expanded to encourage extended physical fitness OPERATION or a heart attack improved faster and and sports activities in the schools and support felt better than those who remained on bedrest. businesses and corporations in promoting exercise Doctors also noted that early mobility, now a and fitness programs and opportunities among 212 Fitness: Exercise and Health employees. Health agencies such as the National • Increase the proportion of adolescents and Institutes of Health (NIH) and health organiza- adults who engage in vigorous physical activity tions such as the American Heart Association that promotes the development and mainte- (AHA) and the American Diabetes Association nance of cardiorespiratory fitness three or (ADA) espoused exercise and fitness as preventive more days per week for 20 or more minutes measures as well as adjuncts for clinical treatment per occasion. regimens. In 1990 and in 2000 the US Centers for • Increase the proportion of adults who perform Disease Control and Prevention (CDC) the US physical activities that enhance and maintain government’s health promotion and prevention muscular STRENGTH and ENDURANCE. agendas for Americans, the Healthy People 2000 • Increase the proportion of adults who perform and HEALTHY PEOPLE 2010 initiatives, incorporated physical activities that enhance and maintain daily physical activity for youth and adults among FLEXIBILITY. their priority areas with the overriding objective of • Increase the proportion of US public and pri- preventing health conditions and reducing overall vate schools that require daily physical educa- premature deaths that result from physical inac- tion for all students. tivity. • Increase the proportion of work sites offering employer-sponsored physical activity and fit- KEY HEALTHY PEOPLE 2010 PHYSICAL ACTIVITY GOALS ness programs. • Reduce the proportion of adults who engage in • Increase among children, adolescents, and no leisure-time physical activity. adults the proportion of trips made by walking. • Increase the proportion of adolescents and • Increase among children, adolescents, and adults who engage regularly, preferably daily, adults the proportion of trips made by bicy- in moderate physical activity for at least 30 cling. minutes per day. A–B

aerobic capacity The maximum amount of oxy- tive because there is a strong correlation between gen the body can extract from ambient air (the air low aerobic capacity and increased risk for CARDIO- of the normal environment) and use during physi- VASCULAR DISEASE (CVD). Increasing aerobic capacity cal activity, expressed as V˙ O2max in terms of milli- consequently lowers CVD risk factors. liters of oxygen per kilogram of body weight per Direct measurement of V˙ O2max is fairly complex; minute (mL/kg/min). Because men have larger because of this doctors tend to conduct direct aer- LUNGS and thus greater surface area for oxygen obic capacity testing only in people who have pul- exchange, all other factors being equal men have monary disease. A pulmonary function testing greater aerobic capacity than women. Higher center conducts direct V˙ O2max measurement, for ˙ VO2max correlates with increased ability to sustain which the person runs on a treadmill or rides a high-intensity exercise for an extended time, such stationary bicycle wearing specialized equipment as during ENDURANCE activities. People who partici- that measures the exchange of oxygen and carbon pate in athletic events at a competitive level, ama- dioxide. Calculations using the measurements teur or professional, typically have higher aerobic determine the V˙ O2max, usually along with other capacity in general and a significantly higher measures that provide a detailed perspective of ˙ VO2max in the activity of specialty such as bicy- lung function and lung capacity. cling, cross-country skiing, distance running, and There are several methods for indirectly meas- swimming. Aerobic capacity is a key indicator of uring aerobic capacity, all of which involve per- cardiovascular fitness. forming sustained aerobic exercise such as running or walking for a determined period of REPRESENTATIVE AEROBIC time or a known distance. Calculations use the ˙ CAPACITY MEASUREMENTS (VO2MAX) information to project the anticipated V˙ O2max for ˙ sedentary woman 38 milliliters per kilogram per minute the data. Indirect VO2max measurement is less pre- ˙ (mL/kg/min) cise than direct VO2max measurement but is accu- aerobically fit woman 60 mL/kg/min rate enough for most people who are engaged in sedentary man 42 mL/kg/min aerobic exercise and want to know, or monitor aerobically fit man 80 mL/kg/min improvements in, their aerobic capacity. See also FITNESS LEVEL. Researchers believe the foundation of aerobic capacity is genetic; some people are born with aerobic exercise Physical activity that raises the greater aerobic capacity potential, and with sus- HEART RATE to 60 percent of maximum heart rate, tained AEROBIC EXERCISE at a competitive level they called the target heart rate, for a minimum contin- are able to maximize that potential for high uous time of 20 minutes. ˙ VO2max. A sedentary (physically inactive) person A general guideline for approximating one’s who undertakes a planned, progressive program target heart rate is the “talk test.” At target heart of aerobic exercise can often improve his or her rate, a person should be able to speak. A person aerobic capacity by 20 to 30 percent. Such who cannot talk during exercise is likely exceed- improvement is significant from a health perspec- ing his or her target heart rate and is working too 213 214 Fitness: Exercise and Health hard. A person who can carry on an extended target heart rate. Competitive athletes and people conversation or sing during exercise is likely at high aerobic capacity may derive greater benefit below his or her target heart rate and is not work- from exercising at a target heart rate that is 70 to ing hard enough for aerobic conditioning. 80 percent of maximum heart rate. Among the most familiar and popular aerobic CALCULATING TARGET HEART RATE activities are running, swimming, cross-country The standard formula for calculating target HEART skiing, and bicycling. Brisk walking (five miles per RATE is 220 minus one’s age (an estimated maxi- hour) is aerobic as well. Sports such as basketball, mum heart rate), then multiplying the result by volleyball, soccer, and singles tennis also provide 60 percent. For example, the target heart rate for an aerobic workout. Participating in aerobic exer- a person 35 years old is 111 beats per minute: cise at less than an aerobic level (below target 220 – 35 = 185 x 0.6 = 111. heart rate) provides numerous health and fitness benefits, too, as part of maintaining a physically Aerobic exercise uses the large MUSCLE groups active lifestyle. in rhythmic, repetitive activity that increases the body’s consumption of oxygen, and is the core of AEROBIC ACTIVITIES cardiovascular CONDITIONING. Regular aerobic exer- basketball bicycling cise improves the all-around efficiency of the car- climbing stairs cross-country running diovascular system including cross-country skiing dancing handball ice skating • more powerful contractions of the HEART to inline skating jogging pump BLOOD out to the body jumping rope racquetball • the ability of the LUNGS to exchange carbon roller skating rowing dioxide for oxygen running snow shoeing soccer spinning • the ability of the muscles in the body to con- stair-stepping stationary cycling tract with power and force swimming tennis (singles) • the ability of the blood vessels to dilate (open) volleyball walking to carry more blood with each beat of the heart • lower BLOOD PRESSURE as a result of reduced See also CARDIAC CAPACITY; EXERCISE AND HEALTH; resistance to the flow of blood FLEXIBILITY; LIFESTYLE AND HEALTH; OBESITY AND HEALTH; RESISTANCE EXERCISE; STRENGTH; WEIGHT LOSS AND Health experts recommend a minimum of 30 WEIGHT MANAGEMENT. minutes of aerobic exercise three days every week and encourage more. At the onset of an aerobic aging, changes in physical ability and fitness exercise program a person is likely to achieve tar- needs that occur with As a person grows older, get heart rate quickly because the heart is not his or her physical capabilities, STRENGTH, FLEXIBILITY, accustomed to working in such a way. It is impor- AEROBIC CAPACITY, exercise needs, metabolic rate, tant to stay at the target heart rate for as long as body composition, and risk for injury change. possible, which may not be a full 20 minutes at first. As the FITNESS LEVEL and AEROBIC CAPACITY Children and Exercise improve, it takes longer to reach and becomes eas- Children require physical activity for proper devel- ier to maintain one’s target heart rate. opment and growth. BONE and MUSCLE develop- People who want to increase their fitness levels ment relies in part on the stimulation from should increase both the length and frequency of resistance activities such as walking and running. their exercise sessions, for example 45 minutes of Preschool-age children tend to be on the go con- aerobic activities five days a week. The higher a stantly. However, many develop fairly sedentary person’s aerobic capacity, the more effort the per- habits by the time they reach school age, with son must exert to achieve and maintain his or her activities such as watching television, using the blister prevention 215 computer, and playing video games replacing gone so far as to say that lifestyle factors such as physical activities. Numerous clinical research daily exercise, nutritious EATING HABITS, and not studies correlate such physical inactivity with the smoking have the capability to eliminate 85 percent rise in childhood OBESITY AND HEALTH conditions or more of acquired CARDIOVASCULAR DISEASE (CVD). such as type 2 DIABETES, HYPERLIPIDEMIA, and As well, numerous studies affirm the beneficial OSTEOARTHRITIS that typically do not appear until effects of exercise toward preventing injury and middle age or later. supporting overall health. Health experts recommend an hour a day of Daily physical activity becomes more significant moderate physical activity for children and adoles- with advancing age also because the body natu- cents, though estimate 60 percent or more do not rally begins to change in ways that diminish LEAN meet that recommendation. The health risks asso- MUSCLE MASS, muscle strength, JOINT flexibility, gas- ciated with physical inactivity not only carry into trointestinal function, and hormone sensitivity. adulthood but appear to be more severe. Aerobic Around age 50 hormonal shifts in both men and capacity—the body’s ability to use oxygen effi- women result in loss of muscle tissue, with fat ciently—reaches its peak in the early 20s and then often replacing this loss, and bone density. After begins a gradual decline. Muscle mass and BONE age 70 muscle strength, bone density, and aerobic DENSITY are also at their peak in the early 20s. capacity decline in men and women alike. In men Daily physical activity in late ADOLESCENCE appears these changes are less pronounced; in women par- capable of extending aerobic capacity and muscu- ticularly they can have catastrophic health conse- loskeletal strength well into adulthood. quences if not detected and treated. A woman’s risks for heart disease and osteoporosis jump after Older Adults and Exercise MENOPAUSE, largely the consequence of the drop in A physically active adult has an aerobic capacity, ESTROGENS. The risk of hip fracture due to lost bone measured as V˙ O2max, up to 25 percent greater than density rises in men and women alike after age a person of comparable age who does not exercise. 70. Though daily exercise cannot prevent such Such a difference becomes increasingly significant changes from occurring, it can mitigate their with advancing age. Between age 20 and age 40 severity and help maintain good QUALITY OF LIFE. aerobic capacity declines 8 to 12 percent. Between Older people who have chronic or serious age 40 and age 70 aerobic capacity declines about health conditions may have limited ability to par- 10 percent per decade. After age 70 aerobic capac- ticipate in physical activities. Conditions such as ity declines 20 percent per decade. When daily HEART FAILURE and CHRONIC OBSTRUCTIVE PULMONARY physical activity is an element of lifestyle through- DISEASE (COPD) may limit aerobic capacity, for out life, the decline in aerobic capacity signifi- example. Osteoarthritis and RHEUMATOID ARTHRITIS cantly slows. A 70-year-old who has a moderate may restrict movement. Despite the limitations to good FITNESS LEVEL (exercises at or beyond the chronic health conditions may impose on physical minimum PHYSICAL ACTIVITY RECOMMENDATIONS) has activity, they also benefit from regular exercise an aerobic capacity comparable to that of a person however modest. A health professional such as a 10 to 20 years younger. physical therapist, an exercise physiologist, or a Such a difference correlates to lower HEART RATE, physiatrist (physician who specializes in rehabili- lower BLOOD PRESSURE, stronger muscles and bones, tation medicine) can help develop an appropriate increased HORMONE sensitivity and endocrine physical activity regimen for a person who has a response, smoother and more regular gastrointesti- chronic or debilitating health condition. nal function, and even greater elasticity to the SKIN. See also ANABOLIC STEROIDS AND STEROID PRECUR- These factors lower the risk for numerous health SORS; DISABILITY AND EXERCISE; WEIGHT LOSS AND conditions including HEART disease, HEART ATTACK, WEIGHT MANAGEMENT; YOGA. STROKE, OSTEOPOROSIS, hip FRACTURE, type 2 diabetes, OBESITY, SEXUAL DYSFUNCTION, and various forms of blister prevention Methods to reduce irritation cancer. Though no clinical evidence as yet supports to SKIN surfaces from friction. The feet are the exercise as a panacea for aging, researchers have most common site of blisters acquired during 216 Fitness: Exercise and Health physical exercise. Athletic activities such as rac- Adhesive bandages, blister pads, moleskin, and quet sports, rowing, baseball, golfing, bicycling, other products can provide additional protection and sailing expose the hands to friction and the for areas that are particularly vulnerable to blis- risk for blisters. A BLISTER is the body’s attempt to ters, such as the back of the heels, the toes, and protect itself from friction-generated injury. Fluid any parts of the foot that rub against the shoe. accumulates between the layers of the skin, sepa- Some people apply petroleum jelly or antibiotic rating the layers and buffering damage to the ointment to “hot spots.” Other people find dusting underlying delicate tissues. The process stimulates the feet with foot powder or cornstarch, or apply- the NERVE endings in the skin to send signals of ing a dry lubricant, helps keep the feet dry and PAIN to the BRAIN. Blister prevention techniques smooths their movement within the shoes. attempt to anticipate sites of excessive friction to Athletic gloves, appropriate for the activity and cushion them from irritation. that fit properly, can similarly protect the hands The right footwear can prevent many blisters from friction and moisture. It is important for the from developing on the feet. It is important to glove to fit without bunching or pinching, other- wear shoes or boots that fit properly and are wise the glove itself will become the cause of blis- appropriate for the activity. Shoes that are too ters. Rings worn on the fingers, even with gloves, loose allow the foot and toes to slide against the can contribute to blisters by allowing the skin to inside of the shoe or the shoe to slip up and down pinch against them. on the heel. Shoes that are too tight pinch the toes A CALLUS (thickened pad of skin) will eventually and trap moisture against the skin. Even the best- form at a site that repeatedly blisters, the body’s fitting shoes or boots may cause blisters if they are further attempt to protect itself. Once a callus not right for the activity. Socks absorb moisture forms the area is much less likely to blister. Work- and establish a physical barrier between the foot ing up to a level of activity, such as with running and the shoe; double-layer socks are most effec- or walking, helps prepare the skin for the expo- tive for this purpose. Socks should fit snugly and sure it faces. Blisters are more likely to occur smoothly against the foot, and like shoes or boots when engaging in new activities or at a signifi- should be appropriate for the intended use. People cantly increased level (such as a competitive whose feet sweat excessively (HYPERHIDROSIS) may event) within a familiar activity. want to consult a podiatrist or dermatologist for See also CHAFING; FITNESS LEVEL; PHYSICAL ACTIVITY evaluation and treatment to reduce the amount of RECOMMENDATIONS; TINEA INFECTIONS; WALKING FOR moisture their feet produce. FITNESS. C carbohydrate loading The practice of consum- stances for the clothing to be snug though not con- ing excess quantities of carbohydrates, such as strictive. High-wicking fabrics in combination with pasta and breads, for a period of time before an talcum powder and similar products to absorb athletic or competitive event. The body converts moisture further reduce the likelihood of chafing. the excess GLUCOSE that results into glycogen, the Body lubricants, which form a barrier between short-term storage form of glucose held primarily clothing and the skin, extend protection for dis- in the LIVER. During exercise when the levels of tance activities such as running, hiking, climbing, glucose in the BLOOD circulation drop, the body and bicycling. A CONDITIONING program of steady begins to convert glycogen back to glucose to progress toward fitness goals also helps prepare the replenish glucose blood levels. Because carbohy- body, increasing its resistance to irritation. drate loading increases the amount of glycogen See also BLISTER PREVENTION; FITNESS LEVEL; PHYSI- the body stores, the athlete can sustain a higher CAL ACTIVITY RECOMMENDATIONS; WALKING FOR FITNESS. level of energy output for a longer period of time. The most common approach to carbohydrate charleyhorse A sudden, intensely painful MUSCLE loading is to eat primarily carbohydrates for three contraction, sometimes called a muscle CRAMP. A days before the scheduled event and to reduce the charleyhorse most often affects the legs and feet training schedule during that time to allow the and is typically a consequence of electrolyte body to store, rather than draw from, glycogen. imbalances, especially deficiencies in magnesium Many top amateur and professional athletes prac- and potassium. A charleyhorse may occur during tice some variation of carbohydrate loading, which rest, especially during sleep. A charleyhorse that is most effective for ENDURANCE activities that last occurs during exercise often indicated inadequate two hours or longer. Fitness and nutrition experts HYDRATION. Stretching and massaging the affected also recommend eating a meal that contains both muscle often relieves the contraction, allowing the carbohydrates and protein about two hours after muscle to relax. Some people experience relief intense exercise to help the body replenish the with ice applied to the area while other people stores of glucose and amino acids it drew from find heat more helpful. Sometimes a degree of dis- during the physical activity. comfort continues for a short time after the cramp See also DIET AND HEALTH; EATING HABITS; NUTRI- subsides. Stretching and WARMUP before beginning ENTS; NUTRITIONAL NEEDS. exercise help prevent charleyhorses. See also SHIN SPLINTS; STINGER. chafing Irritation to the SKIN resulting from cloth- ing and body parts that rub. The areas most vulner- conditioning A planned and consistent effort to able to chafing are the inner thighs, groin, inner establish and maintain, through physical exercise, arms and sides of the chest, and front of the chest a FITNESS LEVEL that supports health. Conditioning (especially the nipples). Ill-fitting clothing in com- requires repetitious physical activity that exerts bination with moisture is generally the precipitat- the body for STRENGTH, FLEXIBILITY, and AEROBIC ing factor. It is important to wear clothing CAPACITY. Physical conditioning may be part of a appropriate for the activity and in most circum- rehabilitation program for people recovering from 217 218 Fitness: Exercise and Health serious injury or health condition such as STROKE capacity but also are activities a person enjoys. or HEART ATTACK. Conditioning is also an important These activities, in combination, maintain the fit- component of the lifestyle changes necessary for ness of the entire body. RESISTANCE EXERCISE helps effective WEIGHT LOSS AND WEIGHT MANAGEMENT. maintain BONE DENSITY and BONE strength, which is particularly important for women who are past Building a Conditioning Plan MENOPAUSE. Regular physical activity also benefits It is important to build a conditioning plan that emotional and psychological well-being. Many starts at the current fitness level and moves in people find the commitment to planned exercise progressive increments toward the target fitness allows them time for themselves that provides a level. There are numerous methods for assessing a calming break from the stresses and pressures of person’s existing fitness level. Health experts work and family. Many activities also provide advise a ROUTINE MEDICAL EXAMINATION before begin- opportunities for recreation and social interaction, ning a new physical conditioning effort when any such as walking clubs, yoga groups, organized of the following circumstances apply bicycling rides, group hikes, volksmarch and other volkssports, and structured classes at a gym or fit- • physically inactive for longer than a year ness facility. • over age 50 CALISTHENICS FALLEN FROM FAVOR • BODY MASS INDEX (BMI) over 32 Health and fitness experts no longer recommend • existing health conditions such as heart disease, old-fashioned calisthenics—situps, pullups, and DIABETES, OSTEOARTHRITIS, OBESITY, lung disease, pushups—once the staple of physical fitness pro- or other chronic disorders grams because the resistance involved is that of • physical limitations or disabilities body weight, which allows no FLEXIBILITY for either building up to a competence level or The most effective conditioning results occur increasing the challenge to the body after reach- with an approach that is structured and system- ing a level of competence with the exercises. As atic, with planned activities intended specifically well, these exercises as taught in the middle for exercise such as walking, bicycling, light decades of the 20th century place undue and weightlifting, and YOGA. Many people are able to potentially harmful strain on the joints and the also integrate activities of conditioning into their lower back. daily routines, such as walking to work or school and taking the stairs instead of the elevator. Peo- When circumstances interrupt conditioning it is ple whose jobs are physically active often have the important to get back on track as soon as possible, strength and flexibility to accommodate the approaching it as any other integral component of demands of their job tasks though may lack an lifestyle. It helps to maintain a modified condition- overall state of physical fitness. A qualified fitness ing effort when possible, such as alternative activi- instructor can conduct a baseline assessment of ties when traveling on business or recreation. the person’s fitness status and help develop a con- Fitness level begins to slip after a week without ditioning plan that integrates work activities with any exercise at all, though is quickly recoverable fitness activities. The appropriate clothing, equip- with return to the regular physical activities. It is ment, and technique for specific physical activities important to reenter the conditioning plan at the help ensure maximum benefit from the activities current fitness level and work back to the target as well as minimize the risk for injury. fitness level. See also ATHLETIC INJURIES; EXERCISE AND HEALTH; Maintaining a Conditioning Plan PHYSICAL ACTIVITY RECOMMENDATIONS; TRAINING; WALK- Conditioning is successful when it becomes an ele- ING FOR FITNESS; WEEKEND WARRIOR. ment of lifestyle and an aspect of daily routine that incorporates a variety of daily activities that cross training The practice of alternating differ- not only improve strength, flexibility, and aerobic ent kinds of exercise to provide a well-rounded cross training 219 workout for the body that establishes and main- STRENGTH, such as weightlifting, with stretching tains a high overall FITNESS LEVEL. Cross-training activities to improve FLEXIBILITY, such as YOGA. The exercise typically complements a person’s primary alternation may occur in the form of two or more athletic activity. Runners may cross train by activities in a single session or alternating activities engaging in swimming to work the upper body, among different sessions. For example a runner for example, and bicycle one day a week to work may run one day, lift weights the next day, run different muscles from those that running works the next day, and swim the next day. Cross train- in the lower body. Many athletes alternate AEROBIC ing also helps reduce the risk for ATHLETIC INJURIES. EXERCISE with RESISTANCE EXERCISE to improve See also AEROBIC CAPACITY. D–E

disability and exercise Regular exercise is ticularly to the extremities and the SKIN. They also important for health and well-being for everyone, maintain BONE DENSITY and JOINT range of motion, and most people are able to participate in physical permitting the best mobility possible. Passive exer- activities to some degree. Though chronic or debil- cise (in which a therapist or caregiver guides the itating health conditions may limit a person’s person’s body gently through structured move- physical abilities, it is possible to adapt many phys- ments) benefits people who have severely ical activities to accommodate individual needs. restricted mobility or PARALYSIS such as due to For example, 30 minutes of pushing oneself in a STROKE or SPINAL CORD INJURY. wheelchair is comparable to 30 minutes of walk- See also AEROBIC EXERCISE; FITNESS LEVEL; PHYSICAL ing. In other circumstances health conditions such ACTIVITY RECOMMENDATIONS; RESISTANCE EXERCISE; as moderate to severe CARDIOVASCULAR DISEASE STRENGTH. (CVD) may limit AEROBIC CAPACITY; conditions such as CEREBRAL PALSY and OSTEOARTHRITIS may restrict endurance The ability to persist in performing a FLEXIBILITY and mobility. physical activity. Endurance may refer to AEROBIC CAPACITY (the fitness of the cardiovascular system), Anyone who has a physical disability the ability to sustain a position over time (such as should consult with his or her doctor in YOGA), or the ability to repeatedly and consis- before beginning a new physical activity tently perform a set of movements (such as lifting or exercise plan. weights). Endurance is an important element of overall physical fitness that requires an integration Physical therapists and exercise physiologists, of aerobic capacity with STRENGTH and FLEXIBILITY. particularly those who specialize in sports medi- Endurance improves with exercise that chal- cine, can help people who have disabilities lenges the body’s capabilities at a moderate level, develop effective CONDITIONING or TRAINING plans encouraging the muscles to draw energy from and modify physical activities to meet their fitness glycogen stores and the LUNGS to function at goals and interests. Such modifications may take higher efficiency in the amount of air, and conse- the form of adaptations in technique or alterations quently oxygen, they take in with each breath. in intensity or duration of activity. Individual cir- Endurance training emphasizes activities that cumstances also may require adaptive clothing, extend the duration of performance. For aerobic shoes, and equipment. Many communities and fit- activities this means extending the length of time ness facilities have special physical fitness pro- for TRAINING sessions in incremental fashion, for grams, including team and competitive events, for example increasing distance for running or the people who have disabilities; such programs allow duration of holding a yoga pose. RESISTANCE EXER- participation at levels that match individual capa- CISE also can improve endurance by increasing the bilities and interests. number of repetitions of a resistance activity such Strengthening and flexibility activities are as lifting weights or working with resistance important for maintaining as much function as bands. possible. Such activities improve BLOOD flow, par- See also CONDITIONING; FITNESS LEVEL. 220 exercise and health 221 exercise and health The correlations between • improves INSULIN sensitivity, decreasing the risk daily physical exercise and health are numerous for type 2 diabetes and helping stabilize dia- and solidly affirmed through clinical research betes that already exists studies. In an overarching context physical activity • reduces the risk for COLORECTAL CANCER, BREAST improves the efficiency of metabolic functions at CANCER, and PROSTATE CANCER the cellular level throughout the body. Physical • strengthens bones and increases BONE DENSITY, exercise further has specific effects on nearly lowering the risk for OSTEOPOROSIS every system of the body, helping the body func- tion with optimum efficiency. • increases FLEXIBILITY and STRENGTH, improving Though researchers do not fully understand the mobility and reducing the risks for OSTEOARTHRI- mechanisms within the body through which exer- TIS and injury from falls cise affects health and disease, they do know that • relieves stress and DEPRESSION, improving well- physically inactive people are being and the ability to cope with daily difficul- ties and challenges • twice as likely to develop CORONARY ARTERY DIS- • lowers total CHOLESTEROL BLOOD LEVELS and EASE (CAD) increases high-density lipoprotein (HDL) cho- • 50 percent more likely to develop HYPERTENSION lesterol (“good” cholesterol) blood level, reduc- (high BLOOD PRESSURE) ing the risk for ATHEROSCLEROSIS and CAD • up to 6 times more likely to develop type 2 DIA- • improves cardiovascular efficiency and lung BETES between the ages of 18 and 30 capacity • twice as likely to die prematurely for any reason • stimulates gastrointestinal activity, shortening the amount of time food takes to complete its Many researchers believe that physical inactiv- journey through the digestive process and ity is nearly as significant a risk factor for CARDIO- decreasing the likelihood of CONSTIPATION and VASCULAR DISEASE (CVD) as cigarette smoking. As other gastrointestinal disorders well, the correlation between physical inactivity and OBESITY, also a key risk factor for numerous Numerous studies show that modest to moder- health conditions and premature death, is strong. ate physical exercise—30 minutes a day most days Though in combination these two risk factors— of the week—is sufficient to generate measurable physical inactivity and obesity—affect every level health benefits. About 40 percent of Americans of bodily function from molecular (metabolic meet this objective. Additional exercise increases activity) to mechanical (how the body as a whole benefits. It is important to choose a variety of moves and performs) and are sometimes difficult activities that are enjoyable, convenient (logisti- to separate, exercise alone influences health in cally feasible and require minimal preparation), distinct ways. People who are overweight yet within an individual’s skill range, and safe within physically active every day have overall better the context of any existing health conditions. health and lower risk for serious health conditions Structured activities—even when structure is as such as CVD and type 2 diabetes than people of basic as setting aside 30 minutes each day to comparable weight and are physically inactive. walk—helps give exercise a sense of priority in a Very modest physical activity, such as walking 20 person’s life, which encourages ongoing participa- to 30 minutes every day, can result in significant tion. Nevertheless, all efforts to increase physical weight loss over time, lowering health risk related activity in daily living, however small or brief, to both obesity and physical inactivity. improve health and QUALITY OF LIFE. Consistency Evidence conclusively demonstrates that regu- maintains fitness most effectively. lar exercise, done at least at the minimum level of See also CHOLESTEROL, ENDOGENOUS; DIET AND recommended physical activity HEALTH; EATING HABITS; HEALTH RISK FACTORS; LIFESTYLE AND HEALTH; METABOLISM; NUTRITIONAL NEEDS; OBESITY; • lowers BLOOD pressure and can reduce hyper- OBESITY AND HEALTH; PHYSICAL ACTIVITY RECOMMENDA- tension, decreasing the risk for STROKE TIONS; SMOKING CESSATION. F

fitness level The ability of the body to perform activities, which can be as effective as structured physical activity. Fitness encompasses AEROBIC exercise and makes the most of available time. CAPACITY (cardiovascular fitness), STRENGTH, and Activities such as gardening, cleaning house, FLEXIBILITY. These three components combine to washing the car, mowing the grass (especially help configure a person’s LEAN MUSCLE MASS, BODY with a nonmotorized mower), and walking when- FAT PERCENTAGE, and BODY MASS INDEX (BMI), which ever possible are among the many ways to are key risk factors for numerous health condi- increase physical exertion on a daily basis that tions, including CARDIOVASCULAR DISEASE (CVD) and result in improved fitness level over time. Though DIABETES. A high fitness level, indicating daily physical activity recommendations and fitness physical exercise, reduces numerous HEALTH RISK level classifications may appear daunting to people FACTORS. Conversely a low fitness level, indicating who are not presently active and whose lives are physical inactivity, correlates to increased health busy, fitness is the accumulated result of numer- risk. ous and daily small physical efforts that pay off in Exercise physiologists use various scales to big ways when it comes to health as well as satis- quantify an individual’s fitness level. Some assess- faction with how one feels and looks. ment scales emphasize cardiovascular fitness and See also BODY SHAPE AND CARDIOVASCULAR DISEASE; others measure general fitness. CONDITIONING, EXERCISE AND HEALTH; LIFESTYLE AND HEALTH; OBESITY; which targets overall fitness status, and TRAINING, OBESITY AND HEALTH; WALKING FOR FITNESS; WEEKEND which prepares a person for a particular event or WARRIOR; WEIGHT LOSS AND WEIGHT MANAGEMENT. activity often at a competitive level, are structured methods to improve a person’s fitness level. flat feet A structural circumstance in which the People whose fitness levels are “very poor” or ligaments in the foot do not support the bones to “poor” do not receive enough physical activity to form an appreciable arch. The arch of the foot support their bodies in health and are at increased helps cushion the foot’s structure during impact. risk for injury and health disorders. A “moderate” Young children normally have flat feet until regu- fitness level meets general PHYSICAL ACTIVITY RECOM- lar walking and running strengthens the muscles MENDATIONS to support health, weight manage- and ligaments of the feet, a process that typically ment, and reduction of health risk factors. People occurs between the ages of 3 and 10 years. Unless who have a “good” fitness level enjoy optimum there is an underlying deformity, there is no med- benefit from physical activity. People who have a ical reason to attempt to treat flat feet in young “very good” fitness level dedicate focused effort to children because it is the normal state of the feet. physical fitness and are often athletes who partici- Adults sometimes speak of having “fallen pate in organized or competitive events. arches,” a casual term that refers to stretching and As with EATING HABITS and nutrition, fitness loosening of the foot ligaments that sometimes level represents an integration of physical exercise occurs with increasing age. Flat feet that develop into lifestyle such that activity is an inherent com- in such a way are more common in people who ponent of daily living. Many people can find ways are physically inactive and overweight. Extra body to increase physical exercise through their daily weight stresses the feet’s structure in the absence 222 flat feet 223

GENERAL FITNESS LEVEL CLASSIFICATIONS Fitness Level Activities Duration Frequency very poor very little physical activity beyond that brief seldom required for daily living (sedentary) poor may walk at work, to and from the mailbox, and one to two hours one to three days a week for tasks such as grocery shopping combined each day done moderate walks one or two blocks at a time two to three hours three to five days a week walks up two flights of stairs without shortness combined each day done of breath some regular physical activity required at work (such as lifting or walking)

YOGA, TAI CHI, or structured stretching exercises 10 to 20 minutes each one to three days a week day done

walk or casual bicycle ride for pleasure 20 to 30 minutes each one to two days a week day done good walks for or more blocks at a time three or more hours four to five days a week walks up three or more flights of stairs without combined each day done shortness of breath job requires moderate physical activity

participates in structured exercise activity 30 to 60 minutes combined three to five days a week each day done

yoga, tai chi, or structured stretching exercises 10 to 20 minutes three days a week combined each day done

lifts weights or works out with resistance bands 30 to 45 minutes three days a week combined each day done

brisk walk, moderate bicycle ride, run, or swim 30 to 90 minutes two to three days a week combined each day done

1 very good walks distances greater than ⁄2 mile with ease one to three hours six or seven days a week walks up multiple flights of stairs without shortness combined each day done of breath

lifts weights or works out with resistance bands 30 to 45 minutes three days a week combined each day done

job requires steady, moderate to vigorous physical six to eight hours three to five days a week activity combined each day done

yoga, tai chi, or structured stretching exercises 10 to 30 minutes three to five days a week combined each day done

engages in moderate to vigorous aerobic activities two to three hours two to five days a week or participates in competitive events combined each day done 224 Fitness: Exercise and Health of physical exercise that would strengthen the flexibility The ease with which MUSCLE groups muscles and ligaments. and joints allow movement. Flexibility is an inte- Many adults who have flat feet have no dis- gral though often undervalued component of comfort or other symptoms and do not need treat- overall physical fitness. ment. Flat feet become problematic only when Fitness experts advocate stretching and WARMUP they cause abnormal pronation (side to side before and after physical activity, even that which movement of the foot with impact), which can is work related, to prepare the body for activity alter the alignment of the leg and thus affect the and reduce the risk for injury. Lack of use, injury, ankles, knees, and hips. For flat feet that cause surgery, and health conditions such as discomfort, treatment is a combination of properly OSTEOARTHRITIS may limit range of motion (the abil- designed and fitted shoes along with shoe ity of a JOINT to move through the full scope of its orthotics that support the inner surface of the arch capability). Exercises that improve range of area and the heel, stabilizing the foot during motion include stretches and movements that pre- movement. Foot care experts typically further rec- pare the joints for physical activity. YOGA, TAI CHI, ommend a structured approach of planned, pro- and qigong also improve flexibility. Flexibility gressive physical activity to strengthen the extends the ability of the body to participate in structures of the foot as a component of an overall and benefit from strengthening and AEROBIC EXER- WEIGHT LOSS AND WEIGHT MANAGEMENT strategy. CISE. Cycling and swimming combine the benefits Rarely, flat feet may require surgery to tighten lig- of flexibility, strengh, and aerobic workouts. aments and realign the bones. See also AGING, CHANGES IN PHYSICAL ABILITY AND See also CONDITIONING; LIGAMENT; MUSCLE; OBESITY FITNESS NEEDS THAT OCCUR WITH; AEROBIC CAPACITY; AND HEALTH; STRENGTH; SURGERY BENEFIT AND RISK ATHLETIC INJURIES; CONDITIONING; ENDURANCE; FITNESS ASSESSMENT; TALIPEDES. LEVEL; STRENGTH; TRAINING; WEEKEND WARRIOR. M metabolic equivalent (MET) A unit of measure mechanisms within the body regulate the complex for the amount of oxygen the body uses during chemical interactions that constitute metabolism, physical activity. One MET is equivalent to the with the HYPOTHALAMUS and the endocrine system oxygen an adult requires when sitting quietly for taking the lead roles. Hormones such as THYROXIN one minute. A four-MET activity, such as brisk (T4), which the THYROID GLAND produces, and walking or riding a bicycle on a level surface, INSULIN, which the ISLETS OF LANGERHANS in the PAN- requires four times the amount of energy (oxygen CREAS produce, determine the rate at which cells consumption) as the one-MET activity of sitting convert GLUCOSE (one of two fuel sources for cells) quietly. An eight-MET activity, such as running or to energy. The hormones of the body’s stress riding a bicycle uphill, requires eight times as response—CORTISOL, EPINEPHRINE, and NOREPINEPH- much energy as sitting quietly. METs are the basis RINE—also can accelerate metabolism, usually as a for calculating the number of calories that particu- short burst; though in times of trauma the STRESS lar activities burn. Activities that require three to RESPONSE HORMONAL CASCADE can alter the body’s six METs are considered to be of moderate inten- metabolism on a long-term basis as a mechanism sity and burn 3.5 to 7 calories per minute. Activi- to facilitate HEALING. ties that require greater than six METs are The common perception of metabolism is as a considered to be of vigorous intensity and burn rate that represents a balance between calories more than 7 calories per minute. consumed and calories expended. Metabolism Knowing an activity’s MET value helps an indi- may also refer to the processes that occur during vidual calculate how long to participate in that digestion to convert foods and drugs into chemical activity to meet a desired level of CALORIE con- molecules the body can use. Metabolism has two sumption. For example, a person who wants to primary modes: anabolism and catabolism. burn 150 calories a day (the minimum recom- Anabolism is energy expended toward construc- mendation for adults) may choose to walk at three tion (building tissue) and catabolism is energy and half miles per hour, a four-MET activity, for expended toward destruction (breaking down tis- 40 minutes or run at five miles per hour, an eight- sue). Energy needs increase when a person is MET activity, for 20 minutes, depending on the recovering from major surgery, injury, or illness, desired level of intensity. as the processes of healing engage the body in See also AEROBIC CAPACITY; AEROBIC EXERCISE; BODY extra anabolic (constructive) effort. MASS INDEX (BMI); CONDITIONING; FITNESS LEVEL; PHYSI- CAL EXERCISE RECOMMENDATIONS; TRAINING; WALKING Measuring Metabolic Rate FOR FITNESS. The fundamental measure of metabolism is the basal metabolic rate (BMR), which identifies the metabolism The processes through which cells amount of energy, in terms of calories, that the convert NUTRIENTS to energy. In the most basic body requires over 24 hours to function at sense, metabolism is the point of transition from absolute rest. Nutritionists and exercise physiolo- energy intake (food consumption) to energy gists generally use mathematical formulas to cal- expenditure (molecular conversion). Multiple culate BMR because its actual measurement is 225 226 Fitness: Exercise and Health complex and requires an overnight stay in a spe- Metabolic Response to Trauma cial lab to capture measurements at precisely the When the body experiences significant physical point of minimal metabolic activity. A common trauma, such as due to BURNS or major injuries, its formula for estimating BMR is the Harris-Benedict natural stress response initiates metabolic changes equation. There are separate equations for women that allow the body to rapidly convert protein to and for men, accommodating gender differences amino acids (and subsequently to glucose) for the in the ratio of LEAN MUSCLE MASS to body fat. body to use as energy. Major surgery may also ini- Easier to measure directly is the resting meta- tiate this response. The purpose of the metabolic bolic rate (RMR), which provides similar informa- response to trauma is to muster every available tion about the body’s energy requirements at resource for healing; the result is rapid destruction minimal activity. Many exercise physiology clinics (catabolism) of muscle tissue. During healing the can measure RMR. More sophisticated methods metabolic rate rises significantly, reflecting the are available that allow determination of precise body’s efforts to repair and reconstruct damaged metabolic measures for elite athletes as well as for tissue (anabolism). However, the rate of catabo- people who have severe health conditions. Most lism may be up to 10 times that of anabolism, people expend 50 to 75 calories per hour at rest, establishing an imbalance that makes it difficult so a rough generalization of metabolic rate is for the body to replace its protein stores. 1,200 to 1,800 calories. The larger a person, the Intensified nutritional support in combination higher his or her metabolic rate, whether body with physical exercise (particularly RESISTANCE size results from MUSCLE mass or fat accumulation. EXERCISE) can expedite muscle tissue restoration However, increased muscle mass further raises the and help metabolism return back to normal. The metabolic rate because muscle cells use more most effective nutritional support incorporates a energy than fat cells in the normal course of their high-protein diet (up to two times the recom- functions. Men generally have higher metabolic mended dietary allowance) and NUTRITIONAL SUP- rates than women because their bodies have PLEMENTS to supply increased amounts of certain B larger muscles and greater lean muscle mass. vitamins that are essential for cellular energy pro- duction and the efficiency with which cells can Metabolism and Weight Management use glucose. Physical activity stimulates muscle From a practical perspective either RMR or BMR cells to improve the efficiency with which they presents the body’s energy needs in terms of calo- contract and relax, and encourages development ries, allowing an individual to estimate daily of new muscle tissue. Sometimes doctors may energy use (CALORIE expenditure) to tailor daily prescribe hormones to further stimulate muscle calorie intake. Activity factors and injury factors growth. further determine the body’s overall energy expenditure and intake needs. A person whose Metabolic Disorders lifestyle is sedentary, for example, uses less energy Metabolic disorders are health conditions that and consequently requires less intake than a per- alter the function of the body’s metabolic, or son whose lifestyle includes daily physical exer- energy-producing, pathways. Among the most cise. However, the metabolic rate decreases at common metabolic disorders are DIABETES, HYPER- about 5 percent per decade between the ages of 25 THYROIDISM, HYPOTHYROIDISM, and PHENYLKETONURIA and 75, largely because lean muscle mass (PKU). Though doctors understand the mecha- decrease; thus at age 75 a person requires about a nisms of most metabolic disorders, the causes third fewer calories each day than at age 25. With- remain largely unknown. Genetic factors play a out a comparable increase in exercise, the differ- significant role and may be the sole cause of cer- ence can amount to a weight gain of four to seven tain metabolic conditions such as glycogen-storage pounds a year. Regular physical activity boosts the disorders (which affect the body’s ability to metab- metabolic rate by maintaining a higher percentage olize carbohydrates) and lipid-storage disorders of lean muscle mass. (which affect the body’s ability to metabolize fats). metabolism 227

Doctors commonly refer to genetic-based con- Hormone replacement therapy is the treatment for ditions as inborn errors of metabolism. Many of hypothyroidism and insulin-dependent diabetes. these disorders affect the function of specific Confirming the diagnosis of metabolic disorders enzymes that facilitate the conversion or storage may be as simple as common blood tests, such as of nutrients to energy within the metabolic path- for diabetes or hypothyroidism, or may require way. The consequence may affect the body as a sophisticated laboratory procedures and genetic whole or the activity of specific kinds of cells such (DNA) testing. There are no known methods of as muscle cells or nerve cells (neurons). prevention for most metabolic conditions. Lifestyle Researchers do not know the extent to which factors such as diet and daily exercise can influ- genetic factors influence acquired metabolic con- ence, and often prevent or reduce the severity of, ditions such as hyperthyroidism, hypothyroidism, type 2 diabetes. and type 2 diabetes. Symptoms of metabolic disorders vary depend- DISORDERS OF METABOLISM ing on how the disorder affects metabolism and acid lipase disease coenzyme A deficiencies may include DIABETES Fabry disease G6PD DEFICIENCY galactosemia • neurologic deficit and development delays gangliosidoses Gaucher disease • CARDIOMYOPATHY HEMOCHROMATOSIS hyperoxaluria • hearing loss HYPERTHYROIDISM HYPOTHYROIDISM • vision disturbances lipidoses metachromatic leukodystrophy mitochondrial myopathies muscular dystrophies • myoclonus Niemann-Pick disease OBESITY • seizures oxalosis PHENYLKETONURIA (PKU) • weakness or movement difficulties Tay-Sachs disease WILSON’S DISEASE • failure to thrive Continuing advances in genetic and molecular Inborn disorders of metabolism may not research are allowing scientists to identify gene become apparent until a child is several months to mutations that underlie a number previously several years old, by which time the condition poorly understood syndromes with symptoms of often causes significant damage to organ systems. impaired physical and intellectual development. Newborn screening for some such disorders, such Researchers are hopeful that new findings will as PKU, is common in the United States and many result in GENE THERAPY approaches to remedy or other countries. Early detection of PKU and many prevent the defective metabolic functions. other metabolic disorders allows treatment or See also ANABOLIC STEROIDS AND STEROID PRECUR- management, such as enzyme replacement ther- SORS; CELL STRUCTURE AND FUNCTION; EXERCISE AND apy or dietary restrictions, to prevent the condi- HEALTH; HORMONE; METABOLIC EQUIVALENT (MET); tion from causing damage. However, most genetic NUTRITIONAL NEEDS; VITAMINS AND HEALTH; WEIGHT LOSS disorders of metabolism are not curable at present. AND WEIGHT MANAGEMENT. P–R physical activity recommendations The guide- Vigorous physical activities are those which lines health and fitness experts suggest as mini- raise HEART RATE to 60 percent of maximum for 20 mum standards to maintain a FITNESS LEVEL that minutes or longer and consume 7 calories or more supports good health and reduces HEALTH RISK FAC- (eight metabolic equivalents [METs]) per minute. TORS for conditions such as CARDIOVASCULAR DISEASE Running, bicycling, swimming, cross-country ski- (CVD), type 2 DIABETES, OSTEOPOROSIS, OSTEOARTHRI- ing, jumping rope, step aerobics, aerobic dance, TIS, and OBESITY. General physical activity recom- rowing, and stair stepping are among the numer- mendations emphasize AEROBIC EXERCISE to ous activities capable of accomplishing this objec- improve AEROBIC CAPACITY because this is the foun- tive. Vigorous physical exercise is most effective dation for physical fitness. when it continues for 20 minutes or longer. Most The amount of physical activity necessary to vigorous exercise also incorporates resistance, have a positive effect on health is less than people increasing MUSCLE STRENGTH and mass as well as commonly perceive. Recent research findings supporting BONE density. demonstrate that when it comes to exercise, a lit- Meeting these recommendations increases tle goes a long way. Though more is nearly always energy expenditure by 1,200 to 1,400 calories better, the baseline recommendations for physical each week, helping with WEIGHT LOSS AND WEIGHT activity to support health are modest. To achieve MANAGEMENT. For a person striving to lose weight, and maintain a moderate fitness level health exercising at the recommended level can allow experts recommend healthy adults engage in weight loss of 18 to 21 pounds over the course of a year without a change in the number of calories • 30 minutes of moderately intense physical consumed. Exercise in combination with nutri- activity on five days of each week tious EATING HABITS that maintain dietary intake at and the recommended level further expedites weight • 20 minutes of vigorous physical activity on loss. Adding physical activity beyond these recom- three days of each week mendations, which health experts encourage, fur- ther improves physical fitness and aerobic capacity WARMUP and stretching should open and close and lowers health risk factors for HYPERTENSION every activity session, improving FLEXIBILITY and (high BLOOD PRESSURE), HYPERLIPIDEMIA, ATHEROSCLE- lowering the risk for injury. Walking is an ideal ROSIS, CORONARY ARTERY DISEASE (CAD), and INSULIN activity for exercise of moderate intensity and has RESISTANCE. the added advantage of being easy for most people Health experts recommend a minimum of 60 to incorporate into their daily lifestyle routines. minutes of moderate physical activity daily (seven Walking is also a good RESISTANCE EXERCISE, improv- days a week) for children and adolescents. ing BONE DENSITY. Short sessions, such as 5 to 10 Research findings support the belief that such a minutes at a time, that add up to 30 minutes over level of physical activity provides health benefits the course of a day are as effective as a single, con- that extend well into adulthood. Among these tinuous 30-minute sessions. benefits are strong bones, cardiovascular effi-

228 resistance exercise 229 ciency, flexible joints, and healthy BODY MASS INDEX resistance exercise Physical activity, also called (BMI). Regular physical activity during childhood resistance TRAINING, in which the muscles exert appears to further reduce risk factors for numer- effort against pressure, such as lifting weights. ous health conditions in adulthood, even when Resistance exercise, often called weight training activity eases. Children for whom daily exercise is when it involves the use of weights, enlarges and a part of lifestyle are far more inclined to maintain strengthens muscles and decreases body fat. It also physical activity as a priority in adulthood. improves the ability of the bones to retain cal- See also EXERCISE AND HEALTH; HEALTHY PEOPLE cium, maintaining BONE DENSITY and STRENGTH. 2010; METABOLIC EQUIVALENT (MET); NUTRITIONAL Resistance exercise is particularly important for NEEDS; WALKING FOR FITNESS. women over the age of 50, as BONE loss that can lead to OSTEOPOROSIS becomes a significant concern protein loading The practice of consuming after MENOPAUSE. Health and fitness experts recom- increased quantities of protein, such as in meats, mend resistance exercise two or three days a for a period of time before an athletic event. Some week, alternating with AEROBIC EXERCISE for a com- athletes who participate in activities that require prehensive fitness program. MUSCLE STRENGTH eat high amounts of protein to help build muscle mass. Though the body requires BIG MUSCLES amino acids, which it acquires from dietary pro- Some people desire and other people dread the teins, to repair and maintain tissues of all kinds prospect of bulky muscles. Conventional resist- throughout the body, including muscle tissue, a ance exercise is more likely to disappoint the for- typical diet that contains about 15 percent protein mer and please the latter. Though resistance generally meets the body’s protein needs. exercise decreases the number of fat cells in Excessive quantities of protein consumed in the MUSCLE tissue to give the muscles firmness and diet, like excesses of dietary fats and carbohy- definition, it does not generate monster muscles. drates, eventually becomes first GLUCOSE and then glycogen (short-term energy storage) and fat A methodical approach exercise physiologists (long-term energy storage). Some studies suggest call progressive overload is the key to effective that long-term excessive protein consumption resistance training. Progressive overload is the (usually of protein supplements) can strain the fil- practice of periodically increasing the difficulty of tering mechanism of the KIDNEYS and can cause resistance as MUSCLE groups develop strength and kidney damage. However, these findings are become accustomed to the established resistance inconclusive, particularly in people who have nor- level. Most people should increase resistance mal kidney function and have no significant every six to eight resistance exercise sessions, or health conditions. about every two weeks. When working with Nutrition and fitness experts recommend eating weights, progressive overload can take place by a meal that contains primarily carbohydrates and increasing the amount of weight (intensity), the protein about two hours after intense exercise or a number of repetitions (duration), or the number competitive event to help the body more quickly of sessions (frequency). Many people combine replenish the stores of glucose and amino acids it these approaches. Resistance bands, another pop- drew on during the physical activity. Most health ular method of resistance exercise, come in differ- experts do not recommend protein loading before ent resistance levels, though generally the same an event or a competition, and recommend pro- concepts of progressive overload apply. tein supplements only for people who cannot Each resistance exercise session should include obtain adequate dietary protein because of health multiple sets with rest periods of one to two min- conditions. utes between each set. Rest, which allows the See also CARBOHYDRATE LOADING; DIET AND HEALTH; muscles to recover and “learn” the exercise (mus- NUTRIENTS; NUTRITIONAL NEEDS; NUTRITIONAL SUPPLE- cle memory), is a crucial component of a resist- MENTS. ance exercise program. For most people, 20 to 40 230 Fitness: Exercise and Health minutes of resistance exercise is sufficient. Ath- loskeletal system in the same fashion as working letes in training for events or a competitive season out with weights. These activities further build may engage in longer sessions. Some people move strength and increase FLEXIBILITY. from one muscle group to the next within each session; other people focus on one muscle group RESISTANCE ACTIVITIES in each session, working a different muscle group body bar free weights the next session. pullups pushups Resistance exercise also encompasses activities resistance bands running that exert pressure against the musculoskeletal walking weight machine system, such as walking and running, which some people refer to as impact exercise. Nonimpact See also AEROBIC CAPACITY; ENDURANCE; FITNESS activities such as moderate to intense bicycling LEVEL; HEALTHY PEOPLE 2010; PHYSICAL ACTIVITY REC- and cross-country skiing challenge the muscu- OMMENDATIONS. S–T

shin splints PAIN along the tibia, the area in the See also ATHLETIC INJURIES; CONDITIONING; FLAT lower leg commonly called the shin. Shin splints FEET; SPRAINS AND STRAINS. are common among people who participate in physical activities such as walking, running, sports drinks and foods Specialty products mar- marching, and hiking. Pain is the primary symp- keted as beneficial for replenishing NUTRIENTS dur- tom, often occurring at the start of the activity, ing and after exercise. Though many people use subsiding as the activity continues, and returning these products, most do not need or derive much up to several hours after the activity ends. The benefit from them. Health and fitness experts rec- affected area of the leg is tender to the touch. ommend following nutritious EATING HABITS to Simple shin splints seldom require a doctor’s maintain the body’s level of nutrients at optimal attention; treatment is rest. Many people find ice, level and maintaining adequate HYDRATION by applied two or three times a day for 20 minutes drinking sufficient water before, during, and eases the pain. NONSTEROIDAL ANTI-INFLAMMATORY after exercise. Sports products are most helpful DRUGS (NSAIDS) can relieve INFLAMMATION. Full HEAL- for people who exercise at high intensity for ING takes three to four weeks; it is important to extended periods of time, such as those who par- avoid the responsible activity during this time. ticipate in competitive ENDURANCE events such as Substituting nonimpact activities, such as bicycling randonneuring, climbing, triathlon, or marathon. and swimming, can help maintain FITNESS LEVEL or In such circumstances, using these products to continue a training regimen during the healing supplement nutritional needs can provide a steady period. source of energy to fuel the body’s intensified Because the pain of shin splints can be intense, activity. people often worry about stress FRACTURE. Stress fracture is much less common than shin splints Products and nutritional supplements and occurs with extensive, repeated trauma over that contain ephedra (which is banned time or when TRAINING for an event bumps up the in the United States) or the Chinese level of intensity, whereas shin splints is a soft tis- herb ma huang, which are STIMULANTS, sue injury that typically occurs when starting a may cause dangerous ARRHYTHMIA (irreg- new activity after a period of inactivity. ularity of the HEART RATE). Properly fitted footwear appropriate for the activity in combination with proper technique can Many energy and sports drink products contain reduce the risk for shin splints and other repetitive high amounts of sugars, which can deliver an trauma injuries. Some people benefit from shoe energy boost in the form of simple carbohydrates. orthotics, devices that correct pronation (the angle They also deliver significant calories. Some prod- of the foot on impact). However, hard surfaces ucts also contain CAFFEINE or herbal STIMULANTS such as pavement and concrete challenge even the such as GINSENG. Sports and nutrition bars may be best footwear and technique. Rest from the activ- primarily carbohydrates as well, though some ity at the first signs of shin splints can avert products contain a mix of carbohydrates, proteins, extended down time. and fats that can provide quick nutrition when 231 232 Fitness: Exercise and Health eating other foods is impractical. It is important to in the form of increased weight or resistance to read product labels carefully. maintain their strength. See also DIET AND HEALTH. PAIN is a signal that the body has stinger An injury to the brachial plexus, the reached its limit or is injured. Stop a large NERVE cluster that branches from the SPINAL strengthening activity at the first indi- CORD to innervate the shoulder, arm, and hand. cation of pain. Rest five minutes and try the activity again. If the pain persists, An injury that causes numbness on stop the session and implement relief both sides of the body suggests SPINAL measures such as rest and ice to the CORD damage and requires immediate area. medical attention. Only medical per- sonnel should attempt to move a per- When exercising with weights it is important to son who has a possible SPINAL CORD start at an appropriate level for both the amount of INJURY. weight and number of repetitions and work up to the desired level. Excessive weight can cause injury A stinger, also called a burner, is a common and inadequate weight does not challenge the mus- injury in contact sports and occurs when a blow cles. In general, a person should be able to perform or intense pressure displaces the neck and the 8 repetitions with a particular weight, feeling some compresses the cervical nerve roots between the resistance though no PAIN with each repetition. cervical vertebrae (spinal bones in the neck). The When it becomes easy to do 12 to 15 repetitions, compression causes symptoms that include sharp the muscle group is ready for an increase in weight. burning or stinging and numbness. Though the At the new weight, start again with 8 repetitions discomfort can be severe, it generally goes away and increase as the repetitions become easier to within minutes. Occasionally symptoms may con- perform. Fewer repetitions with heavier weight tinue for up to several weeks. An isolated stinger builds muscle mass and increases strength faster leaves no residual damage, though repeated than more repetitions with lighter weight, though stingers can cause permanent damage to the the latter builds ENDURANCE. Specific weight TRAIN- nerves. The injury at the neck affects the shoulder ING regimens may have different guidelines. and arm on the opposite (contralateral) side. The body itself can become the source of See also ATHLETIC INJURIES; NEURITIS; NEUROPATHY. weight and resistance. Exercises such as curls, pushups, pullups, and squats use the body’s strength The ability of a MUSCLE to engage in weight to generate resistance against movement. physical activity, particularly resistance activity. The drawback to these exercises is that body Common measures of strength are the abilities to weight is inflexible as the source of resistance; one move weight (such as in weightlifting) or to exert cannot built up to or increase the effect. force against pressure (such as in bicycling or row- Physical activities that use large muscle groups ing). Strength improves through repetitious in repetitious activity also use the body’s weight as actions that generate force against muscle fibers as resistance against gravity (such as with walking they contract and relax, which causes them to and running) or against equipment and gravity enlarge as well as become more efficient in their (such as with cycling and rowing). Aerobic activi- use of oxygen. Muscles exposed to consistent ties such as swimming further tone muscles and exercise develop denser networks of capillaries, improve AEROBIC CAPACITY though are not as effec- facilitating rapid oxygen exchange, and larger tive for strengthening. A person can expect to see mitochondria capable of expanded functions. a 20 percent increase in strength after two months Mitochondria are the “engines” of the cell, per- and a 40 percent increase in strength after four to forming multiple metabolic tasks that allow cells six months of consistent strength training. to generate and use energy. As muscles become Many factors influence how strong muscles can stronger and larger, they require more challenge become, key among them being regular participa- training 233 tion in strengthening activities (such as RESISTANCE with incremental increases in intensity and dura- EXERCISE), FITNESS LEVEL, FLEXIBILITY, and the range tion as ability and fitness improve. It is important of motion of the joints. Additional factors that to have specific, stepped goals and methods for may become important for competitive athletes measuring progress toward them. Goals should include individual genetic characteristics and accommodate competitive as well as personal fac- physical structure, which influence the manner tors. A new runner might establish first level goals and rate at which muscle fibers contract, relax, of achieving a 12-minute mile and completing a and recover. Rest is an important element of 5-K race or organized running event, for example. resistance exercise or strength training. Most regi- Proper nutrition and HYDRATION are essential as mens alter body regions, such as upper body one well. day and lower body the next day or rotate Most people benefit from the advice of experts strengthening activities with endurance activities. in their chosen activities, such as by taking classes, Strength exercises are particularly important joining clubs, or researching training methods in for adults over age 65, helping sustain a high per- books and on the Internet. Such advice can jump- centage of LEAN MUSCLE MASS as well as to maintain start a training regimen, getting to the core of BONE DENSITY and BONE strength. Lean muscle mass methods with proven effectiveness as well as naturally declines with advancing age, with fat reducing the likelihood of injury. The most com- cells replacing muscle cells. Activity that chal- mon injuries that occur early in a training regi- lenges the muscles encourages conversion of fat to men are those related to doing too much too fast muscle, improving lean muscle mass. Changes in or to inadequate WARMUP. Such injuries are gener- HORMONE levels in the body, particularly in women ally preventable through proper technique and after MENOPAUSE, cause changes in the amounts of include MUSCLE soreness, blisters, CHAFING, and calcium in the BLOOD circulation that regulate how SPRAINS AND STRAINS. much calcium enters and leaves the bones. Regu- lar muscle activity improves calcium distribution TIPS FOR SUCCESSFUL PHYSICAL TRAINING mechanisms, keeping more calcium in the bones. • When starting a training regimen, begin slowly and aim for See also AEROBIC EXERCISE; CONDITIONING; DISABIL- steady improvement. ITY AND EXERCISE; PHYSICAL ACTIVITY RECOMMENDA- • Establish specific goals and methods for measuring progress TIONS; WEIGHT LOSS AND WEIGHT MANAGEMENT. toward them. • Start and end every training session with WARMUP exercises training The process of improving the body’s FIT- and stretches. NESS LEVEL through targeted, repetitious physical • Vary activities to let the body recover, keep interest, and activity that has specific goals. Training also may improve overall fitness. refer to the preparation necessary for an event • Increase intensity and duration in increments as ability and such as a race or a circumstance such as a sports fitness improve. season. The premise of training is to gradually • Eat nutritiously and drink water often. escalate the challenge to the muscles for improved • Enjoy the chosen activities. STRENGTH and FLEXIBILITY and to increase AEROBIC CAPACITY for improved ENDURANCE. Maintaining a Training Regimen Once a person reaches his or her desired training Building a Training Regimen level, it is important to continue varying activities A typical training regimen emphasizes preparation and intensity levels to provide a mix of challenges for the dominant activity, for example running or for the body. Some people alternate types of activ- playing tennis. Flexibility, strength, and AEROBIC ities each day, for example doing an aerobic activ- EXERCISE target measurable improvement in the ity one day and weight training or resistance activity’s performance. A runner may strive for a training the next. Other people prefer to mix it up faster pace, a tennis player may aim for a stronger within each exercise session. serve or backhand. Short, focused sessions are It is also important to let the body rest. Com- most effective at the onset of a training regimen, petitive athletes often incorporate “time off” from 234 Fitness: Exercise and Health their primary sports into their training regimens, performance level; thus may also minimize the using other activities to exercise their bodies in risk for injury. A competitive athlete may choose different ways. A runner or bicyclist may swim to consult or work with a personal trainer who and jump rope for aerobic exercise, for example. can tailor specific training activities, including Rest allows the body to heal any minor injuries as nutrition and hydration, for his or her individual well as to recover its capacity to perform, particu- needs. larly after participation in a competition or organ- ized event. Clothing, Equipment, and Technique Philosophies differ on the optimal approach to The proper clothing, equipment, and techniques final preparation for a competitive or organized are important for safety as well as performance in event. Many sports trainers recommend backing any training regimen. Every activity has special- off on training for 5 days before the event, engag- ized items that are either necessary or make the ing in light activity to keep the body flexible but activity easier and safer to perform. Safety equip- not at such a level as to exert the muscles or aero- ment, such as helmets and EYE protection, is cru- bic capacity. A bicyclist training for a century ride cial in many activities. The right clothing, such as (100 miles), for example, may do an 85- to 100- padded bicycle shorts or walking shoes, cushions mile ride 10 days before the event, ride 30 to 45 and protects the body. Proper technique is essen- miles every other day until 5 days before the tial for improvement toward performance goals as event, and not ride again until the event. A tennis well as to reduce the risk for injury. It is important player may engage in two-a-day sessions until the to choose equipment and clothing that is appro- week before a match, drop to a couple days of priate for the activity and that fits the individual. light volley practice, and then rest until the match. See also ATHLETIC INJURIES; PHYSICAL ACTIVITY REC- The premise behind this approach is to let the OMMENDATIONS; RESISTANCE EXERCISE; WEEKEND WAR- body fully recover and prime itself at its optimal RIOR. W walking for fitness A planned approach for activity sufficient to use 150 calories each day improving and maintaining overall physical fitness (1,000 calories a week). Sustained periods of exer- and health through walking. Health and fitness cise that raise the HEART RATE and BREATHING rate experts believe walking is the ideal exercise for for 20 minutes at a time or longer help develop people of nearly any age, FITNESS LEVEL, and health AEROBIC CAPACITY. BODY MASS INDEX (BMI) influences status. Walking is also an excellent component of the pace and time necessary to reach this goal. As any WEIGHT LOSS AND WEIGHT MANAGEMENT strategy. well, varying the walking pace and time achieves Everyday walking is a good means for becoming this goal in different ways depending on a person’s consistently more active. Walking for fitness takes interests and circumstances (such as time con- walking to the next level, integrating it into one’s straints). A general guideline is to increase the individual lifestyle as an activity in its own right. intensity of exercise no greater than 10 percent Though walking alone will allow most people to per week. Pushing to reach a higher level of inten- reach the minimum recommended level of physi- sity increases the risk for injury. cal activity, walking in combination with other The accompanying table shows the approxi- physical activity such as lifting weights (RESISTANCE mate energy output (number of calories burned) EXERCISE and STRENGTH exercise) and swimming or for different paces and times at representative bicycling (moderate to vigorous AEROBIC EXERCISE) BMIs for individuals at healthy weight (BMI range provides a more vigorous workout. 18.5 to 24.9), at overweight (BMI range 25 to As with any physical activity, it is important to 29.9), and at OBESITY (BMI 30 and above). The dress appropriately and plan a gradual progression higher one’s BMI, the more calories required to of pace and time. Clothing should fit comfortably perform the activity. The slower the pace, the enough to allow free movement but not be baggy. more time walking necessary to meet the mini- Fabrics that wick moisture minimize CHAFING. mum recommended daily activity level for calories Though 100 percent cotton is comfortable for consumed in physical exercise. A pedometer, a casual wear, it is not a good fabric for exercise computerized device that clips to a belt or the edge because it tends to absorb rather than wick away of a pocket, functions as a timer and counts strides moisture. Wet clothing contributes to BLISTER for- to measure pace and distance. Many pedometer mation, chafing, and chilling. There are technical models also calculate calories consumed and aver- fabrics on the market, available in casual as well as age pace. athletic styles, that pull perspiration away from See also AGING, CHANGES IN PHYSICAL ABILITY AND the body to keep the SKIN surface dry. Shoes FITNESS NEEDS THAT OCCUR WITH; BLISTER PREVENTION; should be designed for walking and fit snugly CONDITIONING; DISABILITY AND EXERCISE; OSTEOPOROSIS; without pinching or gapping. Double-layer walk- PHYSICAL ACTIVITY RECOMMENDATIONS; SHIN SPLINTS; ing socks absorb friction to help prevent blisters. WEEKEND WARRIOR. A person whose lifestyle is physically inactive may want to start with a relaxed pace of two miles warmup Stretches and light-intensity move- per hour, walking for 5 to 15 minutes at a time. ments that prepare the muscles and joints for Health experts recommend minimum physical physical activity. Warmups increase BLOOD flow to 235 236 Fitness: Exercise and Health

WALKING FOR FITNESS: APPROXIMATE ENERGY OUTPUT Walking Pace Walking Time Walking Distance Energy Used (Calories) BMI 22 BMI 27 BMI 32 (healthy) (overweight) (obesity)

1 2 mph (relaxed) 15 minutes ⁄2 mile 43.75 53.75 63.75

2 mph (relaxed) 30 minutes 1 mile 87.5 107.5 127.5

1 2 mph (relaxed) 45 minutes 1 ⁄2 miles 131.25 161.25* 191.25*

2 mph (relaxed) 1 hour 2 miles 175* 215 255

3 3 mph (moderate) 15 minutes ⁄4 mile 57.5 70 83.75

1 3 mph (moderate) 30 minutes 1 ⁄2 miles 115 140 167.5*

1 3 mph (moderate) 45 minutes 2 ⁄4 miles 172.5* 210* 251.5

3 mph (moderate) 1 hour 3 miles 230 280 335

4 mph (brisk) 15 minutes 1 mile 87.5 106.25 126.25

4 mph (brisk) 30 minutes 2 miles 175* 212.5* 252.5*

4 mph (brisk) 45 minutes 3 miles 262.5 318.75 378.75

4 mph (brisk) 1 hour 4 miles 350 425 505

1 5 mph (fast) 15 minutes 1 ⁄4 miles 137.5 170* 202.5*

1 5 mph (fast) 30 minutes 2 ⁄2 miles 275* 340 405

3 5 mph (fast) 45 minutes 3 ⁄4 miles 412.5 510 607.5

5 mph (fast) 1 hour 5 miles 550 680 810 *Passes minimum daily physical activity recommendation Source: Copyright © Amaranth Illuminare. Used by permission. the muscles, bringing more oxygen and enhancing A general approach to a warmup is to begin the ability of the BLOOD to carry away metabolic with either the feet or the head and gently move wastes, such as lactic acid, that result when MUSCLE and stretch each group of muscles, taking 5 to 7 cells contract. Fitness experts recommend 10 to 15 minutes to cover the entire body. Then spend minutes of warmup before activity and 5 to 10 another 5 to 10 minutes slowly engaging in the minutes of the same warmup routine after activ- planned activity, easing the muscles into the pat- ity. Warmup stretches and movements after activ- terns of its movements and efforts. Some people ity, sometimes called cool-down, ease the run in place for a few minutes to loosen the mus- transition of the muscles back to a less intense cles and joints. YOGA postures are effective for level. stretching and FLEXIBILITY. After the activity, repeat weekend warrior 237 the process in reverse. Spend about 5 minutes available free time by doing as much activity as going slowly through the movements of the activ- possible. The risk of injury, especially soft tissue ity, then take 5 to 7 minutes to stretch and injuries such as SPRAINS AND STRAINS, is much sequentially move the muscles in groups for the higher with this pattern of exercise. WARMUP is entire body. especially important to help relax and the muscles See also CONDITIONING; FITNESS LEVEL; HYDRATION; and prepare them for activity. Proper nutrition TRAINING. and HYDRATION before, during, and after exercise is essential. weak ankles A circumstance in which the liga- Many people slip into weekend warrior pat- ments and muscles of the ankles are lax, failing to terns because they do not have time during the provide the ankle with the stability it requires to work week to participate in exercise activities at support the body during physical exercise. Weak the same intensity level. However, even short ankles often result from physical inactivity though periods of moderate exercise improve STRENGTH, may also occur after injury or surgery to the FLEXIBILITY, and stamina to make weekend activi- ankle. Excessive body weight exacerbates the situ- ties more enjoyable as well as reduce the risk for ation. A weak ankle has a tendency to allow the injury. People who participate in competitive foot to roll inward or outward, presenting risk for events or strenuous physical activities on the sprain (stretched LIGAMENT) or ACHILLES TENDON weekends can bump up their level of daily activity INJURY. A planned program of structured exercise by running stairs, lifting hand weights, and doing to strengthen the ankle’s ligaments and muscles, stretching and strengthening exercises. The great- coupled with weight loss if indicated, improves est health benefits come from a pattern of regular weak ankles for most people. Properly fitted shoes activity. Health experts recommend daily walking that provide good support for the foot further at a minimum (30 to 45 minutes, five to seven improve the ankle’s stability. Some people benefit days a week). from wrapping or taping the ankles before activity. Some soreness and aches are reasonable to See also CONDITIONING; FLAT FEET; MUSCLE; PHYSI- expect after a weekend of intense activity or a CAL THERAPY; SPRAINS AND STRAINS; TENDON; WEIGHT competitive event. Ice or heat often provide relief. LOSS AND WEIGHT MANAGEMENT. However, most such discomforts should be gone within a day or two. Those that linger to the next weekend warrior An individual who partici- weekend or that limit function may indicate an pates in intense physical activities on the week- injury that a doctor should evaluate. ends but gets very little physical activity during See also ATHLETIC INJURIES; CONDITIONING; EXERCISE the week. There is a tendency to make the most of AND HEALTH; PHYSICAL ACTIVITY RECOMMENDATIONS. HUMAN RELATIONS

The area of human relations covers the interactions between people as those interactions affect overall health, specific health conditions, and QUALITY OF LIFE. Practitioners who provide services within human relations may be psycholo- gists, social workers, mental health nurse practitioners (MHNPs), professional counselors, school counselors, and orga- nizational development specialists.

This section, “Human Relations,” presents an the framework of culture and society, around the overview discussion of the general relationship world and across generations. They are essential between human interaction and health and to health and often play roles, directly and indi- entries about specific issues within human rela- rectly, in the development of disease. tions. The section “Psychiatric Disorders and Psy- chologic Conditions” presents entries about the Interventions to Treat or Prevent Disease health and health conditions of thought and emo- Awareness of the interactions between social rela- tion. The section “The Nervous System” contains tionships and health provides opportunity to pre- content about the health and health conditions of vent adverse effects. Stress is perhaps the classic the structures of the BRAIN and nerves. example, as much research in recent decades has illuminated the numerous and varied effects of Human Interactions and Health emotional and psychologic stress on physical The diagnostic models of many Eastern health health. Stress may arise from any aspect of systems evaluate an individual’s temperament and human relations or social settings, from family to overall circumstances in conjunction with, as well work, and may manifest through diverse expres- as on equal standing with, physical signs such as sions ranging from outwardly explosive anger or PULSE and body temperature. Interest in how peo- acts of VIOLENCE to inwardly ravaging disease ple and their interactions with one another as processes such as CVD. Sustained emotional stress well as with their environments entered the realm can maintain BLOOD PRESSURE and HEART RATE at of Western medicine’s empirical evidence model higher than normal levels for extended periods of in the 1950s when research began to confirm cor- time, potentially altering the function of the car- relations between factors such as stress and health diovascular system in negative and permanent conditions such as CARDIOVASCULAR DISEASE (CVD). ways. Recognizing and learning to manage the Other associations rapidly emerged, quantifying underlying factors responsible for such stress may and substantiating the complex relationships mitigate the physiologic and health consequences. among health, disease, attitudes, and satisfaction At the other end of the spectrum is growing with life circumstances. awareness of the extent to which a person’s spiri- Social relationships are crucial in the human tual beliefs and cultural traditions affect the per- experience, ranging from the limited though ceptions of health and disease as well as sometimes intense interactions of in the work- receptiveness to treatments. Health-care providers place to lifelong friendships to the emotionally are quick to point out that despite the astonishing and physically intimate partnerships of romantic technologic advances of recent decades, much of partners to the bonds of family. Relationships are modern medicine remains more art than science. 238 239 The Eyes Human Relations 239

How people feel about themselves, their health mately have greater significance in preventing and situations, the partnerships and relationships in treating health conditions than medications, sur- their lives, and their reasons for living may ulti- geries, and high-tech therapies. A adolescence The stage of emotional and mental and regulations, which are subject to change as a development that marks the transition from child- consequence of legislation (new laws) or legal rul- hood to adulthood, accompanying the physical ings (court cases). transition that occurs with PUBERTY. By adoles- cence an individual has the physical appearance HEALTH CONCERNS COMMON IN ADOLESCENCE and characteristics of an adult, including sexual ACCIDENTAL INJURIES ACNE maturity and reproductive capability though does ALCOHOL abuse BODY DYSMORPHIC DISORDER not yet have complete neurologic development cigarette smoking CONDUCT DISORDER and psychologic and emotional maturity. DEPRESSION EATING DISORDERS Though most of the health issues of concern in GENERAL ANXIETY DISORDER (GAD) OBESITY adolescence may occur at any age, some may be OBSESSIVE–COMPULSIVE DISORDER OPPOSITIONAL DEFIANT difficult to distinguish from the normal turbulence (OCD) DISORDER of this developmental period. The risk for some PEER PRESSURE SEXUAL ASSAULT health conditions is highest during adolescence, SEXUAL HEALTH SEXUALITY such as ACCIDENTAL INJURIES and SEXUALLY TRANSMIT- SEXUALLY TRANSMITTED DISEASES substance abuse TED DISEASES (STDS), because adolescence represents (STDS) SUICIDAL IDEATION AND a unique convergence of an intense desire to trauma SUICIDE explore adult behaviors with an immature sense unintended PREGNANCY VIOLENCE of consequences. During adolescence most Ameri- cans learn to drive, start dating, and begin work- See also PARENTING; PEER PRESSURE; SECONDARY ing, all of which are important steps in the SEXUAL CHARACTERISTICS; SEXUAL ORIENTATION; YOUTH transition to independence and adult responsibili- HIGH-RISK BEHAVIOR. ties yet expose young people to new risks. Though the general age of consent (legal adult- anger and anger management Anger is a natu- hood) is 18 in the United States (though 21 for ral, intense emotion of displeasure that represents ALCOHOL purchase and consumption), the age of an interaction between the limbic system, which consent for health-care services and medical treat- directs the body’s emotional responses, and the ment varies among states. Some states grant the frontal lobes of the cerebral cortex, which both right to receive health-care services and medical interpret information and initiate conscious treatment for certain circumstances (such as men- behavior in response. The frontal lobes are also tal health, CONTRACEPTION, PREGNANCY, and SEXUAL the source of conscious inhibition, the innate HEALTH) as early as age 14 though require the mechanisms that control extremes in emotional authorization of a parent or legal guardian for sur- expression and behavior. Anger’s expression is gery, invasive diagnostic or therapeutic proce- normal and essential and may span the spectrum dures, and most nonemergency health-care from irritation to rage. services until the child reaches age 18. Hospitals, Anger results in physiologic changes within the health-care providers, and public health agencies body. The STRESS RESPONSE HORMONAL CASCADE know the limits and constraints of applicable laws releases surges of CORTISOL, EPINEPHRINE, and NOREPI- 240 anger and anger management 241

NEPHRINE—the stress hormones. This cascade tify circumstances that trigger anger and appropri- causes BLOOD vessels throughout the body to con- ate ways of expression through approaches that strict, raising BLOOD PRESSURE. It also causes HEART may include RATE to go up and BREATHING rate to increase. These changes can take place within seconds, though the • COGNITIVE THERAPY to change the way a person body takes much longer to return to normal. thinks about anger Anger can become a personal health issue or a • BEHAVIOR MODIFICATION THERAPY to change a per- social problem when its expression is inappropri- son’s actions and behaviors ate or when it is a persistent state of being. On the health front, prolonged elevations of the stress • discussion of underlying worries, fears, and hormones can cause permanent changes in the issues that may contribute to feeling angry cardiovascular system. Numerous research studies • problem-solving and communication skills linking prolonged anger in particular with CORO- NARY ARTERY DISEASE (CAD). The suppression of People who are unable to control anger and anger can also result in physical manifestations their behavior responses through therapy may such as chronic HEADACHE, chronic gastrointestinal have a psychiatric disorder called intermittent symptoms such as NAUSEA or DIARRHEA, or clinical explosive disorder, which often improves with DEPRESSION. selective serotonin reuptake inhibitor (SSRI) med- The inappropriate expression of anger that ication treatment. The SSRIs are ANTIDEPRESSANT involves aggressive or violent words or actions MEDICATIONS that extend the presence of serotonin, may also risk the well-being of others. Such a NEUROTRANSMITTER, in the BRAIN. Serotonin is key expressions may include prolonged yelling, throw- in the movement of electrical impulses among ing things, physically fighting with others, acts of brain neurons responsible for mood and emotion. road rage, acts of VIOLENCE, and in other ways lash- Some people also benefit from alternative and ing out. ALCOHOL abuse and substance abuse often complementary approaches such as HYPNOSIS and contribute to inappropriate anger or anger expres- BIOFEEDBACK and from relaxation methods includ- sion. ing MEDITATION and YOGA. Regular physical exercise reduces stress, provides an outlet for physical ten- INAPPROPRIATE EXPRESSIONS OF ANGER sion, and induces the release of endorphins and getting into fights hitting enkephalins, biochemicals in the brain that cause passive–aggressive behavior persistent yelling or tirades feelings of pleasure. Health conditions that can placing blame pretending nothing is wrong cause changes, sometimes sudden, in a person’s reckless or erratic driving swearing and abusive anger response and anger management ability tantrums (at any age) language include serious illness or injury, STROKE, BRAIN throwing or breaking things TUMOR, degenerative neurologic conditions such as ALZHEIMER’S DISEASE, and TRAUMATIC BRAIN INJURY Anger management is the structured effort to (TBI). express anger in appropriate, constructive ways See also CHILD ABUSE; DOMESTIC VIOLENCE; ELDER through learned responses and behaviors. Thera- ABUSE; EXERCISE AND HEALTH; PROBLEM-SOLVING AND pists and psychologists can teach methods to iden- CONFLICT RESOLUTION; STRESS AND STRESS MANAGEMENT. C child abuse Actions by parents and other care- Typically an abused child experiences more givers that endanger a child’s physical and emo- than one type of abuse; emotional abuse is nearly tional well-being. Child abuse affects about 1 always a component of any other type of abuse. million children in the United States each year, Child abuse may also occur when parents or care- 1,200 of whom die as a result of the abuse they givers fail to take action to prevent harm or injury experience. In many countries child abuse is both a to the child, including intervening to stop the abu- health concern and a legal matter. In the United sive actions of another parent or caregiver. States federal law establishes basic legal criteria that define child abuse; each state further describes the Signs of Child Abuse actions that meet such criteria and may extend the Indications of child abuse may be physical or criteria to include additional circumstances of behavioral. Signs that suggest neglect and child abuse. There are four basic types of child abuse: abuse include

• Neglect occurs when the parent or caregiver • unexplained bruises, BURNS, fractures, or other fails to provide for the child’s basic needs such physical injuries as appropriate nutrition, clothing, shelter, med- • weight and size significantly less than appropri- ical care, and physical and emotional attention. ate for age Examples of neglect include grossly unsanitary living conditions, persistently depriving a child • steals food or has an extremely unhygienic of meals, locking a child in a room or out of the appearance house, and leaving a child alone and unat- • flinching, ducking, and other fearful behavior tended for extended periods of time. in response to sudden movements from adults • Physical abuse occurs when a child receives • nightmares and unusual fears injuries, regardless of whether the parent or • inappropriate sexual knowledge or behavior caregiver intended to cause harm. Examples of physical abuse include harsh physical disci- • symptoms of SEXUALLY TRANSMITTED DISEASES pline, hitting, shaking, kicking, and choking. (STDS)

• Sexual abuse occurs when there is inappropri- A sudden, unexplainable change in a child’s ate physical contact of a sexual nature between behavior is a warning sign that bears investigation a parent or caregiver and the child. Examples of because it can indicate any number of serious child sexual abuse include fondling, indecent issues, from abuse to physical illness to ILLICIT DRUG exposure, incest, and rape. USE. A child often will not acknowledge that a par- • Emotional abuse occurs when the words or ent or caregiver is abusive. Children depend on actions of the parent or caregiver impair the their caregivers and may fear retribution from the child’s sense of self and value. Examples of abuser or may not recognize that the behavior or emotional abuse include persistent threatening, situation constitutes abuse. As well, secrecy is yelling, criticizing, and ostracizing. often a key component of abuse, with the abuser 242 cultural and ethnic health-care perspectives 243 threatening the child with harm should he or she tures and ethnicities within the conventional prac- say anything to others about the abuse. tice of medicine. Factors may include language (non-English speaking), immigration status, views It is crucial that anyone who suspects a about doctors and personal privacy, and the influ- child is being abused, regardless of the ence of religious or spiritual beliefs as they relate person’s relationship to the child, notify to the reasons for illness and the role of treatment. a health-care provider or other author- The American model of medicine encourages ity. Many communities have anony- shared participation between health-care mous telephone hotlines for reporting providers and patients. This model expects suspicions of child abuse. patients to question what they do not understand. People from some cultures may expect the Detection and Intervention provider will choose the appropriate therapy and All communities have child protection agencies are reluctant to ask any questions. In other cul- and legal mechanisms to safeguard the well-being tures families make decisions about health care, of children. Most states require health-care sometimes without participation from the person providers, educators, and other adults who have who is receiving the care. These factors influence frequent interactions with children to report any patient compliance—whether the person carries suspicions or signs of child abuse. Child protection out the treatment the doctor or other health-care authorities then investigate the situation and may provider recommends. The American model of remove, temporarily or permanently, an endan- medicine also has a relative openness about per- gered child from an abusive environment or situa- sonal privacy and the sanctity of the body, facets tion. The longer the child remains in the abusive of health care that are often distressing or offen- situation, the more serious and long-lasting the sive to people of other cultures who may refuse physical and especially emotional consequences. diagnostic or therapeutic procedures unless The safety and health of the child is the priority providers are able to accommodate their customs in circumstances of neglect and abuse. However, and beliefs. because not all neglect and abuse is purposeful, Cultural competency is now part of education parent education programs that teach PARENTING and training for many health-care professionals in skills as well as nonabusive methods to manage the United States, including physicians, physician child discipline and the stress of parenting may assistants, nurses, dentists, and allied health staff. help a parent or caregiver change his or her Nearly all hospitals have translators available to behavior such that it becomes appropriately nur- overcome language barriers. About 18 percent of turing and supportive. the population in the United States speaks a pri- See also CULTURAL AND ETHNIC HEALTH-CARE PER- mary language other than English, and cultural SPECTIVES; DOMESTIC VIOLENCE; ELDER ABUSE; FACTI- and ethnic minorities collectively make up about a TIOUS DISORDERS. third of the US population. See also AYURVEDA; GENERATIONAL HEALTH-CARE cultural and ethnic health-care perspectives PERSPECTIVES; NATIVE AMERICAN HEALING; SPIRITUAL Awareness of, respect for, and accommodation of BELIEFS AND HEALTH CARE; TRADITIONAL CHINESE MEDI- the traditions, beliefs, and customs of diverse cul- CINE (TCM). D–E

domestic violence Actions and behaviors that • acts abusively or forcefully in sexual situations; use aggression, threats, and fear to control demeans partner another person in a household or partner relation- • persistently yells or argues; breaks items in the ship such as a marriage or dating. Domestic VIO- house LENCE has health as well as legal ramifications. In the United States, state laws define the parameters The priority in domestic violence is for the of behaviors that constitute domestic violence. abused person to get away from the situation, which is often difficult. There are the emotional The National Domestic Violence Hot- ties of the relationship, however dysfunctional, as line—1-800-799-SAFE (7233)—is avail- well as the practical matters of resources and able tollfree, 24 hours a day, seven days where to go. Some people are able to go tem- a week, from anywhere in the United porarily to the homes of other family members or States. friends, though sometimes others who know of the violence are reluctant to become involved. Each year more than four million American More often the circumstance is that the abused women seek medical care for injuries resulting person has told no one of the situation and is not from domestic violence. However, either partner willing to do so until a crisis precipitates action. may be the abuser. Domestic violence can exist in Most communities have public and private agen- any domestic partnership, including marriage, cies and services to support people who are nonmarried partners, same-sex partners, and dat- leaving circumstances of domestic violence. Per- ing. Surveys among American high school and manent solutions in circumstances of persistent or college students suggest violence among dating severe domestic violence are difficult and often couples, such as hitting and forced sex, is a serious require filing appropriate criminal charges against issue. the abuser as well as relocating and re-establishing Signs and indications of domestic violence in a work and life. partnership may be emotional, psychologic, physi- See also ANGER AND ANGER MANAGEMENT; CHILD cal, or a combination. Such signs may include ABUSE; ELDER ABUSE. • behaves in a jealous and possessive manner • attempts to isolate partner from family and elder abuse Actions by caregivers and family friends or monitor visits and activities members that endanger the health, well-being, and life of an older person. Many though not all • controls finances and other resources such as older people who are in situations of abuse are car keys weak or debilitated and depend on those who • constantly criticizes, uses name calling, and abuse them, making escape from the abuse diffi- humiliates cult or impossible. Elder abuse affects more than • threatens or carries out physical harm to part- two million older adults in the United States each ner, children, friends, or pets year. There are four basic types of elder abuse: 244 elder abuse 245

• Neglect occurs when family members or care- • progressive weight loss givers fail to provide for the elder’s daily needs • sunken eyes and dry, loose SKIN such as meals, appropriate clothing, assistance with bathing and toileting, administration of • DECUBITUS ULCER (bed sore) medications, and receiving medical care. • health conditions that do not respond as expected with the medications prescribed • Physical abuse occurs when the elder receives injuries or is in physical peril as a result of the • vaginal or anal discharge or bleeding actions of family members or caregivers. Exam- • SYMPTOMS OF SEXUALLY TRANSMITTED DISEASES ples of physical abuse include hitting, pushing, (STDS) exposure to water that is too hot or too cold, • evasiveness or reluctance to participate in social physical restraints, and overmedication or activities undermedication. • fearfulness or suspicion • Sexual abuse occurs when there is inappropri- ate physical contact of a sexual nature between Some conditions of old age, such as Alzheimer’s a family member or caregiver and the elder. disease, ORGANIC BRAIN SYNDROME, and stroke, may Examples of elder sexual abuse include inde- result in aggressive, combative, or otherwise chal- cent exposure, touching of the genitals or forc- lenging behavior in the older person. Such a cir- ing the elder to touch the caregiver’s genitals, cumstance complicates the picture by making it rape, and sodomy. difficult to determine who is the abused and who • Emotional and psychologic abuse occurs when is the abuser. Patterns of abuse present earlier in family members or caregivers intimidate, life, such as DOMESTIC VIOLENCE between spouses or threaten, belittle, or ignore the elder. Stealing CHILD ABUSE the elder inflicted on a now-adult from the elder, mismanaging finances, and tak- child, often continue or may reverse when the ing over control of possessions such as a home person becomes older and unable to live inde- or car are also forms of emotional and psycho- pendently. The once-abused child may turn logic abuse. against the now-dependent parent, for example.

Often the elder experiences more than one It is crucial that anyone who suspects type of abuse; emotional and psychologic abuse elder abuse report it to health-care or are almost always present with any other type of law enforcement authorities for investi- abuse. Elder abuse may also result from the failure gation. Many communities have anony- of family members or caregivers to take actions to mous telephone hotlines for reporting prevent harm or injury. Though the dynamic of suspicions of elder abuse. elder abuse is complex, it is nearly always inten- tional. Detection and Intervention Elder abuse is difficult to detect because it is possi- Signs of Elder Abuse ble for the elder to remain relatively secluded Indications of elder abuse may be obvious or dis- without raising much suspicion. Older people may creet and may be physical or manifest as emo- be reluctant to report abuse for fear of retribution tional or psychologic symptoms. Signs of elder from the abusive family member or caregiver. abuse may be difficult to distinguish from the Elderly people commonly fear any change that symptoms and consequences of health conditions might require a move to a residential care center. such as STROKE or ALZHEIMER’S DISEASE. Signs that As well, many older people have well-established may suggest elder abuse include beliefs that what happens in the family stays in the family; there would be irrecoverable loss of • unexplained bruises (especially on the wrists, pride in revealing abuse at the hands of family lower arms, and lower legs), BURNS, scalds, frac- members. There are relatively few mechanisms in tures, or other physical injuries American culture to safeguard the health and 246 Human Relations well-being of the elderly, though most states have and leaving loved ones, and legal matters such as mandatory reporting requirements for health-care medical power of attorney and other advance providers and others involved in caring for the directives. Cultural and generational factors elderly when they suspect abuse. When doctors or greatly influence end of life desires and practices, authorities do detect elder abuse, they often have though each person’s needs are unique. little choice but to remove the elder from the situ- The focus of end of life concerns sharpens ation—which is often what the elder fears most. when a person approaches the end stages of ter- One of the most effective deterrents of elder abuse minal illness. Open communication with health- is social participation—having people visit the care providers, family members, and other older person and getting the older person out to caregivers establishes clear expectations and inten- participate in social activities. This approach also tions around supportive care and medical inter- provides a break for family members and care- ventions including pain relief and resuscitative givers, relieving some of the stress that is inherent efforts. It also allows a person to make choices and in providing care for an elder. decisions about hospice and other supportive care See also GENERATIONAL HEALTH-CARE PERSPECTIVES. and to reach closure with loved ones. Sometimes family members have different ideas about what end of life concerns The fears and worries that care a loved one might want at the end of life; it is may arise when a person faces the prospect of often helpful as well as prudent to put one’s dying. End of life concerns in regard to health and wishes in writing. health care may relate to physical symptoms such See also CULTURAL AND ETHIC HEALTH-CARE PER- as PAIN and loss of function, health-care issues SPECTIVES; GENERATIONAL HEALTH-CARE PERSPECTIVES; such as feeding tubes and mechanical life support, GRIEF; QUALITY OF LIFE; SPIRITUAL BELIEFS AND HEALTH emotional concerns such as fear of the unknown CARE. G–I

generational health-care perspectives Aware- providers who specialize in meeting the unique ness of, respect for, and accommodation of the dif- needs of infants and children (pediatricians). ferent viewpoints toward health care across These doctors and other health-care providers are generations. Each generation has inherently dif- often around the same age as the parents—the ferent expectations around what medical care can middle generations—and can personally identify accomplish as well as how doctors and hospitals with some of the life circumstances and issues should provide such care. These differences in they face. The very old—the oldest see health-care expectations shape the nature and outcome of providers who similarly specialize in treating many medical interventions, from preventive to health conditions common in or unique to aging therapeutic efforts. Health-care providers must (geriatricians). These health-care providers are consider these differences when evaluating treat- often significantly younger than the patients they ment options and approaches. treat and have little personal identification with People who are today in their 80s lived much their perspectives and life circumstances. of their lives in a time when medical care was lim- Generational perspectives and perceptions ited and doctors came to them to provide care. influence the point at which an individual will Most of the drugs, surgical operations, and tech- seek medical care for a health concern, which nologies that are the mainstay of medical treat- may have significant effect on the outcome ment today were developed after 1950 and many of treatment. Many health conditions, from DIA- only since the 1980s. The elderly may view illness BETES to CARDIOVASCULAR DISEASE (CVD) to cancer, as inevitable to certain degree, expect the doctor are treatable or curable with early diagnosis and to take a leadership role in health care, and be treatment. Generational views on what informa- unknowledgeable about the ways in which tion is private and personal also affect health out- lifestyle influences health and illness. comes. By contrast, people who are today in their 30s See also ANTIBIOTIC MEDICATIONS; CULTURAL AND have lived all of their lives in a time in which ETHNIC HEALTH-CARE PERSPECTIVES; SPIRITUAL BELIEFS medicine prevents many of the illnesses that were AND HEALTH CARE; VACCINE. common causes of death in earlier generations and treats or cures nearly every sort of illness and grief Emotions and feelings, often intense, of injury. They have grown up knowing of the irretrievable loss. Grief may be a response to the health significance of lifestyle factors such as diet, loss of a loved one through death or the end of a exercise, and cigarette smoking. They may view relationship or to the diagnosis of a health condi- illness as either avoidable or curable and expect to tion that signifies the end of a certain way of liv- participate in considering options and making ing. It is natural and normal for people to mourn decisions about their health care. losses of function, potential, and other aspects of The structure of the practice of medicine to their own health as well as to grieve the prospect some extent supports generational separations of their own impending deaths. Some people also through its model of specialization. The very experience grief during significant life transitions, young—the newest generation—see health-care such as when a child leaves home. 247 248 Human Relations

Though the grieving process, also called tial degree of intimacy. Other people prefer to bereavement, consists of predictable kinds of socialize with groups in which there is no distinct responses and feelings, each person handles grief pairing or partnering. Such group relationships uniquely. The range of emotions associated with often form around common interests, ranging grief includes sadness, anger, disbelief, denial, from sports and recreational activities to religious despair, numbness, and guilt. A person may expe- beliefs and intellectual or educational pursuits. rience some or all of these emotions at varying Gender and generation also influence the ways of intensities and periods of time. Grief can be over- socialization and the nature of relationships. whelming and incapacitating, particularly at its Whatever their configuration, interpersonal onset and in circumstances of unexpected loss. relationships are essential for emotional and psy- Grief is also important for HEALING from the sense chologic health and often also for physical well- of loss. being. Numerous studies show that people who A person who is grieving may appreciate sup- live in isolation are more likely to develop psycho- port and comfort from others or may prefer to logic conditions such as depression as well as grieve in private. It is important for the grieving physical health problems. The romanticized notion person to know others are there, however. Rituals that one could die of a broken HEART becomes sub- such as funeral ceremonies are among the ways stantiated in reality in situations when people lose societies deal with grieving in communal ways. their longtime partners, particularly men whose Age, culture, and spiritual beliefs are among the wives die before them. Studies show that even many factors that influence the expression and interaction with pets improves emotional stability process of grieving. and satisfaction with life. See also DEPRESSION; END OF LIFE CONCERNS; INTER- Intentional deprivation of interpersonal rela- PERSONAL RELATIONSHIPS; SPIRITUAL BELIEFS AND HEALTH tionships, such as may occur with CHILD ABUSE, can CARE. cause lifelong and sometimes irreparable psycho- logic damage that inhibits the ability to form interpersonal relationships The partnerships friendships and intimate partnerships. Relation- and associations people form with other people. ships with parents and siblings are the first to These may include family, friendship, intimate, form. Family life provides early guidance and sexual, workplace, and social relationships. teaches the skills a person needs to develop rela- Though the need to socialize is universal, individ- tionships outside the circle of family. uals and cultures approach social bonds in differ- See also AUTISM; DOMESTIC VIOLENCE; ELDER ABUSE; ent ways. Some people prefer a few close PEER PRESSURE; PROBLEM SOLVING AND CONFLICT RESO- individual partnerships that have a fairly substan- LUTION; QUALITY OF LIFE. P parenting The functions and processes of raising approaches to provide appropriate guidelines with a child. Most people grow and change in their each developmental shift. It is important for par- roles as parents as their children also grow and ents to be aware of activities in which children change. Parents learn from their experiences and may engage that put them at risk. The increasing their mistakes. Though one’s own parents are mobility and technology of the current culture, often the most dominant role models for parent- coupled with the reality that more children than ing, new understandings about childhood devel- not today grow up in what earlier generations opment may emphasize a different approach or set would have perceived as nontraditional house- of skills for parenting today. holds, allows greater independence and access at Numerous classes and programs are available— an earlier age. many of which community agencies offer at little Parents also need to balance their careers and cost or no cost—that teach effective parenting social interests with the demands of parenting. It skills, appropriate discipline methods, and ways is important for parents to maintain time for their for coping with the unique stresses of each devel- partners and friends, though this is often a chal- opmental stage from infancy through ADOLESCENCE. lenging and sometimes daunting goal, because it Friends and peers who are also raising children helps them maintain balance overall. It is also often provide alternative ways of looking at and important for parents to be able to have time handling specific though universal situations such away from their children. As well, staying with as tantrums, defiant behavior, dating, and driving. other adults helps children develop comfort in knowing their parents can leave and will return. KEY PARENTING RESPONSIBILITIES Many parents worry that they do not give enough • provide a loving, nurturing, safe environment of themselves to the functions of parenting, partic- • provide adequate nutrition and physical activity ularly when behavior problems arise. However, • provide appropriate medical care and dental care behavior is fluid and dynamic and nearly all chil- • establish expectations and enforce limits dren engage in some behaviors that distress their • listen and respond to the perspectives and concerns the parents, teachers, and sometimes even their own child expresses friends and peers. Most child development experts • seek help when things get out of hand agree that whatever the parenting style, flexibility • encourage appropriate achievement and express pride in and the ability to “go with the flow” for at least a accomplishments short time are approaches that help children to find their bearings and move on to more appropri- Just as there are stages of development for chil- ate behaviors. Exceptions, of course, are behaviors dren, there are periods of learning and changing that threaten the safety and well-being of the for parents. The needs of children shift as they child or others, circumstances that require imme- grow and mature, and it is important for parents diate and appropriate intervention. to adapt to support and accommodate those shifts See also CHILD ABUSE; INTERPERSONAL RELATION- and the child’s increasing independence. Parents SHIPS; STRESS AND STRESS MANAGEMENT; WORKPLACE need to relearn supervision and discipline STRESS. 249 250 Human Relations peer pressure The influences of friends, See also PROBLEM SOLVING AND CONFLICT RESOLU- acquaintances, colleagues, and co-workers. Peer TION; YOUTH HIGH-RISK BEHAVIOR. pressure may be positive or negative. Though the common perception of peer pressure is of a child- problem solving and conflict resolution Skills hood and ADOLESCENCE phenomenon, the attitudes and methods to resolve differences between indi- and actions of others remain influential to varying viduals and among groups. The essence of prob- degree throughout life. One’s peers—those with lem solving and conflict resolution is to find whom a person feels relatively equal—are instru- common ground—shared values, beliefs, goals, mental in shaping compliance with societal norms intentions, and expectations. From such a plat- and behavioral standards. In the workplace peer form it is often possible to resolve differences. pressure becomes the corporate culture, for exam- There are numerous methodologies for prob- ple. Peer pressure is also a pivotal component of lem solving and conflict resolution, the appropri- the “one for all” dynamic of military training and ateness of which depends on the setting and performance. circumstances. Conflicts in the workplace require Even in adolescence, a time when individuals a different focus from problems in the classroom are particularly concerned about fitting in and or challenges in the family, even though the behaving the same as everyone else, peer pressure underlying challenges are similar. Regardless of is more often positive than negative. Friendships, methodology, there are some basic steps common because they develop from shared interests, often to nearly all settings: reinforce values and behaviors that are desirable • Isolate the problem: What—not who—accounts within the context of community or family ideals for the differences that are creating disagree- and expectations. ment and conflict? Peer pressure becomes problematic when it induces individuals to think and behave in ways • Establish a common base of expectation for res- that have negative or adverse consequences. olution: What will improve the situation? Negative peer pressure may manifest as experi- • Agree on steps that will move all parties toward mentation with ALCOHOL or ILLICIT DRUG USE, crimi- resolution: How will the situation improve? nal activity, or socially unacceptable attire and • Implement the steps, along with a process for appearance. Such manifestations are most com- assessing the success of each step. mon in adolescence because it is a time of vulner- • Reevaluate: Does the solution solve the prob- ability and searching for self-identity, but it may lem or resolve the conflict? occur at any point in life. Corrupt and illegal actions within corporations, which periodically Personalities and personal agendas often get in become prominent, represent negative peer pres- the way of objective conflict resolution. It is sure as well. important to recognize, however, that it is atti- Peer pressure is unavoidable. It is a dynamic tudes, behaviors, and actions that are responsible that shapes conformity with group, societal, and for conflict. These factors are within the ability of cultural expectations. The key is for individuals to an individual to change. People are more willing have a strong enough internal framework of to make changes when they are able to see the integrity to know when those expectations are outcome as gaining rather than giving up. inappropriate and to be able to stand apart from See also ANGER AND ANGER MANAGEMENT; STRESS them when they are. AND STRESS MANAGEMENT; WORKPLACE STRESS. S sexual assault Unwilling, unconsenting, or Health Issues of Sexual Assault forced sexual interaction. Sexual assault involves Traumatic injury resulting from forceful penetra- implied or actual use of VIOLENCE to force compli- tion, SEXUALLY TRANSMITTED DISEASES (STDS), ance and is an act of violence, not an act of sexual unwanted PREGNANCY, and emotional trauma are gratification. Sexual assault is also criminal act and the key health issues of sexual assault. Doctors has potentially serious health consequences. Rape may recommend or administer (with consent) is sexual assault in which there is attempted or emergency CONTRACEPTION when pregnancy is a completed penetration of the VAGINA, ANUS, or possibility. Doctors also typically offer ANTIBIOTIC MOUTH by the PENIS, finger, or an object. In some PROPHYLAXIS as a defense against STDs, with recom- states the legal term for penetration other than mended follow-up testing for STDs that have vaginal is sodomy. Incest is sexual assault in which longer incubation periods or are viral, such as HEP- the perpetrator is a family member and may occur ATITIS, HIV/AIDS, SYPHILIS, and GONORRHEA. as a form of CHILD ABUSE. The emotional consequences of sexual assault Women, men, and children may be the victims can be long lasting and significant. Doctors recom- of sexual assault. Those at highest risk are women mend counseling even when the person does not between the ages of 16 and 20. About 100,000 feel it is necessary. ACUTE STRESS DISORDER and POST- sexual assaults are reported to police in the United TRAUMATIC STRESS DISORDER (PTSD) are common. States each year, which health experts believe rep- Sexual assault may result in prolonged inability to resents perhaps only 1 in 4 of sexual assaults that form intimate relationships or enjoy sexual part- actually occur. Sexual assault in which the victim nerships, either in existing circumstances such as is male is even less frequently reported. marriage or in subsequent circumstances.

Legal Issues of Sexual Assault Risk Reduction Measures Though it is a natural desire to immediately bathe Because sexual assault is a criminal act of violence or shower after a sexual assault, it is crucial to first that is often random, it is not possible to com- seek medical attention. SEMEN and other bodily pletely prevent attack. However, law enforcement fluid samples are essential for identifying the per- officials recommend these measures to reduce the petrator of the assault, even when the victim risk for sexual assault knows the assailant. Hospital emergency depart- • maintain high awareness of one’s surroundings, ments often have staff (sexual assault nurse exam- particularly during times of darkness (including iners) who have special training in obtaining such early morning hours especially in the winter) samples and conducting sexual assault examina- tions that are in compliance with the standards of • when walking alone, walk at a purposeful legal evidence. Most hospitals have sexual assault stride and in the center or closer to the curb advocates and support services they contact who side of sidewalks can provide assistance for the victims of sexual • do not enter a car, home, or other setting if assault. anything about it seems suspicious

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• do not consume so much ALCOHOL when out modate sexual orientation issues and whether to with a group or on a date that it impairs one’s engage in intimate relationships. ability to take action to stop unwanted sexual See also INTERPERSONAL RELATIONSHIPS; SEXUAL advances HEALTH. • do not accept or consume “party drugs” sexuality A person’s overall attitudes, percep- See also DOMESTIC VIOLENCE; ELDER ABUSE; GAMMA tions, and expressions of sexual identity, SEXUAL HYDROXYBUTYRATE (GHB). ORIENTATION, and sexual behavior, intimate rela- tionships (whether or not those relationships sexual orientation A continuing or enduring include sexual activity). The organs of reproduc- physical and emotional attraction and sexual tion provide the physical basis for gender and sex- interest in another person. Most health experts uality. Other factors, from genetics to view sexual orientation as a continuum with biochemistry, add further layers of complexity so exclusive heterosexuality (attraction only to peo- that sexuality becomes a fundamental element of ple of the opposite sex) at one end and exclusive human existence along the entire continuum of homosexuality at the other end (attraction only to life. Sexuality plays a significant role in self- people of the same sex). Along the continuum are esteem and self-confidence, shaping how people varying degrees of mixed attraction (heterosexual perceive themselves, and how they present them- and homosexual), often called bisexuality. Sexual selves to others. orientation is distinct from an individual’s sexual Numerous health circumstances affect sexual- identity and perceptions of SEXUALITY. ity, from physical development and aging to injury Most researchers believe sexual orientation and illness. Changes in the body’s physical appear- develops in early childhood as a complex interac- ance shift awareness of sexuality at key life pas- tion of numerous psychologic, biologic, and sages such as PUBERTY, PREGNANCY, and MENOPAUSE. behavioral factors. However, some researchers Health conditions that affect physical function believe sexual orientation is purely biologic or may affect an individual’s interest in or ability to genetic, and others maintain that it is purely participate in SEXUAL INTERCOURSE and other sexual behavioral. Within these attempts to understand activity. Among such health conditions are and explain sexual orientation, nearly all OBESITY, DIABETES, CARDIOVASCULAR DISEASE (CVD), researchers agree that whatever its origins, sexual neurologic disorders, STROKE, HEART ATTACK, and orientation is not a matter of choice. The basis for CHROMOSOMAL DISORDERS such as TURNER SYNDROME this agreement is the recognition that sexual ori- and KLINEFELTER SYNDROME. Because the base of entation emerges before sexual exploration. sexuality is inherently linked to the organs of The American Psychological Association, Amer- reproduction, conditions (and their treatments) ican Psychiatric Association, American Counseling that affect those organs are often especially chal- Association, and other organizations of health- lenging to sexuality. Treatments that result in care professionals affirm that sexual orientation, physical alterations of the body, such as AMPUTA- no matter where it is along the continuum of pos- TION and MASTECTOMY, often affect the person’s per- sible expressions, is simply a dimension of individ- ceptions about his or her physical attractiveness ual experience and definition and adamantly and sexual desire. oppose efforts to change sexual orientation See also AGING, REPRODUCTIVE AND SEXUAL (notably homosexuality) through therapy and CHANGES THAT OCCUR WITH; ERECTILE DYSFUNCTION; refute claims that therapy can accomplish such an INTERPERSONAL RELATIONSHIPS; LIBIDO; SEXUAL DYS- objective. Rather, mental health professionals hold FUNCTION; SEXUAL HEALTH. that the purpose of therapy related to sexual ori- entation is to help an individual who is uncom- spiritual beliefs and health care The influences fortable with his or her sexual orientation reach a of an individual’s faith on health-care decisions level of understanding and acceptance about it, and outcomes. Spirituality is the sense of how one which may include choices around how to accom- fits within and relates to the scheme of existence, stress and stress management 253 helping define such concepts as the purpose of The Health Consequences of Excessive Stress life. Interactions between the sense of spirit, the Stress becomes problematic for health when it mind, and the body provide powerful connections exists in excess for an extended time. Sustained that shape the experiences and expressions of elevation of the stress hormones damages cells, health and well-being as well as of illness and tissues, and organs throughout the body, most injury. notably those of the cardiovascular system. Indica- Faith is often the factor that provides comfort tions of prolonged, excessive stress may include during health crises and confidence that treatment will succeed. Numerous studies show correlations • irritability, moodiness, or outbursts of anger between positive outcomes in serious illness or • worry, crying, or panic attacks injury and directed manifestations of belief such as • difficulty sleeping, sleeping too much, or feel- prayer circles, HEALING ceremonies, and spiritual ing that sleep is not restful rituals. In some cultures spiritual practices are • PALPITATIONS inseparable from healing. A person’s faith or reli- gion (a particular belief structure) may also be the • frequent HEADACHES source of acceptance in chronic or terminal health • gastrointestinal distress such as NAUSEA, VOMIT- conditions. ING, or DIARRHEA As well, religious or spiritual beliefs may guide • increased APPETITE or loss of interest in eating the kinds of health-care decisions, including diag- nostic procedures and treatments, individuals Elevated cortisol alters the body’s ability to pro- make. For example, a religion’s doctrines may duce and use INSULIN, which affects METABOLISM of proscribe FERTILITY testing, CONTRACEPTION, or the lipids. Researchers believe this contributes to receipt of donor BLOOD (BLOOD TRANSFUSION) or HYPERLIPIDEMIA and resulting ATHEROSCLEROSIS and organs. may play a role in the development of type 2 DIA- See also AYURVEDA; CULTURAL AND ETHIC HEALTH BETES. Excessive stress may also exacerbate chronic CARE PERSPECTIVES; MEDITATION; MIND–BODY CONNEC- health conditions such as HYPERTENSION (high blood TION; NATIVE AMERICAN HEALING; PRAYER AND SPIRITU- pressure), INFLAMMATORY BOWEL DISEASE (IBS), MULTI- ALITY; TRADITIONAL CHINESE MEDICINE (TCM). PLE SCLEROSIS, PARKINSON’S DISEASE, and DIVERTICULAR DISEASE. stress and stress management Stress is any fac- tor that alters equilibrium. Stress management is Inappropriate Stress Relief Efforts the effort to manage stress to maintain equilib- People sometimes turn to ALCOHOL, cigarette smok- rium. Stress is a constant and necessary dimension ing, and drugs (legal as well as illicit) to relieve of life. Stress can be physiologic, psychologic, or stress. Though these approaches may provide emotional and often exists in combination. relief in the short term, they can have numerous Physiologic stress maintains vital bodily func- adverse effects on health over the long term. Alco- tions such as BREATHING, HEART RATE, and BLOOD hol is a mild depressant, acting to slow NERVE PRESSURE. The STRESS RESPONSE HORMONAL CASCADE impulses and neuron function in the brain. instigates the “fight or flight” response that mobi- Though occasional and moderate alcohol con- lizes the body’s resources. The key HORMONE of this sumption does not present health issues for most cascade is CORTISOL, which the ADRENAL GLANDS people, long-term use of alcohol for stress reduc- secrete. Cortisol influences or regulates numerous tion is both counterproductive and damaging to physiologic functions, either directly or through health. Chronic alcohol consumption has numer- the release or suppression of other hormones such ous deleterious effects on the body, from LIVER and as EPINEPHRINE and NOREPINEPHRINE. It also initiates nerve damage to increased risk for STOMACH CAN- HEALING, stimulating the IMMUNE RESPONSE, and CER, LIVER CANCER, cognitive dysfunction, memory focuses NEUROTRANSMITTER release and NEURON com- impairment, and impaired healing. Tobacco, munication in the BRAIN to intensify cognitive though regular smokers feel it calms them, con- function. tains NICOTINE, a powerful and addictive stimulant. 254 Human Relations

The calming effect of smoking a cigarette is more See also ACUTE STRESS DISORDER; ALCOHOLISM; COG- that of quieting the addictive need than genuine NITIVE FUNCTION AND DYSFUNCTION; GENERALIZED ANXI- relaxation. ETY DISORDER (GAD); MEMORY AND MEMORY IMPAIRMENT; POST-TRAUMATIC STRESS DISORDER (PTSD); Methods to Manage Stress WORKPLACE STRESS. The most effective means of managing excessive stress is to reduce its sources to the extent possi- support groups People who have in common ble. This may require evaluation of the demands specific health-care conditions, either as patients of work, family, and other commitments to priori- or family members and caregivers, who meet to tize them. Much excessive stress results not so provide information and a safe environment for much from an individual source but from the dialogue about fears, worries, expectations, and cumulative effects of multiple demands. Some- other concerns. Hospitals and health organizations times simply the process of evaluation reveals often maintain support groups, providing meeting potential for change. Though it may not be possi- space, structured meeting times, and sometimes a ble to eliminate the source of the stress, it often is doctor, nurse, therapist, or other health-care possible to mediate, through various techniques, provider to serve as moderator or host when the its ability to cause stress. A key dimension of stress group meets. Other support groups are casual and management is the ability to gain control over the may meet in a member’s home or social setting on circumstances of stress, including personal either a regular or an ad hoc (as-needed or spon- responses to it. taneous) basis. A less traditional though sometimes more acces- sible type of support group is one that communi- EFFECTIVE METHODS FOR STRESS RELIEF cates through Internet forums and message boards. ACUPUNCTURE AROMATHERAPY Such online venues allow people to share their BIOFEEDBACK BREATHING EXERCISES comments and questions any time. Some also fea- COGNITIVE THERAPY LABYRINTH ture scheduled presentations from specialists who MEDITATION physical exercise provide information and answer questions. prayer TAI CHI See also PSYCHOTHERAPY; STRESS AND STRESS MAN- VISUALIZATION YOGA AGEMENT. V–W

violence Actions of aggression that cause inten- • punching, hitting, or choking others in “fun” tional harm to others. Violence may be targeted or • disparaging attitudes and comments toward random and may occur in the workplace, at individuals, ethic groups, or organizations (such school, or in the home (DOMESTIC VIOLENCE). Vio- as schools, employers, or the government) lence is a leading cause of injury and death in the United States, accounting for nearly two million Depending on the person’s behavior, age, and hospital emergency visits and 20,000 deaths a other circumstances, the appropriate authorities year. Homicide is also the leading cause of death may be able to intervene to thwart potential acts among pregnant women, claiming about 2,000 of violence. PSYCHOTHERAPY and BEHAVIORAL MODIFI- lives each year. CATION THERAPY may help individuals replace vio- Those most vulnerable to injury and death due lent reactions and behaviors with behaviors that to violence are young people, primarily men, are more appropriate; therapy can help individuals between the ages of 15 and 24, for whom homi- understand what causes the feelings of frustration cide is the second leading cause of death (and or anger that are often behind their violent leading cause of death among African Americans). actions. Psychotherapy and COGNITIVE THERAPY may Firearms (mostly handguns) account for nearly help people who have experienced violence to two thirds of all homicides in the United States. develop constructive COPING MECHANISMS. The most common form of violence against young See also ACCIDENTAL INJURIES; ANGER AND ANGER people is date violence—actions such as hitting, MANAGEMENT; CHILD ABUSE; ELDER ABUSE; SEXUAL choking, and forced sex. Youth gangs are also ASSAULT; STRESS AND STRESS MANAGEMENT; SUICIDE often violence oriented. IDEATION AND SUICIDE. The long-term consequences of violence include physically disabling health conditions such workplace stress Tension and pressure among as TRAUMATIC BRAIN INJURY (TBI) and SPINAL CORD co-workers in the work environment or within INJURY, which often result in permanent BRAIN individuals as a consequence of work demands. In damage or PARALYSIS. Psychologic conditions such the work environment people must work as ACUTE STRESS DISORDER, DEPRESSION, GENERALIZED together, often in collaborative ways, with people ANXIETY DISORDER (GAD), PHOBIA, and POST-TRAUMATIC they might otherwise not associate. Though many STRESS DISORDER (PTSD) are also common among employers attempt to foster good relationships people who have experienced violence. among employees, co-workers may have little in Efforts to reduce violence include recognition common beyond specific work qualifications and of warning signs that a person may be inclined job skills. More than 25 percent of workers in the toward violence or is planning an act of violence. United States consider work the most significant Such signs may include source of stress in their lives. About 60 percent of work absenteeism is directly attributable to stress. • outbursts of extreme anger or rage Issues in the workplace may include co-work- • talk of committing acts of violence ers who do not get along with one another, people • possession of weapons or destructive devices who do not pull their share of the workload, 255 256 Human Relations heavy workloads, tedious or repetitious work, families have only a single parent, resulting in sig- demanding customers, and short staffing. As well, nificant stress around child care arrangements and people may work in jobs that are not a good expenses. Even among families in which both par- match for their needs and interests—because such ents work, parents find it necessary to juggle work a job may pay more than a better-suited job, offer responsibilities and child needs such as illness, more lenient time away to deal with children, health-care appointments, and school activities. have health insurance benefits the person or fam- Unmitigated work stress has numerous conse- ily needs, or be the only work available in a par- quences for both physical and psychologic stress. ticular location. Physical danger inherent in Stress-related physical conditions may include fre- certain jobs also establishes a high level of emo- quent headaches, IRRITABLE BOWEL SYNDROME (IBS), tional stress. and ACCIDENTAL INJURIES. Work stress may also con- tribute to various psychologic conditions in which FACTORS THAT CONTRIBUTE TO WORKPLACE STRESS stress is a significant factor. An extreme of work automation stress is burnout, in which a person may experience child care issues symptoms such as PALPITATIONS, trembling, sleep dis- complex, time-sensitive work tasks turbances, and unprovoked outbursts of anger. co-worker conflict The most effective solutions for work stress downsizing and corporate restructuring combine changes in the work setting with stress family demands management methods. Many people may benefit heavy workload from career counseling to help them determine inability to make decisions about work tasks what kinds of work or jobs might be more appro- lack of privacy priate for their interests and abilities. Sometimes it noisy work environment is necessary to change jobs to relieve work stress. repetitious or tedious work Other approaches may include identifying one work unsuited to interests specific problem at work that causes stress and coming up with possible solutions. Work responsibilities are often in direct compe- See also ANGER AND ANGER MANAGEMENT; OCCUPA- tition with family responsibilities for a person’s TIONAL HEALTH AND SAFETY; SOMATIZATION DISORDER; time and interest. About 40 percent of American STRESS AND STRESS MANAGEMENT; VIOLENCE. SURGERY

Surgery is the specialty within the practice of medicine in which its practitioners use instruments, devices, and tech- niques to repair or remove organs and structures affected by congenital defect, injury, or disease processes. Surgical operations are invasive—that is, they enter or open the body in some way.

Two health-care disciplines merge within the therapeutic purposes—has long been among the arena of surgical operations: ANESTHESIA and sur- treatment options of physicians. Ancient gery. Physicians who administer anesthesia are Ayurvedic physicians extracted cataracts, ampu- anesthesiologists (MDs or DOs). Registered nurses tated limbs, delivered babies by CESAREAN SECTION, who have advanced practice education and certifi- drained pus from infected wounds, removed blad- cation in anesthesiology are certified registered der stones, and even performed what plastic sur- nurse anesthetists (CRNAs). Anesthesiologists geons today call pedicle flap tissue grafts to repair may also choose to further specialize in PAIN man- damaged noses. Greek physicians operated on sol- agement care. diers to repair battle wounds. In Babylonia and Physicians who perform surgical operations are Egypt surgeons were distinct from physicians, surgeons, with further designation according to the with clearly defined duties and responsibilities. surgeon’s subspecialization. For example, a sur- Toward the end of the 19th century vastly geon who operates exclusively on structures of the improved understanding of anatomy (the body’s chest except the HEART is a thoracic surgeon; a sur- structure) and physiology (the body’s functions) geon who operates exclusively on the heart is a encouraged physicians to explore the intentional cardiac surgeon. A surgeon who operates exclu- opening of the body to remove tumors and repair sively on bones and joints is an orthopedic surgeon. damage such as from injury or disease. Nearly all This section, “Surgery,” presents an overview of the misconceptions perpetuated through cen- discussion of the concepts and practices of surgery turies evaporated in the evidence researchers and general entries about surgical operations and acquired through scientific study and dissection of their role in diagnosis and treatment of diseases, human cadavers. Surgeons boldly ventured into congenital anomalies, and injuries. Entries about new territory: the inner body. Unfortunately, specific operations are in the sections that discuss though surgeons had the knowledge their patients the relevant body system—for example, the entry were less than eager to allow its display. Few will- for HYSTERECTOMY (an OPERATION to remove the ingly submitted to the scalpel when the only UTERUS) is in the section “The Reproductive Sys- escape from pain was a fortuitously well-placed tem” and the entry for CHOLECYSTECTOMY (an oper- upper right to the jaw that delivered UNCONSCIOUS- ation to remove the GALLBLADDER) is in the section NESS. As well, more people died of INFECTION after “The Gastrointestinal System.” surgery than recovered from the operation. But in the 20th century two advances in medi- Surgery Comes of Age cine converged to make surgery feasible: antisep- Early documents from diverse cultures provide sis and anesthesia. As a result of these two crucial evidence that surgery—entering the body for developments, today surgery is the treatment of 257 258 Surgery

first choice for numerous health circumstances. operations and dental procedures. Over the latter Surgical operations can restore and improve func- decades of the 19th century surgeons refined the tion, improve appearance, repair the damage of mechanisms for delivery of anesthetic agents to traumatic injury, replace dysfunctional organs and provide relatively predictable and safe anesthesia structures, remove tumors and infected tissue, and during surgery. In the 1880s surgeons experiment- correct potentially life-threatening congenital ing with controlled delivery of anesthetic agents anomalies. Surgeons in the United States perform had developed valve-controlled inhalers and the more than 25 million operations a year. precursor of the endotracheal tube, a tube inserted into the trachea with an air-filled cuff on the end SURGERY NOMENCLATURE: TYPES OF OPERATIONS to hold it in place and seal the trachea. By 1930 Term Ends In Operation Is to endotracheal intubation had become the standard -ectomy remove a body part or segment of tissue method for administering inhalation anesthesia, as -ostomy establish a passage between two structures it remains today. -otomy open an area of the body Modern anesthetic agents are faster acting, -plasty repair or reconstruct a body part more specific in the effects they achieve, and much safer than their predecessors. Though Anesthesia: Making Surgery Painless unpleasant side effects remain possible, anesthesia Until the middle of the 19th century surgery was a for most people accomplishes precisely and only treatment of last resort, chosen only when the only the intended purpose. Anesthesiologists and certi- alternative was certain death. The most effective, fied nurse anesthetists (physicians and registered albeit unpredictable, anesthesia was a surprise nurses, respectively) who specialize in the delivery uppercut punch to the jaw that could render a per- of anesthesia, carefully administer anesthesia tai- son unconscious long enough for a fast surgeon to lored to each individual patient’s needs and health complete an operation such as extraction of a bullet circumstances. or AMPUTATION of a limb. ALCOHOL and opium were the drugs of choice for postoperative pain relief. Antisepsis: Making Surgery Safe The first effective anesthetic agent was ether, Though surgeons knew all too well the high rate administered by having the person breathe fumes of death after surgery, it was an obstetrician rather as they evaporated from a saturated cloth. Though than a surgeon who made the connection chemists had compounded ether (sulfuric acid dis- between antisepsis and death rates among tilled in alcohol) since the 13th century and patients. Hungarian physician Ignaz Philipp Sem- explored it as a solvent and a sedative for cen- melweis (1818–1865) noticed that the death rate turies, its properties as an anesthetic did not in the maternity ward was much higher among become known until chemistry students in the women cared for by doctors than by midwives. His early 1800s began using it for entertainment at investigation led him to recognize that doctors parties. Their instructors observed that the more often went directly from performing autopsies ether a person inhaled, the more impervious he or (procedures in which midwives had no role) to she was to pain. But not until the middle of the delivering babies. In 1846 Semmelweis imple- century did surgeons begin to explore using ether mented procedures for doctors to wash their to intentionally intoxicate an individual to create a hands with chlorinated lime before examining state of unconsciousness. In 1842 American physi- obstetrical patients, and maternal death rates from cian Crawford Long (1815–1878) used ether to childbirth FEVER (puerperal fever) plummeted. anesthetize a friend, then surgically removed sev- It was 20 years later that Louis Pasteur eral cysts from the friend’s neck. The friend felt no (1822–1895) and Joseph Lister (1827–1912) pain and had no memory of the surgery. proved the connection between microscopic Discoveries of similar properties for chloroform “germs” and illnesses such as infection, and by the and nitrous oxide rapidly expanded anesthesia 1870s antisepsis was the standard of practice not options. These substances were more effective and only for childbirth but also for surgery and other less noxious than ether and soon displaced it for treatment modalities. Today surgeons and other Surgery 259 members of the surgical team follow stringent HAND ous health conditions, revolutionizing care as well WASHING (scrubbing) procedures, and wear sterile as survival for heart disease, cancer, CONGENITAL gowns and gloves in the operating room. The wide- ANOMALY, and major trauma. OPEN HEART SURGERY spread use of ANTIBIOTIC MEDICATIONS has further and ORGAN TRANSPLANTATION are now conventional reduced the risk for postoperative infection. treatment options. Among the most exciting advances in surgery in recent years has been the THE SURGERY TEAM evolution of MINIMALLY INVASIVE SURGERY, operations A typical surgery team today includes the that use tiny video cameras to display the opera- • primary surgeon tive site on a monitor similar to a television • assisting surgeon or physician assistant; may be several screen. The surgeon operates using the display for depending on the type of operation visual guidance, much like a sophisticated video • scrub nurse or surgery technician (also called surgical game. Through small incisions, called ports, the technologist) surgeon inserts tiny instruments. Minimally inva- • circulating nurse sive surgery reduces the need for large, open inci- • anesthesiologist or certified nurse anesthetist sions, decreasing patient discomfort and recovery • perfusionist for certain surgeries time. Operations that were once major ordeals have become fairly minor procedures. Surgeons Breakthrough Research and Surgical Advances look forward to a future in which minimally inva- The last half of the 20th century saw surgery surge sive surgery becomes the standard for nearly all to the forefront of treatment options for numer- kinds of operations. A–E

ambulatory surgery Surgery, sometimes called See also ANALGESIC MEDICATIONS; ENDOSCOPY; same-day or outpatient surgery, in which the per- LASER SURGERY; POSTOPERATIVE PROCEDURES; PREOPERA- son comes to the hospital or AMBULATORY SURGERY TIVE PROCEDURES; SURGERY BENEFIT AND RISK ASSESS- FACILITY the day of the surgery, has the OPERATION, MENT; WOUND CARE. and goes home without an overnight stay in the hospital. Often the operation uses MINIMALLY INVA- anesthesia The intentional establishment of loss SIVE SURGERY procedures such as endoscopic meth- of PAIN sensation or of consciousness to make a ods (laparoscopy, arthroscopy), which greatly surgical OPERATION possible. Anesthesia may be reduce the size of the incision and the amount of local, regional, or general, depending on the oper- trauma the body experiences during operation. ation and on the individual’s health circumstances Minimally invasive surgery techniques allow a and preferences. Doctors sometimes use local and rapid course of recovery in the immediate postop- regional forms of anesthesia to treat severe or erative period as well as over the longer term. CHRONIC PAIN not related to surgery. Surgeons also can perform numerous OPEN SUR- Anesthesia today is very effective as well as GERY procedures on an ambulatory surgery basis. safe. There are several types of anesthesia and People tend to feel more comfortable recovering numerous anesthetic agents. The anesthesiologist in their own homes and often require lower doses or anesthetist selects the types and agents accord- of PAIN medications during their recovery. As well, ing to the operation and the person’s health con- a shorter stay reduces the risk for NOSOCOMIAL ditions and health status, and may combine types INFECTIONS (infections acquired from exposure to and agents to achieve the desired anesthetic effect. BACTERIA in the hospital environment) and more The risks of anesthesia vary with the type and quickly returns a person to regular activities. agent though are generally minimal. Because each person’s rate of recovery is Individual response to anesthetic agents varies, unique, some people more quickly return to CON- so the anesthesiologist or anesthetist very closely SCIOUSNESS from sedation or general ANESTHESIA and monitors the person’s vital signs and level of anes- to function from regional anesthesia to engage in thesia throughout the operation. After the opera- basic activities such as drinking fluids and going to tion monitoring continues in the postanesthesia the bathroom. Underlying health conditions also care unit (PACU), also called the recovery room, influence how quickly a person is ready to leave until the person has emerged from anesthesia after ambulatory surgery. Hospitals and ambula- enough to go to a hospital room or for discharge tory (outpatient) surgery facilities are equipped home (AMBULATORY SURGERY). and staffed to handle medical emergencies that may arise and are prepared for a person to stay Local Anesthesia overnight in a hospital should circumstances war- Local anesthesia numbs a small area of the body for rant additional care or observation. The person minor operations such as removal of a LIPOMA returns to his or her surgeon for follow-up care (benign tumor of fatty tissue) or NEVUS (SKIN lesion such as wound check, suture removal, and dress- such as a mole). The surgeon generally administers ing changes. local anesthesia by injection into and surrounding 260 anesthesia 261 the site of the operation. Local anesthetic agents • spinal, in which the anesthesiologist or anes- block the ability of neurons (NERVE cells) to send thetist administers a single injection of the nerve signals, preventing the perception of pain. anesthetic agent directly into the CEREBROSPINAL Some local anesthetic agents contain EPINEPHRINE, a FLUID around the spinal cord to block sensation vasoconstrictor that reduces bleeding. from the point of injection downward for oper- The effect of a local anesthetic may last from 20 ations on the abdomen and lower extremities minutes to 12 hours or longer, depending on the agent and the extent of infiltration of the area. Many of the anesthetic agents are the same for Surgeons sometimes use local anesthetic to infil- regional anesthesia as for local anesthesia. As trate the area of an operative site at the end of the occurs with local anesthetics, a small amount of operation to provide extended pain relief. Sur- the anesthetic agent enters the blood circulation geons may combine local anesthesia and conscious and can cause mild effects such as HEADACHE or TIN- sedation to reduce anxiety and improve the per- NITUS (ringing in the ears). These effects generally son’s level of comfort during and after the opera- go away within an hour. Because caudal, epidural, tion. Some amount of a local anesthetic enters the and spinal anesthesia affect the pelvic region and BLOOD circulation and can cause sensations such as the muscles of the BLADDER, the surgeon may lightheadedness or a feeling that the lips are instruct placement of a urinary catheter until the buzzing. anesthetic wears off. The surgeon may sometimes leave the epidural catheter in place for 24 to 48 COMMON LOCAL AND REGIONAL ANESTHETIC AGENTS hours for postoperative administration of light benzocaine bupivacaine chloroprocaine anesthesia or ANALGESIC MEDICATIONS for pain relief. etidocaine lidocain emepivacaine Regional nerve blocks, caudal anesthesia, and prilocaine procaine ropivacaine epidural anesthesia may take up to 20 minutes to tetracaine become effective. Spinal anesthesia takes effect immediately. Though regional anesthesia blocks Regional Anesthesia only the sensory nerves, movement of the anes- Regional anesthesia is an injection that infiltrates thetized region is difficult because the lack of sen- nerves to blocks pain signals from a large area of sation makes the affected body parts feel heavy the body. An anesthesiologist or anesthetist and uncontrollable. A person has adequately administers regional anesthesia. The most com- recovered from regional anesthesia when he or mon forms of regional anesthesia include she can safely walk or regains preanesthesia sen- sation or movement of the affected area. • regional nerve block, in which the anesthesiol- Complications are rare with regional anesthesia ogist or anesthetist administers a single injec- though may include prolonged labor during CHILD- tion of the anesthetic agent into or around a BIRTH, irritation or bleeding at the injection site, major nerve to block sensation from the fin- drop in BLOOD PRESSURE, and post-anesthesia gers, hand, arm, toes, foot, or leg headache (with epidural or spinal anesthesia). • caudal, in which the anesthesiologist or anes- Infection and injury to the nerves are possible thetist administers a single injection of the though extremely rare. Recovery from regional anesthetic agent into the caudal canal in the anesthesia is generally uneventful and fairly rapid. sacrococcygeal (tailbone) region of the spine to block sensation in the pelvis and perineum Conscious Sedation • epidural, in which the anesthesiologist or anes- Conscious sedation alters a person’s awareness of thetist places a thin catheter into the space sur- pain and activities taking place to and around him rounding the SPINAL CORD and injects the or her. With conscious sedation a person generally anesthetic agent, potentially as a steady flow or can answer questions, respond to instructions, and repeated times, to block sensation from the tell the doctor whether he or she is experiencing point of injection downward for operations on pain or discomfort though has little or no memory the lower abdomen and lower extremities of the operation and events surrounding it when 262 Surgery full consciousness returns. Surgeons often use that oxygen and anesthetic gases directly enter the conscious sedation to improve a person’s comfort lungs. General anesthesia is the standard for oper- and reduce anxiety during minor operations, usu- ations on the upper abdomen and chest as well as ally in combination with local or regional anesthe- for many major orthopedic operations. In some sia. Usually an anesthesiologist or anesthetist circumstances the anesthesiologist may combine administers the sedative medication intravenously epidural or spinal anesthesia with general anes- with ongoing monitoring of the person’s response thesia. Many general anesthesia agents are fast to the medication, level of awareness, and vital acting and short lived, allowing rapid anesthetic signs such as BREATHING rate, HEART RATE, and blood induction as well as quick recovery. pressure. Rarely, a person may experience NAUSEA or COMMON GENERAL ANESTHETIC AGENTS headache after conscious sedation. More rarely, a Inhaled person may have distressing memories of the enflurane halothane isoflurane operation. Though a person appears to return to methoxyflurane nitrous oxide normal consciousness quickly, the medication may remain at a level in the blood circulation that Injected affects perception and function for 24 hours after etomidate KETAMINE methohexital its administration. Doctors caution people to avoid propofol thiopental driving or performing activities that require alert- ness and coordination for at least 24 hours after Sophisticated equipment allows precise and conscious sedation. safe administration of inhaled anesthetics, includ- ing ongoing adjustments of carbon dioxide and POTENTIAL DRUG INTERACTIONS WITH ANESTHESIA oxygen concentrations. The anesthesiologist or Many prescription medications, OVER-THE- anesthetist continuously monitors the person’s COUNTER (OTC) DRUGS, NUTRITIONAL SUPPLEMENTS, vital signs, including breathing rate, oxygen satu- and MEDICINAL HERBS AND BOTANICALS can interfere ration, heart rate, blood pressure, and body tem- with anesthesia or BLOOD clotting. It is important perature. The most common side effects of general to tell the surgeon of all such medications and anesthesia are nausea, VOMITING, a slow return to products. The surgeon or the anesthesiologist normal bowel activity, and a prolonged sense of may request the person to stop taking certain grogginess. The anesthesiologist or anesthetist can drugs or herbs for a period of time before and administer medications to ease or relieve these sometimes also after surgery. symptoms. Sore throat is a common complaint after general anesthesia, a consequence of the General Anesthesia endotracheal tube. General anesthesia establishes a state of deep Though most general anesthetic agents do not UNCONSCIOUSNESS in which the anesthetic agents persist in the body at functional levels beyond 24 circulate in the body to block pain signals, prevent to 36 hours, many people feel they are not quite movement, and block memory of the operation. themselves for several days after general anesthe- The anesthetic agents may be gases the person sia. Postoperative analgesic medications can exac- inhales or medications (such as sedatives, hyp- erbate this perception. Walking, to the extent notics, and MUSCLE relaxants) the anesthetist or possible, and stool softeners help BOWEL MOVEMENT anesthesiologist injects intravenously. An endotra- return to normal. Allergic reaction to anesthetic cheal tube inserted through the MOUTH, into the agents is uncommon but occurs, so it is important THROAT, and to the top of the trachea allows the to tell both the surgeon and the anesthesiologist anesthesiologist to seal the airway to prevent for- or anesthetist of any allergies, including to foods. eign matter from entering the LUNGS, as the anes- Smoking, certain prescription medications, ILLICIT thetic suppresses the COUGH REFLEX that would DRUG USE, and ALCOHOL consumption affect the normally keep mucus and debris from entering ways in which various anesthetic agents function the trachea. The endotracheal tube also ensures in the body. bloodless surgery 263

recipient. Pretransfusion testing can detect most It is important to avoid driving or but not all of these scenarios. Autodonation also engaging in activities that require ensures the availability of blood for people who focused attention (including making have uncommon blood types. important decisions and signing legal See also ANTIBODY; BLOOD TRANSFUSION; BLOOD documents) until it is clear that the TYPE. effects of general anesthesia have com- pletely worn off. bloodless surgery Specialized techniques that allow surgeons to perform major operations to A rare but potentially life-threatening complica- avoid the need for BLOOD TRANSFUSION. Many peo- tion of general anesthesia is malignant hyperther- ple oppose BLOOD transfusion on the basis of reli- mia, in which the person’s body temperature rises gious beliefs and others because they have rapidly and high, muscles become rigid or SPASM, concerns about the safety of donated blood. and heart rate and blood pressure vacillate wildly Though stringent screening and testing procedures and widely. Doctors believe malignant hyperther- for donated blood have minimized the risk of mia has a genetic foundation because it occurs in acquired INFECTION from the US blood supply, a families, though the precise genetic involvement slight risk of this remains for whole blood and cer- remains unknown. Death as a complication of gen- tain blood products. eral anesthesia, though possible, is very rare. Performing surgery when blood transfusion is Continued advances in anesthetic agents and not an option requires careful planning. When the administration techniques are improving the expe- OPERATION is elective (nonemergency) the person rience and safety of general anesthesia. can prepare by taking medications such as ERY- See also NEURON; POSTOPERATIVE PROCEDURES; PRE- THROPOIETIN (EPO) to boost his or her ERYTHROCYTE OPERATIVE PROCEDURES; SURGERY BENEFIT AND RISK (red blood cell) production and donating his or ASSESSMENT; WOUND CARE. her own blood in advance of the surgery for use if a transfusion becomes necessary. Having more blood autodonation A practice in which a per- erythrocytes means the blood can carry more oxy- son donates his or her own BLOOD for potential gen, which encourages HEALING. It also allows the self-use during a major OPERATION or health emer- surgeon to administer intravenous fluids during gency such as major trauma. The hospital or blood surgery to maintain adequate fluid volume with- bank stores the blood for specific and sole use by out concern for diluting the blood to the extent the person. The person may authorize the hospital that ANEMIA develops. or blood bank to release the blood for general use During the operation, whether elective or as components (such as ALBUMIN and PLASMA) if he emergency, the surgeon can use methods to col- or she does not require it, though guidelines vary lect any blood the person loses, filter it, and return according to the procedures in place for collecting it to the person instead of transfusing donor blood. autodonated blood. Testing procedures for Surgeons also use precision techniques that mini- autodonated may be less stringent than for gen- mize blood loss when they perform bloodless eral BLOOD DONATION because only the donor will operations. Sometimes these techniques are time receive the blood. consuming, which makes the surgery more Most people who choose autodonation do so expensive. However, many of the surgical tech- out of concern about the potential for INFECTION niques surgeons use for bloodless surgery have such as HEPATITIS acquired from general donation become standard for all operations of the same blood. Though screening procedures and tests type because they reduce the risk for postopera- make the blood supply as safe as possible, the risk tive infection and encourage more rapid healing of such infection remains a possibility. Autodona- and recovery. tion also eliminates the risk for transfusion reac- Emergency bloodless surgery can be more of a tion, which may occur when donor blood carries challenge, particularly when there are bleeding antibodies that activate an IMMUNE RESPONSE in the injuries that deplete the blood supply even before 264 Surgery surgery begins. Fluid expanders sometimes can See also BLOOD AUTODONATION; SPIRITUAL BELIEFS maintain the body’s fluid level without impairing AND HEALTH CARE. the blood’s ability to carry oxygen. Bloodless sur- gery techniques and blood recycling become endoscopic surgery See MINIMALLY INVASIVE SUR- essential when the operation is an emergency. GERY. L–M

Langer’s lines The natural linear pathways, also • directional and concentrated called cleavages, of the fasciae fibers (connective tissue layer beneath the SKIN that covers the mus- There are different types of lasers, classified cles) throughout the body. Langer’s lines resemble according to the mechanism by which they pro- a topographic map when overlaid on an outline of duce lightwaves, the length of the lightwaves, and the human body. Each person has a unique con- the pattern of emission (continuous or pulsed). figuration of Langer’s lines, though general pat- The different wavelengths and pulse patterns of terns are common across individuals. Alignment emitted light permit targeted use of lasers from with relevant Langer’s lines is one of several fac- making incisions (cutting) to treating discol- tors a surgeon considers when planning an OPERA- orations of the SKIN such as a port wine stain TION’s incision. Surgical incisions that parallel BIRTHMARK. The laser’s lightwave determines what Langer’s lines tend to require less suturing and to tissues will absorb the light and what tissues will heal with less obvious scarring than incisions that allow the light to pass through them. For exam- run counter, and particularly perpendicular, to ple, the BLOOD in blood vessels absorbs the yellow Langer’s lines. Wounds from cuts or punctures are light of the pulsed laser, though the pigment of often more severe when they occur in opposition light-colored skin does not. Most lasers emit light- to Langer’s lines, tending to gape and tear more waves in the infrared spectrum; the “cool” lasers than wounds that parallel Langer’s lines. The RASH emit lightwaves in the ultraviolet spectrum. or eruptions of some skin conditions, such as Laser lightwaves, like other lightwaves, can PITYRIASIS rosea, follow Langer’s lines. travel via fiberoptics, allowing the surgeon to See also DERMATOME. direct the laser emission to a specific location, even one that is deep within the body. Laser sur- laparoscopic surgery See MINIMALLY INVASIVE SUR- gery requires the surgeon to complete specialized GERY. training and requires specialized equipment and facilities for safe use. laser surgery Any OPERATION in which the sur- Surgical lasers have increased options in all geon uses a device that focuses high-intensity areas of surgery but have revolutionized two areas lightwaves that generate heat to cut or ablate of treatment in particular: ophthalmologic (EYE) (destroy) tissue. Laser is an acronym for “light surgery and dermatologic (skin) surgery. The sur- amplification by stimulated emission of radiation.” geon can so precisely focus and target the laser’s Lasers came into common use in medicine and beam that any incidental damage to surrounding surgery in the 1960s; the first applications were tissue is nearly nonexistent. Laser surgery inci- for the repair of detached RETINA. sions tend to heal with minimal scarring. The heat The lightwave emission of a laser differs from the laser generates kills BACTERIA on the skin at the ordinary light because it is incision site, reducing the risk for postoperative INFECTION. As well, the intense heat instantly seals • all one wavelength (monochromatic) blood vessels to reduce bleeding at the site of the • organized and unified incision, making the surgical laser the instrument 265 266 Surgery

TYPES OF SURGICAL LASERS Laser Type Characteristics Surgical Application argon gas shallow penetration dermatologic procedures moderately hot refractive surgery (vision correction) only pigmented tissues and fluids absorb the coagulate bleeding BLOOD vessels lightwaves

carbon dioxide (CO2) shallow penetration instead of scalpel for incisions very hot vaporize tissue (including tumors) only pigmented fluids absorb the lightwaves dermatologic procedures such as SKIN resurfacing neodymium:yttrium- aluminum garnet (Nd:YAG) deep penetration fiberoptic transfer to locations within the body moderately hot vaporize or shrink tumors all fluids in the body absorb the lightwaves remove pigmented lesions remove tattoos pulsed dye shallow penetration port wine stain and other vascular birthmarks moderately hot tunable wavelength

of choice for BLOODLESS SURGERY as well as for treat- See also LASER SKIN RESURFACING; MINIMALLY INVA- ing vascular disorders of the skin such as birth- SIVE SURGERY; OPEN SURGERY; PHOTOTHERAPEUTIC KERA- marks. TECTOMY (PTK); REFRACTIVE SURGERY; SURGERY BENEFIT AND RISK ASSESSMENT; TATTOOS. Because the intense light the laser gen- erates can burn the RETINA and cause minimally invasive surgery Any OPERATION in permanent blindness, people undergo- which the surgeon uses an endoscope and special- ing laser surgery as well as the surgeon ized instruments to enter the body through small and other members of the surgical team incisions, called ports. An endoscope is a lighted, must wear EYE protection when the flexible tube with a tiny camera at the tip that laser is in use. sends visual images of the operative site to a mon- itor similar to a television screen. The endoscope is Laser surgery has the same risks as conven- specialized for the procedure, such as a laparo- tional surgery for bleeding and infection, and car- scope for operations within the abdominal cavity. ries additional risk for BURNS and related damage. The surgeon watches the images on the screen A laser can permanently discolor the skin, particu- rather than seeing the operative site directly. Min- larly the skin of people of color (notably African imally invasive surgery is in contrast to OPEN SUR- Americans, Asian Americans, and Hispanic Ameri- GERY, in which the surgeon makes an incision cans). Lasers may also cause burns of the skin. large enough to allow direct access to the opera- Though laser surgery makes many operations eas- tive site. Surgeons must receive specific training in ier and more comfortable, it is important to the minimally invasive procedures they perform, choose a surgeon who is qualified to perform laser which require special equipment and instruments. surgery and to fully understand the potential ben- Surgeons sometimes combine minimally invasive efits and risks of laser surgery compared to con- procedures with LASER SURGERY, assisted open sur- ventional surgery. gery, or other operative techniques. minimally invasive surgery 267

Recovery time is typically faster and less painful case with any surgery, minimally invasive proce- than with open surgery as there is less intrusion dures carry some risk for ANESTHESIA complications, into the body. Many minimally invasive surgery bleeding, and INFECTION. operations are ambulatory surgeries that do not See also AMBULATORY SURGERY; ENDOSCOPY; SUR- require an overnight stay in the hospital. As is the GERY BENEFIT AND RISK ASSESSMENT. O

open surgery Any surgical OPERATION in which with minimally invasive surgery. As well, recovery the surgeon makes an incision that allows direct and recuperation take longer with open surgery, access to the operative site. An open surgery inci- generally 4 to 12 weeks, depending on the type of sion may be quite large. Until the emergence of operation. Open surgery may also leave a more MINIMALLY INVASIVE SURGERY procedures in the 1980s noticeable SCAR after HEALING. open surgery was the standard of surgical treat- See also ANESTHESIA; LASER SURGERY; SURGERY BEN- ment for nearly all operations. Surgeons today can EFIT AND RISK ASSESSMENT. perform many operations with minimally invasive techniques, reserving open surgery for circum- operation A surgical procedure to enter the stances in which the surgeon needs the broad body and conduct a repair, remove a tumor, or in exposure open surgery provides. Such circum- some other way alter a structure or organ. A sur- stances include OPEN HEART SURGERY for operations gical operation takes place under sterile conditions such as CORONARY ARTERY BYPASS GRAFT (CABG) and in a controlled environment, an operating room, heart valve replacement, open THORACOTOMY for used exclusively for surgery. Minor operations operations on the LUNGS, open laparotomy for may take place in AMBULATORY SURGERY centers and major operations on the structures of the specialized surgical clinics; major operations take abdomen such as the GALLBLADDER and intestines, place in hospitals that have sophisticated facilities and ORGAN TRANSPLANTATION. Common risks of any and experienced staff to provide care before, dur- surgery include bleeding and INFECTION, which are ing, and after surgery. Though traditionally the somewhat more likely with open surgery than term surgery has applied to the medical specialty of

COMMON SURGICAL OPERATIONS Surgical Operation Purpose adenoidectomy remove chronically infected and enlarged adenoids

APPENDECTOMY remove an inflamed or infected APPENDIX

ATHERECTOMY remove ATHEROSCLEROTIC PLAQUE deposits from within arteries

BLEPHAROPLASTY repair or reconstruction of the eyelids

CHOLECYSTECTOMY remove the GALLBLADDER colectomy remove part or all of the COLON

COLOSTOMY create a passage from colon through the abdominal wall

268 operation 269

Surgical Operation Purpose craniotomy operations on the BRAIN and related structures, PITUITARY GLAND cystectomy remove the urinary BLADDER

ENDARTERECTOMY remove an occlusion from an ARTERY

EPISIOTOMY incision to widen the vaginal opening during CHILDBIRTH

GASTRECTOMY remove part or all of the STOMACH hernioplasty repair of a HERNIA

HYSTERECTOMY remove the UTERUS

LAMINECTOMY remove a vertebral disk laparotomy operations on structures of the abdomen such as the intestines, LIVER, appendix, uterus, OVARIES, FALLOPIAN TUBES

LARYNGECTOMY remove the larynx lobectomy remove a lobe of the LUNGS

MASTECTOMY remove a BREAST

NEPHRECTOMY remove a kidney nephrotomy remove a tumor or remove kidney stones

OOPHORECTOMY remove ovaries

ORCHIECTOMY remove a testicle

OTOPLASTY repair or reconstruction of the outer EAR pneumonectomy remove an entire lung

PROSTATECTOMY remove the PROSTATE GLAND resection remove (excise) a portion of a structure

RHINOPLASTY repair or reconstruction of the NOSE

RHYTIDOPLASTY repair or reconstruction of the face (facelift) salpingectomy remove a fallopian tube

SPLENECTOMY remove the SPLEEN 270 Surgery

Surgical Operation Purpose THORACOTOMY operations on structures within the chest except the HEART tonsillectomy remove chronically infected and enlarged tonsils

TRACHEOSTOMY create a passage from the TRACHEA through the surface of the neck

TYMPANOPLASTY repair or reconstruction of the TYMPANIC MEMBRANE (eardrum)

VASECTOMY remove a segment of the VAS DEFERENS

surgery, many people now use the terms operation Organ Allocation and Acquisition and surgery interchangeably. Organ transplantation transitioned from experi- See also ARTHROSCOPY; BARIATRIC SURGERY; CARDIAC mental to mainstream in the 1980s, riding a wave CATHETERIZATION; CATARACT EXTRACTION AND LENS of technologic advances and the success of REPLACEMENT; CESAREAN SECTION; ENDOSCOPY; JOINT cyclosporine, the first effective immunosuppres- REPLACEMENT; LASER SURGERY; MINIMALLY INVASIVE SUR- sive DRUG. In 1984 the US Congress passed the GERY; MOHS’ SURGERY; PLASTIC SURGERY; REFRACTIVE National Organ Transplant Act (NOTA), which SURGERY; SURGERY BENEFIT AND RISK ASSESSMENT; TUBAL established the Organ Procurement and Trans- LIGATION. plantation Network (OPTN) to ensure consistency and equity in the allocation of deceased donor organ transplantation The surgical replacement organs. OPTN is a not-for-profit organization that of a nonfunctioning vital organ with a functional is a collaborative union of public and private organ acquired from a donor. Most donor organs organizations. The United Network for Organ are allogeneic, also called deceased donation or Sharing (UNOS) administers OPTN under contract cadaver donation, in which a specialized surgical to the US Department of Health and Human Ser- team removes the donated organs after a person’s vices. Hospital transplant programs across the death when the person has previously authorized, United States determine a person’s eligibility for or when the person’s family authorizes at the time transplantation, then submit the person’s name of the person’s death, organ donation. In some cir- and health data (such as organ needed and blood cumstances a person may make a living organ type) to the UNOS database. donation to another person, such as for kidney, A regional organ procurement organization lung lobe, and partial LIVER. US surgeons perform (OPO) receives notification from hospitals and almost 27,000 organ transplantations each year, other health-care providers when deceased donor nearly 7,000 of which are organs from living organs become available within its geographic donors. The most commonly transplanted organs boundaries. The OPO coordinates the effort to are KIDNEYS and livers. However, approximately match the organs with appropriate donors, initiat- 89,000 people remain on waiting lists for donor ing a “match run” from the UNOS database. The organs. match run identifies prospective transplant recipi- ents waiting for the particular kind of organ, the medical urgency of the transplant need, the gen- TRANSPLANTED ORGANS AND TISSUES eral health circumstances, and the geographic BONE MARROW CORNEA HEART proximity of the donor organ to the prospective ISLETS OF LANGERHANS cells kidney LIVER recipient. The matched names go on a list for lung PANCREAS SKIN the organ, ranked in order of need. UNOS gener- SMALL INTESTINE stem cells ates a new match run each time an organ becomes organ transplantation 271 available, specific for each kind of organ, so a Life after Transplantation waiting recipient may appear on several lists and The course of recovery after transplantation varies in different rankings relative to others on the with the organ transplanted, age, and overall same list. health circumstances. Most organ transplant recip- The available organ goes to the waiting recipi- ients are able to return to previous work, recre- ent who is the best match on as many criteria as ational, and lifestyle activities they enjoyed before possible. For organs such as the HEART and LUNGS, experiencing the health circumstances that made geographic proximity is a critical factor because their transplants necessary, usually within two to the window of opportunity for transplantation is three months. Transplant recipients do require so short. Body size may be important for organs ongoing medical assessment and care, which may such as the liver, heart, and lungs. Typically gen- consist of doctor visits every few weeks for the der and ethnicity or race are not factors for vascu- first 6 to 12 months after the transplant and every larized organ transplants unless they influence 6 to 12 months indefinitely, depending on the body size. Financial status is not a consideration organ transplanted and general health status. under any circumstances. Living donor transplants The key health risks after transplantation are are not subject to OPTN/UNOS procedures but primary organ failure and organ rejection. Primary rather are coordinated privately between the organ failure occurs when the organ does not donor and the recipient. function after transplantation. The organ may start to function and then stop or may never begin Organ Transplantation Surgery functioning. Some organs, such as the kidneys, Transplantation of vascularized (solid) organs is may take several weeks to several months to start major surgery that may require the organ recipi- functioning or to function normally, which is the ent to be prepared for surgery within hours of usual course of events for them and does not nec- notification that an organ is available. Time is essarily indicate that the transplant has failed. It is especially critical for heart, lung, and heart–lung not unheard of for a kidney transplant recipient to transplantation. In most transplant operations the require renal hemodialysis after the transplant surgeon transplants a single organ. Combination OPERATION, and hemodialysis remains a therapeutic transplantations are becoming more common, option when a transplanted kidney does fail. Pri- however, with surgeons transplanting together mary organ failure of the heart, lungs, or liver is a heart and lung, SMALL INTESTINE and liver, or kid- medical emergency that requires retransplantation ney and pancreas. The operation to transplant a as soon as possible. Numerous and often collusive single organ may take three to five hours; combi- factors may account for primary organ failure of a nation transplants may take longer. The transplant transplant. recipient may remain hospitalized for several Organ rejection occurs when the recipient’s weeks after surgery, depending on the organ, rate IMMUNE SYSTEM produces antibodies that attack the of recovery, and overall health status. transplanted organ and is a process rather than an With some organs, such as kidneys, the sur- event. Every transplant experiences rejection to geon can leave the native organ in place and some degree because rejection represents the transplant the donor organ in an adjacent loca- body’s natural IMMUNE RESPONSE. Organ rejection tion. This is a heterotopic transplant. The surgeon may be acute or chronic. Acute rejection develops may also choose to remove the recipient’s native, rapidly and may present symptoms similar to a diseased organ and transplant the donor organ in viral INFECTION such as the flu, though often there its place, such as the liver. This is an orthotopic is tenderness or PAIN at the site of the transplant. transplant. One approach is not necessarily easier Acute rejection requires immediate medical treat- or more effective than the other for either the sur- ment with immunosuppressive agents to attempt geon or the recipient. Circumstances that shape to subdue the immune response and minimize the decision include the recipient’s general health damage to the organ. Episodes of acute rejection status, anatomic characteristics, and the organ are common in the first year after transplantation being transplanted. and can occur months to years later. A single 272 Surgery episode of acute rejection is seldom enough to organ donation for himself or herself; a parent or cause organ failure, especially when treatment is legal guardian must authorize organ donation for prompt. a person under the age of 18. It is also a good idea for a person who desires to donate his or her IMMUNOSUPPRESSIVE AGENTS organs after death to let a close relative or friend TO MINIMIZE ORGAN REJECTION know of this intention. Such knowledge eases the Induction and Antirejection (up to 30 days) decision-making process family members may face. Atgam basiliximab Doctors must follow accepted standards of prac- daclizumab methylprednisolone tice for determining when BRAIN DEATH (irre- muromonab CD3 rapamycin versible loss of complete BRAIN function) has Thymoglobulin occurred or the person is pronounced dead, after Maintenance (long-term) which they may seek the family’s permission to azathioprine cyclosporine proceed. The removal of donated organs, called mycophenolate mofetil prednisone organ retrieval or organ harvesting, takes place in rapamycin tacrolimus an operating room under sterile conditions. The window of opportunity for transplanting a Chronic organ rejection represents the steady donated organ ranges from 4 hours after harvest- and slow consequences of the immune system’s ing for a heart, 6 hours for lungs, 12 hours for efforts to eliminate the organ, which the immune liver, and to up to 24 hours for a kidney. Special system perceives as an “intruder.” At present the preservative solutions and methods (such as pul- standard of treatment to minimize organ rejection satile perfusion, which moves chilled preservative is lifelong IMMUNOSUPPRESSIVE THERAPY, taking drugs fluid through the organ) help keep organs viable that suppress the immune response. Doctors mon- until transplantation. itor immune status and transplanted organ func- tion with regular BLOOD tests. The risks of NO COST FOR DONOR ORGANS AND TISSUES long-term immunosuppression include increased Federal law in the United States prohibits buying vulnerability to infection (such as COLDS, flu, and and selling human organs and tissues. Organs OPPORTUNISTIC INFECTIONS), which may require and tissues for transplantation must come from ANTIBIOTIC PROPHYLAXIS or ANTIFUNGAL MEDICATIONS. donors. The expenses associated with organ Long-term immunosuppression also increases the transplantation are those of medical care before risk for lymphoma and MULTIPLE MYELOMA, two and after the transplantation and for the trans- cancers of the immune system; when detected plant operation and its related costs (such as for early these cancers are easily treatable. Immuno- hospitalization). There is no cost for being on the suppressive agents also have numerous drug inter- organ donor registry or for donor organs and tis- actions and potential side effects. sues.

Organ Donation Surgeons carefully remove organs to preserve Nearly anyone can be an organ donor. Most US them as intactly as possible. Harvesting of hearts states incorporate organ donation permission on and lungs must be take place before the heart stops, driver’s licenses. A driver’s license is the most which requires certification of brain death and common form of identification Americans carry, often life support to maintain oxygenation and and MOTOR VEHICLE ACCIDENTS are the most com- BLOOD circulation until the organ retrieval team can mon cause of unexpected death. As well, organ remove them. When doctors cannot use the entire donation authorization forms are available at hos- organ, they sometimes can make use of key parts. pitals, medical centers, doctor’s offices, public For example, a heart that has significant myocar- health departments, and other providers of dial damage due to HEART ATTACK may have healthy health-care services. Some states also have donor valves, which doctors can harvest for heart valve registries. A person age 18 or older can authorize replacement. There is no cost to the person’s family organ transplantation 273 for harvesting donated organs, nor is there disfigu- tion updates about organ donation and a down- ration of the donor’s body. Under US medical confi- loadable organ donor card. Another Web site dentiality laws, the donor remains anonymous to (www.transplantliving.org) provides comprehen- the recipient and the recipient remains anonymous sive information from OPTN/UNOS about the to the donor’s family. entire organ transplantation process, from eligibil- Availability of donor organs remains the most ity for transplantation to life after receiving a significant challenge for organ transplantation, transplant. which has become the standard of care for END- See also ANESTHESIA; BLOOD TRANSFUSION; CIRRHO- STAGE RENAL DISEASE (ESRD), end-stage HEART SIS; EPSTEIN-BARR VIRUS; GRAFT VERSUS HOST DISEASE; FAILURE, and end-stage LIVER FAILURE. The need for HEART TRANSPLANTATION; ISLET CELL TRANSPLANTATION; donor organs is about four times greater than the KIDNEY TRANSPLANTATION; LIVER TRANSPLANTATION; availability. The US government maintains a Web LUNG TRANSPLANTATION; SKIN REPLACEMENT; SURGERY site (www.organdonor.gov) to provide informa- BENEFIT AND RISK ASSESSMENT. P patient controlled analgesia (PCA) The postop- pass elective operations, the US health-care sys- erative self-administration of intravenous (IV) PAIN tem considers reconstructive surgery to be med- relief (analgesic) medication. PCA requires an IV ically necessary; therefore, health insurance plans (a thin catheter inserted into a VEIN), a PCA pump typically pay for reconstructive operations. Cos- that contains a special syringe with the pain med- metic surgery operations are not medically neces- ication, and a PCA control button. Each time the sary and health insurance plans seldom pay for person depresses the PCA button the PCA pump them. releases a certain amount of pain medication from In some circumstances the nature of a plastic the syringe into the IV. Most people feel pain relief surgery operation overlaps between cosmetic and within a few minutes of pressing the button. reconstructive. For example, a person may desire The PCA pump can release medication only RHINOPLASTY (NOSE alteration) because of dissatisfac- according to the amount and frequency for which tion with the nose’s appearance, though the sur- it is programmed, no matter how often the person geon’s examination leads to the discovery that the presses the button, so there is no danger of receiv- person also has a deviated septum, which affects ing too much. An alarm on the PCA pump notifies BREATHING and the health of the SINUSES. A person nursing staff when the amount of medication in may seek plastic surgery to alter the perception of the syringe gets low or when there is any disrup- aging that arises from drooping eyelids, and then tion of the pump’s proper function. The PCA discover the eyelids obscure the field of vision. pump may also be programmed to deliver a steady flow of pain relief medication, with extra medica- Reconstructive Surgery tion released with the button as the person needs Reconstructive surgery rebuilds missing or lost it to maintain comfort. structures with the goal to restore function. The Numerous studies show that people tend to loss may be due to numerous factors that include have less anxiety about postoperative pain and CONGENITAL ANOMALY, traumatic injury, BURNS, dis- pain relief and use less pain relief medication with ease processes, and surgical treatment for condi- PCA. As well, appropriate pain control facilitates tions such as cancer. Reconstructive surgery is faster HEALING. Within a few days after an OPERA- often complex and requires multiple operations to TION most people are able to switch to oral (by achieve the desired result. Reconstructive opera- MOUTH) pain medications. tions performed in childhood may need revision See also ANALGESIC MEDICATIONS; SURGERY BENEFIT as the child grows. Reconstructive surgeons may AND RISK ASSESSMENT. coordinate care and treatment with surgeons and physicians in other specialties such as orthopedics plastic surgery Any surgical OPERATION to alter (bones and connective tissues) and neurology the appearance of a body area or part. Plastic sur- (nerves). Doctors often request a plastic surgeon gery may be reconstructive (re-creates or repairs a to suture or otherwise repair LACERATIONS and body part that is damaged or missing) or cosmetic wounds to the face or hands. Plastic surgeons per- (changes physical appearance for reasons of per- form about five million operations a year in the sonal preference). Though both disciplines encom- United States. 274 postoperative procedures 275

MOST COMMON RECONSTRUCTIVE OPERATIONS tion with the results. It is crucial to thoroughly

BREAST reconstruction CONGENITAL ANOMALY reconstruction understand what the operation can and cannot laceration repair operations on the hands and fingers accomplish and the full spectrum of potential SCAR revision tumor removal complications and risks; it is equally important to select a qualified (board-certified) plastic surgeon Cosmetic Surgery who is experienced in performing the desired Cosmetic surgery alters appearance for aesthetic operation and who performs surgeries in an reasons and can have profound psychological and appropriately credentialed and licensed facility. emotional benefits. US plastic surgeons perform more than nine million cosmetic surgery proce- PLASTIC SURGERY OPERATIONS dures a year, with Americans spending more than abdominoplasty augmentation mammoplasty $8 billion to have them performed. Surveys sug- BIRTHMARK removal or BLEPHAROPLASTY gest people who undergo cosmetic surgery are reduction body contouring generally satisfied with the results, perceiving brachioplasty BREAST reconstruction improvements in self-image and social interac- brow lift cervicoplasty tions. Realistic expectations are especially impor- facial implants HAIR transplantation tant when making cosmetic surgery decisions. laceration repair LASER SKIN RESURFACING Some cosmetic operations, such as RHYTIDOPLASTY lip augmentation lipoplasty (facelift), have long-lasting though not permanent liposuction mastopexy effects because the SKIN and connective tissues mentoplasty OTOPLASTY continue to undergo natural changes with aging. panniculectomy platysmaplasty POLYDACTYLY correction and reduction mammoplasty MOST COMMON COSMETIC OPERATIONS reconstruction RHINOPLASTY abdominoplasty augmentation mammoplasty RHYTIDOPLASTY SCAR revision BLEPHAROPLASTY body contouring after significant sclerotherapy SKIN graft liposuction weight loss SYNDACTYLY release tissue flap surgery RHYTIDOPLASTY See also BARIATRIC SURGERY; BOTULINUM THERAPY; Plastic Surgery Benefits and Risks CHEMICAL PEEL; DERMABRASION; HAIR TRANSPLANTATION; The benefits of plastic surgery often encompass LASER SURGERY; SMOKING CESSATION; SURGERY BENEFIT improved function, appearance, and self-image or AND RISK ASSESSMENT; WOUND CARE. self-esteem. Specific benefits vary with the opera- tion and often are not entirely apparent for weeks postoperative procedures The events that take to months after the operation when HEALING is place to guide a person’s safe and comfortable complete. As with all operations, plastic surgery recovery from ANESTHESIA and to initiate effective operations entail risk. General risks include exces- PAIN relief after a surgical OPERATION. When the sive bleeding during or after surgery, postoperative operation is over the person goes to a postanes- wound INFECTION, PNEUMONIA (a complication of thesia care unit (PACU) where staff monitor vital general ANESTHESIA), unpredictable SCAR formation, signs (HEART RATE, BREATHING rate, BLOOD PRESSURE, and unsatisfactory or unexpected results. Death and body temperature) and emergence from anes- during or as a complication of plastic surgery is thesia. A person who has had regional or general very rare though can occur. Cigarette smoking, anesthesia may remain in the PACU for two to DIABETES, and PERIPHERAL VASCULAR DISEASE (PVD) can four hours, until he or she regains the ability to limit peripheral BLOOD circulation, slowing healing use the anesthetized region of the body or regains and increasing the risk for complications. CONSCIOUSNESS. It is not possible for the surgeon to guarantee It is common and normal to feel disoriented the outcome of a plastic surgery operation. People when first coming out of anesthesia. Many people sometimes have unrealistic expectations for what who have had general anesthesia do not realize the operation can achieve, leading to dissatisfac- the operation is over. It is also normal to feel 276 Surgery chilled and to experience discomfort, numbness, • consultation with the anesthesiologist or anes- or pain. The surgeon may infiltrate the operative thetist to determine the optimal anesthesia site with a local anesthetic to provide localized choices for the person’s health status and the pain relief for 12 to 24 hours after the operation planned operation or place tiny catheters in the surgical wound to • health insurance preauthorization or financial instill a continuous irrigation of a local anesthetic arrangements for extended pain relief. Most often the person is already receiving analgesic medications to relieve The doctor will provide instructions about not pain and generally receives PATIENT CONTROLLED eating for a specified period of time before the ANALGESIA (PCA) during the recovery period. When scheduled operation, and about taking any daily fully stable the person may go to a room in the medications on the day of the operation. hospital, if an overnight stay in the hospital is nec- essary, or home to recover and recuperate. Before Before signing informed consent docu- discharge the PACU staff provide instructions for ments, it is crucial to fully understand WOUND CARE, pain management, possible complica- the scope of the planned OPERATION, the tions such as unusual bleeding, and follow-up expected benefits of the operation, the appointments with the surgeon. anticipated course of recovery, and pos- See also PREOPERATIVE PROCEDURES; SURGERY BENE- sible complications and risks of the FIT AND RISK ASSESSMENT. operation and of the ANESTHESIA.

The events that take preoperative procedures Most people arrive at the AMBULATORY SURGERY place to prepare a person for a surgical OPERATION. FACILITY or hospital surgery unit several hours Preoperative procedures for elective (nonemer- before the scheduled time of the operation. In gency) operations may begin several days to a preparation for the operation, a person undresses week before the scheduled surgery with activities and puts on a surgical gown. The preoperative such as nurse starts an intravenous (IV) infusion to main- • preoperative consultation with the surgeon or a tain HYDRATION and to administer medications. Sur- member of the surgeon’s staff to discuss the gical staff may apply electrodes to the chest to preparations for surgery, including any revi- monitor HEART RATE, place a BLOOD PRESSURE cuff sions to routine medications, dietary restric- around the arm to monitor blood pressure, and place a PULSE oximeter over the tip a finger to tions, LAXATIVES or ENEMA, or SKIN-cleansing procedures as well as expectations for the oper- monitor blood oxygenation. Some surgical facili- ation’s outcome and the anticipated recovery ties allow a family member or close friend to be period present during these early preparations. The sur- geon or assistant surgeon often visits the person • signing of informed consent documents that before sedation or anesthesia begins to confirm specify, in detail, the planned operation and the the person’s identity, the planned operation, and reasons for it, the scope of surgery the surgeon the location of the operative site (such as left leg may perform, and the operation’s possible com- or right BREAST). Other staff may also make these plications and risks same confirmations to prevent errors. Many sur- • routine BLOOD tests to assess blood cell counts, geons use a marking pen on the skin to identify HEMOGLOBIN level, COAGULATION (clotting) times, the operative site. As the time for the operation to LIVER function, and kidney function begin draws near, most people receive a sedative • possible chest X-RAY, ELECTROCARDIOGRAM (ECG), for relaxation and comfort. and other diagnostic testing, depending on the See also POSTOPERATIVE PROCEDURES; SURGERY BEN- operation and the person’s health status and age EFIT AND RISK ASSESSMENT. S surgery benefit and risk assessment Objective The surgeon who will perform the operation evaluation of the reasons and expectations for a should be qualified and experienced. Many hospi- surgical OPERATION. Surgery is a common therapeu- tals are teaching centers where surgical residents tic approach today, with surgeons in the United (trained physicians who are learning advanced States performing more than 25 million opera- skills in surgery) participate in operations. They do tions a year. Risks and complications related to so under the direction and close supervision of the surgery and ANESTHESIA have declined dramatically primary surgeon. Teaching hospitals are required over the past three decades, making surgery one to obtain signed permission for staff who are in of the safest and most effective treatments for training (physicians, nurses, and ancillary staff) to many health conditions. However, surgery is often participate in care delivery, including surgery. As not the only therapeutic option for a particular well, for most operations the surgeon has at least condition or health circumstance. It is important one other surgeon assisting him or her. A person to fully understand should know who will actually be performing the operation and the other doctors who will be assist- • the specific operation the surgeon recommends ing because these are factors that may influence and why the outcome of the surgery. • the expected benefits of the operation Surgery Benefits • other surgical operations that might also treat The benefits of surgery are numerous and mostly the problem specific to the planned operation. In general, sur- • the possible nonsurgical treatments for the con- gery corrects or repairs defects, injuries, functions, dition or appearance. Surgery may be lifesaving, as in • the potential risks of the operation itself major trauma or CORONARY ARTERY BYPASS GRAFT (CABG), and is the first line of treatment for many • how the operation’s risks compare to the risks forms of cancer. Surgery may also be palliative, of other treatment options (including nontreat- such as to reduce pain, pressure, or other discom- ment) for the condition forts that may occur in chronic health conditions Some people need time to think through their such as NEUROPATHY or terminal cancer. It is impor- options, the reasons the surgeon recommends the tant to discuss with the surgeon the anticipated or operation, and the possible complications of the hoped for benefits of the recommended operation. operation. There is usually no hurry to schedule an elective operation, though symptoms such as POTENTIAL BENEFITS OF SURGERY correct congenital improved appearance PAIN may make the scheduling timely. It is often helpful to write down questions and concerns, defects improved function then schedule an appointment with the surgeon relieve intractable PAIN removal of tumors to discuss them before making the decision to pro- treat injuries or ceed with surgery. conditions

277 278 Surgery

Surgery Risks geon, who may recommend nonsurgical treat- All operations have general as well as specific ment options. risks. General risks include excessive bleeding, Because there are often numerous options for wound INFECTION, PNEUMONIA, and death resulting treating a particular health problem and surgery is from unanticipated crisis during the operation inherently invasive (a treatment that enters the (such as HEART ATTACK or STROKE). Surgeon error is body), health experts recommend a second opin- also a risk for any operation. ion consultation for most elective (nonemergency) Personal health factors that increase surgical operations. People sometimes worry that seeking a and anesthetic risks include cigarette smoking, second opinion will offend the first surgeon in ALCOHOL use, OBESITY, DIABETES, CHRONIC OBSTRUCTIVE some way. However, current standards of practice PULMONARY DISEASE (COPD), HYPERTENSION (high support second opinions, and surgeons are them- BLOOD PRESSURE), CYSTIC FIBROSIS, and CORONARY selves often the first to recommend them. Some ARTERY DISEASE (CAD). Numerous medications health insurance plans require second opinion (including herbal products, over-the-counter consultation for certain, and sometimes all elec- products, and illicit drugs) can interfere with anes- tive, operations. thesia, BLOOD clotting, or HEALING. The second opinion surgeon or physician should Age alone does not increase risk for surgical complications. However with advancing age the • be board-certified in an appropriate and rele- likelihood of numerous health conditions vant specialty increases, many of which can remain undetected • practice in a different group or facility from that until a stress such as anesthesia or surgery brings of the first surgeon them to the forefront of the person’s health pic- • know the consultation is for a second opinion ture. Such health conditions may include type 2 diabetes, ATHEROSCLEROSIS, CAD, renal (kidney) dis- ease, LIVER disease, and sometimes hypertension. ELECTIVE OPERATIONS FOR WHICH HEALTH EXPERTS URGE A SECOND OPINION CONSULTATION POSSIBLE RISKS OF SURGERY adenoidectomy cancer operations ANESTHESIA reaction death carpal tunnel surgery CATARACT EXTRACTION AND LENS excessive bleeding during failure of the OPERATION to CHOLECYSTECTOMY REPLACEMENT or after surgery resolve the condition CORONARY ARTERY BYPASS DILATION AND CURETTAGE (D&C) intestinal adhesions need for BLOOD TRANSFUSION GRAFT (CABG) HERNIA repair nerve injury outcome other than expected hemorrhoidectomy HYSTERECTOMY PNEUMONIA unacceptable SCAR JOINT REPLACEMENT knee surgery worsening of health appearance MASTECTOMY PROSTATECTOMY condition wound INFECTION tonsillectomy vein ligation and stripping

Second Opinion Consultation The surgeon or physician providing the second A second opinion is an assessment from another opinion consultation will require medical records, specialist who provides treatment for the same diagnostic procedure reports, laboratory test condition for which the surgeon recommends an results, and other information relevant to the con- operation. The specialist is often another surgeon dition. The doctor will conduct a thorough exami- though may practice in a different subspecialty of nation of the person, then discuss the findings and surgery. For example, a person considering back his or her professional opinions about the possible surgery as treatment for HERNIATED NUCLEUS PULPO- treatments. The second opinion may or may not SUS (“ruptured disk”) may have a surgery recom- support the initial recommendation for the opera- mendation from an orthopedic surgeon and seek a tion. The person may choose which physician or second opinion from neurologist, as both special- surgeon will provide the recommended care. A ties treat back problems. A person may also seek a complex health circumstance may require multi- second opinion from a specialist who is not a sur- ple consultations from different specialists, in surgery benefit and risk assessment 279 which case it may be helpful to have one’s pri- ments should contain no surprises or new infor- mary-care doctor assist in sorting through the mation; if they do, it is important to discuss the options, benefits, and risks. situation with the surgeon before signing them. In some circumstances the surgeon may request Informed Consent advance permission to perform a more extensive Informed consent documents describe in detail the operation than planned, depending on the find- proposed operation, reason for the operation, rec- ings during the surgical operation. This permits ommended anesthesia options, expected benefits, the surgeon to do what needs to be done in a sin- and possible complications and risks. Informed gle operation rather than having the person go consent is required before the operation may through a second procedure. begin for all surgeries except in certain life-threat- See also CANCER TREATMENT OPTIONS AND DECI- ening circumstances. The informed consent docu- SIONS; QUALITY OF LIFE. W wound care The care necessary, including may use sutures, staples (small wires that pull cleansing and dressing changes, to keep surgical together the edges of the skin), glue, or adhesive incisions, or wounds, healthy as they heal. Most strips to close the final layer of the skin. The surgical wounds heal quickly and without compli- method of closure depends on the incision’s loca- cation and require very little care beyond keeping tion and length, the tension on the skin edges, them clean and dry for one to five days after sur- and the surgeon’s preference. The surgeon may gery. Redness at the incision line is normal, use a combination of closure methods for large or though the surgeon should evaluate any redness abdominal incisions. The surgeon must remove that extends farther than one half inch from the staples and nondissolving sutures, typically 3 to 10 incision because this may indicate INFECTION. days after the OPERATION, though often recom- Sometimes there is bruising (ECCHYMOSIS) around mends leaving the adhesive strips in place until the incision site, which typically heals in about a they fall off on their own, usually in about 5 days. week. Staple or suture removal is quick and usually does By the fifth postoperative day the edges of the not hurt, though some people find the minor wound should be adhered to each other, with or pulling and tugging sensations uncomfortable or without an obvious scab. Most scabs fall off 10 to disconcerting. 14 days after surgery, which indicates the incision is fully closed and about 85 percent healed. Fac- Dressings and Dressing Changes tors that influence HEALING include DIABETES, ciga- At the end of the operation the surgeon will place rette smoking, and OBESITY. a surgical dressing over the incision site. The Full healing is complete in three months. The dressing is typically absorbent, as it is normal for SCAR may at first appear reddened and raised, the wound to bleed a little, and may be a pressure though after about six months most scars are flush dressing to limit the amount of bleeding. The sur- with the SKIN’s surface and are pink or white. A gical dressing stays on for 24 hours, after which scar generally continues to fade over time and the surgeon, if the person stays overnight in the remains lighter in color than the surrounding hospital, or the person may remove it. A larger skin. Incisional scars are more sensitive than the incision may require replacement dressings for the surrounding skin to sun exposure and should be next 72 hours, after which most incisions remain protected with SPF (sun protective factor) 30 sun- uncovered though some surgeons may instruct screen or clothing to prevent SUNBURN. that the incision site remain covered for a longer period. When applying a fresh dressing, it is Skin Closures important to wash the hands with warm water A surgeon closes a surgical wound from the inside and soap before touching bandages or the surgical out, typically using fine sutures (threads that sew wound. The surgeon may instruct the application the tissue edges together) to bring together the of an antibiotic ointment. The surgeon will layers of MUSCLE, FASCIA, and subcutaneous fat. remove nondissolving skin sutures or staples 3 to These sutures, commonly called stitches, dissolve 10 days after the operation, after which the inci- over 5 to 7 days as the tissues heal. The surgeon sion is fairly well healed. 280 wound care 281

Postoperative Complications People who have these conditions should be alert Infection is the most common postoperative to changes in the surgical wound that could sug- wound complication. Rarely a surgical wound gest infection. may bleed. Though some degree of bleeding at the Discomfort or PAIN is a common and expected incision for the first 24 hours after surgery is nor- complication for a period of time after the opera- mal for most operations, bleeding that saturates tion, the severity and duration of which depends the bandage requires immediate assessment by the on the kind of operation. Restricting use of the surgeon or hospital nursing staff. Extended irrita- operated area minimizes discomfort. The surgeon tion at the incision site (redness farther than one will prescribe appropriate ANALGESIC MEDICATIONS to half inch from the incision), pus, and FEVER are relieve pain. early indications of infection that the surgeon Return to Bathing or needs to evaluate. Obesity, diabetes, and PERIPH- Showering and Normal Activities ERAL VASCULAR DISEASE (PVD) can affect the circula- Most surgical wounds are closed enough to permit tion of BLOOD in the body, particularly to the limbs. showering 24 to 48 hours after surgery. Getting the incision wet does not affect the skin closures NOSOCOMIAL WOUND INFECTION (sutures, staples, or adhesive strips). Bathing (sit- About 500,000 of the 27 million Americans who ting in a tub of water) should wait until the inci- undergo surgery every year develop postopera- sion is completely healed (2 to 3 weeks), unless it tive wound infections. About 25 percent of post- is possible to sit in the water without getting the operative infections are nosocomial (also called incision wet. Soaking in bath water softens the iatrogenic)—that is, they occur as a consequence skin at the incision’s edges and may allow BACTERIA of exposure to pathogens in the hospital environ- to gain entrance, causing infection. The full return ment. Proper wound care minimizes the risk for to normal activities depends on the operation and the person’s individual rate of healing and can INFECTION of any kind and supports optimal HEAL- take place anytime from a few days to 3 months. ING. See also SURGERY BENEFIT AND RISK ASSESSMENT. LIFESTYLE VARIABLES: SMOKING AND OBESITY The two lifestyle variables that have emerged in recent years as the key causes of preventable disease are smoking and OBESITY. Each represents a complex mingling of contributory factors, many within the reach of individual control. These variables span health-care specialties; practitioners in nearly all fields of medicine address health issues that derive from either or both. Between them, smoking and obesity account for nearly all preventable HEART disease and many types of cancer.

This section, “Lifestyle Variables: Smoking and quences of cigarette smoking. The report’s publi- Obesity,” presents an overview discussion of cation was a wake-up call for doctors as well as smoking and obesity as they contribute to health the general public, nearly 45 percent of whom conditions. The entries in this section focus on the were smokers. health consequences of smoking and obesity, Over the next 40 years concerted education including weight management topics. The section efforts resulted in cutting the number of smokers “Nutrition and Diet” features an overview discus- nearly in half. However, the health consequences sion and entries that focus on the broad context of of smoking skyrocketed. CARDIOVASCULAR DISEASE nutrition and diet in health and the development (CVD) became the leading cause of death, and ciga- of health conditions. Similarly the section “Fit- rette smoking was identified as the leading cause ness: Exercise and Health” features an overview of CVD. Lung cancer became the leading cause of discussion and entries that focus on the broad death from cancer, and cigarette smoking was context of physical activity in health and the identified as the leading cause of lung cancer. development of health conditions. Over the decades, research unequivocally linked cigarette smoking with oral cancer, laryn- Lifestyle and Smoking geal cancer, ESOPHAGEAL CANCER, PANCREATIC CANCER, Cigarette smoking attained social status in the BLADDER CANCER, PROSTATE CANCER, RENAL CANCER, 1920s when soldiers returning from World War I STOMACH CANCER, and LIVER CANCER. Cigarette brought their habit home with them. Cigarette smoking proved responsible for most nonallergic smoking became fashionable across social strata, a ASTHMA, CHRONIC OBSTRUCTIVE PULMONARY DISEASE mark of sophistication and success. But as early as (COPD), and chronic BRONCHITIS. Researchers also the 1940s doctors recognized that many of their affirmed that ENVIRONMENTAL CIGARETTE SMOKE (sec- patients who had heart disease or lung disease, ondhand smoke) caused these same health condi- including LUNG CANCER, were smokers. Numerous tions in nonsmokers and was also responsible for research studies soon confirmed and detailed the most chronic upper respiratory conditions in chil- specific health risks of smoking, which are exten- dren. sive. In 1964 the US Surgeon General released the By the early 2000s many cities in the United landmark report, Smoking and Health: Report of the States outlawed cigarette smoking in public build- Advisory Committee to the Surgeon General of the Pub- ings and restaurants went smoke-free or estab- lic Health Service, which presented in fairly stark lished separate dining areas for smokers and detail the known and suspected health conse- nonsmokers. Hospitals also banned smoking. By 282 Lifestyle Variables: Smoking and Obesity 283

2004—40 years after the first surgeon general’s the case with cigarette smoking, the health conse- report on smoking and health—48 million Ameri- quences of obesity accumulate slowly over can adults remained smokers, fewer than a quar- decades, lulling a person into believing that noth- ter of the US adult population, and the number of ing adverse is happening in his or her body. The new smokers reached an all-time low. Nonethe- first recognition that obesity is a health problem less, cigarette smoking remains the leading cause often comes when the doctor diagnoses a health of CVD, cancer, chronic lung disease, and prema- condition such as OBSTRUCTIVE SLEEP APNEA or HYPER- ture death in the United States. TENSION and prescribes weight loss among the treatment recommendations. Lifestyle and Obesity For many people with class 2 or 3 obesity, the Cultural and social perceptions strongly influence prospect of losing enough weight to have an effect the extent to which people understand the health on health is daunting if not overwhelming and risks and consequences of obesity, representing a often requires medical assistance. Yet even the loss complex intertwining of personal accountability of 10 or 20 pounds over six months, a goal most and societal pressures. Until the 20th century people can reach simply by adding 30 minutes of being overweight was a sign of personal prosperity walking to every day’s activities, makes a measur- and even a hallmark of health. The corpulent indi- able difference in health. Health improvements vidual was one who could afford unlimited access are apparent almost immediately and extend as to food and indulged in its luxury. No correlation weight loss continues. Some people are able to as yet existed to link obesity with common and stop taking medications to treat conditions such as debilitating ailments such as “dropsy” (the gener- hypertension and type 2 DIABETES when their alized edema of congestive HEART FAILURE) and weight reaches healthier levels. “quinsy” (ANGINA PECTORIS, a symptom of CORONARY Between 1990 and 1999 the percentage of ARTERY DISEASE [CAD]). As doctors began to recog- American adults who have obesity doubled. In nize the health implications of obesity a key chal- 2001 the US Office of the Surgeon General issued lenge that emerged was that of convincing people The Surgeon General’s Call to Action to Prevent and of the connections between health, longevity, and Decrease Overweight and Obesity, another landmark body weight. report identifying obesity as a significant as well as Despite what now amounts to decades of scien- preventable cause of hypertension, type 2 dia- tific evidence, misperceptions persist about the betes, ATHEROSCLEROSIS, OSTEOARTHRITIS, and numer- roles of EATING HABITS, food choices, and daily ous types of cancer. Weight loss became an explicit physical activity in WEIGHT LOSS AND WEIGHT MAN- health objective in HEALTHY PEOPLE 2010, the US AGEMENT efforts. Furthermore, food is essential for national agenda for public health improvement. life—unlike cigarettes and ALCOHOL, which also Many health experts believe obesity, which affects influence health. One cannot simply stop eating as more than 55 million American adults, now rivals one can stop smoking or drinking alcohol (which cigarette smoking for its deleterious effects on are not easy accomplishments themselves). As is health. A–B

abdominal adiposity The accumulation of body EXERCISE AND HEALTH; HEALTH RISK FACTORS; LEAN MUS- fat around the middle of the trunk, forming the CLE MASS; OBESITY; WEIGHT LOSS AND WEIGHT MANAGE- “apple” body shape or the “spare tire” appearance. MENT. Abdominal adiposity has emerged as a pattern of fat storage that correlates to an increased risk for bariatric surgery Any of several types of surgical CARDIOVASCULAR DISEASE (CVD) and particularly operations to achieve rapid and significant weight HEART ATTACK. Doctors assess abdominal adiposity loss in people who have morbid OBESITY (obesity using WAIST CIRCUMFERENCE and WAIST TO HIP RATIO severe enough to pose an imminent risk to life). measurements. Reducing abdominal adiposity People who weigh 100 pounds or more above through weight loss correspondingly lowers healthy weight or who have a BODY MASS INDEX related health risks. Abdominal adiposity may (BMI) of 40 or greater are at severe risk for prema- become a particular concern for women after ture death as well as for health conditions due to MENOPAUSE when hormonal influences can shift fat obesity. At this level, body fat accounts for one storage patterns within a woman’s body. third or more of total body weight. People whose A person can be of healthy weight and still BMIs are between 35 and 40 and who also have have abdominal adiposity because abdominal adi- CARDIOVASCULAR DISEASE (CVD) or OBSTRUCTIVE SLEEP posity is a mechanism of fat distribution in the APNEA are also candidates for bariatric surgery inner tissues of the abdomen such as around the because their obesity is a key contributory factor vital organs. A person who is of healthy weight in these conditions. US surgeons perform about but who has abdominal adiposity often appears to 140,000 bariatric operations a year. have a somewhat thickened trunk and thin arms Types of bariatric surgery are either malabsorp- and legs, carrying the traditional “apple” body tive or restrictive, according to the mechanism by shape even though he or she does not look over- which they impede the digestive process. The weight. In this circumstance health experts rec- long-term success rate for maintaining weight loss ommend more physical activity to lower the BODY varies with the kind of OPERATION and the person’s FAT PERCENTAGE. With overall reduction in body fat commitment to lifestyle changes in EATING HABITS the trunk stores less fat, lowering the health risks and physical exercise after the surgery. In general associated with abdominal adiposity. the amount of weight loss and the extent of com- plications are both more significant with malab- HEALTH CONDITIONS ASSOCIATED sorptive operations. Bariatric operations include WITH ABDOMINAL ADIPOSITY jejunoileal bypass, biliopancreatic diversion, gas- ATHEROSCLEROSIS CORONARY ARTERY DISEASE (CAD) tric bypass, and gastric banding. HEART ATTACK HYPERLIPIDEMIA HYPERTENSION ISCHEMIC HEART DISEASE (IHD) Surgical Procedure PERIPHERAL VASCULAR DISEASE (PVD) type 2 DIABETES Open bariatric surgery operations are complex, extensive, and may take several hours for the sur- See also ASCITES; BODY MASS INDEX (BMI); BODY geon to perform. Laparoscopic, or minimally inva- SHAPE AND CARDIOVASCULAR DISEASE; DIET AND HEALTH; sive, techniques allow the surgeon to operate 284 bariatric surgery 285

BARIATRIC OPERATIONS Operation Benefits Risks and Complications jejunoileal bypass rapid, significant, and sustainable weight loss OPEN SURGERY (seldom performed) reduced health risk for CARDIOVASCULAR DISEASE high risk for postoperative complications (CVD), DIABETES, and OSTEOARTHRITIS malabsorption disorders and nutritional improvement in existing HYPERTENSION and deficiencies diabetes secondary ANEMIA and OSTEOPOROSIS chronic gastrointestinal discomfort and DIARRHEA LIVER FAILURE kidney stones biliopancreatic rapid, significant, and sustainable weight loss open surgery diversion reduced health risk for CVD, diabetes, and moderate to high risk for operative and biliopancreatic osteoarthritis postoperative complications diversion with improvement in existing hypertension and intolerance for high protein foods resulting in duodenal switch diabetes protein deficiency nutritional deficiencies with risk for anemia and osteoporosis gastric ulcers gastric dumping syndrome belching, abdominal cramping, and FLATULENCE chronic, intermittent diarrhea

Roux-en-Y gastric rapid, significant, and sustainable weight loss open surgery bypass reduced health risk for CVD, diabetes, and moderate risk for operative and postoperative osteoarthritis complications improvement in existing hypertension and nutritional deficiencies diabetes VOMITING gastric dumping syndrome PEPTIC ULCER DISEASE vertical banded laparoscopic surgery slight risk for operative and postoperative gastroplasty reversible complications rapid and significant weight loss for people staple failure who also make appropriate lifestyle changes occasional gastric dumping syndrome gastric pouch can expand with continued excessive food consumption adjustable gastric laparoscopic surgery balloon failure banding adjustable and reversible infection at the banding site rapid recovery and return to normal activities slower and less consistent weight loss than with gastrointestinal structure remains unchanged other bariatric operations gastric pouch easily expands with excessive food consumption up to 20 percent of people may experience no weight loss 286 Lifestyle Variables: Smoking and Obesity through several small incisions called ports and its junction with the colon. The stomach becomes generally require less time in the operating room. a very small pouch, restricting the amount of food The stay in the hospital after bariatric surgery that can enter the gastrointestinal tract. The diges- varies from a day for laparoscopic banding opera- tive process bypasses most of the small intestine, tions to five days or longer for open gastric bypass limiting absorption. or biliopancreatic diversion operations. Full recov- A variation of this operation is biliopancreatic ery and return to normal activities can take sev- diversion with duodenal switch. In this operation eral months, though many people are able to the surgeon divides the stomach about in half return to most routine activities and to work in lengthwise, creating a pouch between the ESOPHA- four to six weeks. GUS and the duodenum. The surgeon then divides Jejunoileal bypass Jejunoileal bypass is a mal- the duodenum in half lengthwise and reconstructs absorption operation. The first weight-reduction it into two narrow, tubelike structures. One of operation surgeons performed, the jejunoileal these structures drains digestive enzymes from the bypass joins the first part of the SMALL INTESTINE’s pancreas and bile from the gallbladder into the second segment, the JEJUNUM, to the last part of gastrointestinal tract. The surgeon joins the other the small intestine’s third segment, the ILEUM. This to the end portion of the ileum near the colon. bypasses the stretch of small intestine where most Biliopancreatic diversion with duodenal switch nutrient absorption takes place, rerouting food rel- allows better absorption in the remaining segment atively undigested on a direct path from the STOM- of small intestine of NUTRIENTS such as protein, ACH to the end of the small intestine and into the vitamins, calcium, iron, and fat. COLON. Though successful in generating significant Gastric bypass Gastric bypass operations weight loss jejunoileal bypass has numerous severely restrict food consumption by reducing the unpleasant side effects, including chronic and size of the stomach to a small pouch that can hold sometimes persistent or severe DIARRHEA, MALNU- about 0.5 ounce (15 milliliters); the stomach nor- TRITION, electrolyte imbalance, and small bowel mally holds about 50 ounces (1.5 liters). The most obstruction (ILEUS). Because of the high rate of common and successful gastric bypass operation is complications with jejunoileal bypass and the cur- the Roux-en-Y gastric bypass, a complex operation rent availability of other weight loss operations, in which the surgeon divides the stomach to form surgeons in the United States seldom perform two segments and reroutes the small intestine. jejunoileal bypass today. Both segments of the stomach remain functional. Biliopancreatic diversion Biliopancreatic diver- The upper segment is a small gastric pouch with a sion combines restriction and malabsorption. capacity of 0.5 to 1 ounce. The surgeon joins the Developed as an improvement over jejunoileal jejunum to the bottom of the pouch, bypassing bypass, the operation involves removing a portion the primary absorptive segment of the small intes- of the stomach to reduce the volume of food it can tine. The lower segment of the stomach retains hold as well as bypasses the central segment of the the duodenum, which the surgeon restructures to small intestine to curtail absorption during diges- join the jejunum near the ileum. The duodenum tion. The surgery may be open or laparoscopic feeds digestive enzymes and DIGESTIVE HORMONES (minimally invasive). The first segment of the into the jejunum to aid in the absorption of nutri- small intestine, the DUODENUM, connects the stom- ents. ach to the small intestine and also serves as the Gastric banding Like gastric bypass operations, conduit through which the PANCREAS channels gastric banding operations reduce the stomach to DIGESTIVE ENZYMES and the GALLBLADDER empties a small pouch that can hold about 0.5 ounce and BILE. narrow the outlet at the base of the stomach to In straight biliopancreatic diversion, the sur- slow the passage of food from the stomach to the geon removes the lower two thirds of the stomach small intestine. Gastric banding significantly limits and connects the remaining third directly to the the volume of food the person can consume; ileum, the end portion of the small intestine near exceeding the limit causes VOMITING. Surgeons bariatric surgery 287 most commonly perform two types of gastric remain unchanged and their stomachs quickly banding operations. regain capacity.

• Vertical gastric banding (VGB), also called verti- Risks and Complications cal banded gastroplasty, partitions the stomach Any bariatric operation is major surgery with into two vertical segments. Surgical staples sep- inherent risks, including excessive bleeding during arate the segments, leaving a narrow channel or after the operation and INFECTION. Infection in between them. The small gastric pouch limits the early postoperative period is a particular risk the amount of food the person can consume. A with any surgery on the gastrointestinal tract. silicone band constricts the channel between Leakage of gastrointestinal contents into the the two gastric chambers to significantly slow abdominal cavity can cause PERITONITIS, a poten- the flow of food from the upper gastric pouch tially life-threatening infection of the membrane to the lower segment of the stomach. Food that lines the abdominal cavity. Emergency sur- travels through the gastrointestinal tract in the gery may be necessary to treat peritonitis. BLOOD normal way though moves through the stom- clots may break free from blood vessels at the ach much more slowly than normal. operative site, traveling through the body until • Adjustable gastric banding (AGB), also called lap they lodge in blood vessels too narrow to carry banding, partitions the stomach solely through them any farther. Blood clots can occlude (block) the use of an inflatable silicon band applied so arteries or veins anywhere in the body, including that it creates a gastric pouch that can hold the LUNGS (PULMONARY EMBOLISM), BRAIN (STROKE), about 1 ounce. A narrow catheter extends from and HEART (MYOCARDIAL INFARCTION). the band to a port implanted beneath the SKIN. The surgeon gradually inflates the balloon with Though the risk dying as a consequence sterile saline during follow-up office visits to of bariatric surgery is less than 1 percent, increase constriction of the stomach. many people who have OBESITY also have other health conditions that increase Gastric banding operations are laparoscopic, their risk profile. It is important to fully greatly reducing operative and postoperative risks understand the risks of surgery com- and complications, and have the added benefit of pared to the risks of the obesity. being reversible. Most people return to normal activities within four weeks after the surgery. About 50 percent of people who undergo However, gastric banding has the lowest success bariatric surgery experience complications after rate among the bariatric operations. Weight loss is the operation, most of which are manageable more gradual than with other operations. Over postoperatively though may become chronic. Mal- time the stomach can stretch to hold considerably absorptive operations that bypass the small intes- more volume, depending on how much food the tine have high risk for vitamin, mineral, and person attempts to consume on a consistent basis. protein deficiencies. One in three people who Because food continues to the small intestine and undergo a weight loss operation develops chronic digestion of it remains unaffected, a person who nutritional deficiencies with long-term health consumes high-CALORIE foods after a gastric band- consequences such as OSTEOPOROSIS and ANEMIA. ing operation may end up losing little if any One in five requires additional surgery to repair weight. problems such as fistula (abnormal opening) or About 80 percent of people who undergo gas- HERNIA. The rapid weight loss of bariatric surgery tric banding operations lose weight after surgery triggers GALLBLADDER DISEASE, especially the forma- and about 50 percent reach the goal of losing 50 tion of gallstones, in half of people who undergo percent of their excessive weight within the first bariatric surgery. year after surgery. About 20 percent, however, do Milder common complications include GAS- not lose weight because their lifestyle habits TROESOPHAGEAL REFLUX DISORDER (GERD); belching; 288 Lifestyle Variables: Smoking and Obesity chronic gastrointestinal discomfort; and gastric In general, people who undergo bariatric oper- dumping syndrome, a reaction of the gastrointesti- ations lose 50 percent of excess body weight in the nal tract to eating high concentrations of sugar first year after surgery. The rate of weight loss (sweets) and protein (meats). Excessive body depends on the type of operation and tends to be weight stretches the skin, which may sag and fold most dramatic with gastric bypass operations. after extensive weight loss. About 30 percent of Weight loss tends to peak around three years after people who undergo bariatric surgery subse- surgery, at 70 to 85 percent of excess body weight. quently have PLASTIC SURGERY operations such as Five years after surgery, however, about 70 per- panniculectomy and abdominoplasty to remove cent of people have regained weight to about 50 excess skin after weight loss. percent of the excess (which still falls within the parameters for successful surgery) and about 5 Outlook and Lifestyle Modifications percent of people have regained all of their lost Most people require four to eight weeks for full weight. Doctors attribute these results largely to recovery from bariatric surgery and return to reg- continuation of poor eating habits and physical ular activities. Some people may require longer, inactivity. Food choices and daily exercise are particularly those who experience postoperative essential to sustain weight loss over the long term. complications. The changes to the gastrointestinal Outcome studies of bariatric operations show system that bariatric surgery makes are permanent evidence that people who maintain their weight and alter the way the digestive process functions, loss lower their risk for CVD and type 2 diabetes sometimes in ways that require ongoing medical to the same extent as people who lose the weight care and medications. Many people will also need through nonsurgical methods. Because weight loss to continue taking medications to treat conditions is so dramatic, some people are able to manage they had before surgery, such as HYPERTENSION and mild to moderate hypertension and type 2 dia- DIABETES. betes through lifestyle alone, ending the need for For several weeks to several months, people medications. Researchers believe such findings who have gastric bypass procedures to restrict the further support the role of obesity as an indepen- size of the stomach must eat liquid or pureed dent risk factor for these conditions as well as foods to give their gastrointestinal tracts time to demonstrate the health value of WEIGHT LOSS AND adjust. The gastric pouch can hold such a limited WEIGHT MANAGEMENT. volume that it often is necessary to separate eating See also DIET AIDS; DIET AND HEALTH; DIETING; EAT- and drinking by 30 to 60 minutes. As well, the ING DISORDERS; LIFESTYLE AND HEALTH; MALABSORPTION; person must thoroughly chew food before swal- MINERALS AND HEALTH; MINIMALLY INVASIVE SURGERY; lowing, as the gastric pouch lacks the MUSCLE NUTRITIONAL NEEDS; OBESITY AND HEALTH; SURGERY BEN- capacity and size to participate in further breaking EFIT AND RISK ASSESSMENT; VITAMINS AND HEALTH. down the size of food particles. Despite the changes to the gastrointestinal sys- body fat percentage The proportion of the tem’s structure and function, lifestyle factors such body’s composition that is fat. Body fat percentage as food choices and physical exercise remain is an indirect indicator of LEAN MUSCLE MASS and important for long-term weight management. The correlates to health circumstances such as FERTILITY success of bariatric surgery for maintaining weight as well as health conditions such as type 2 DIA- loss depends on the extent to which an individual BETES and CARDIOVASCULAR DISEASE (CVD). The body makes the necessary changes in these factors. Doc- requires a minimum amount of fat for its func- tors consider bariatric surgery successful when the tions and activities, generally about 4 percent for person maintains weight loss of 50 percent of men and 12 percent for women. Body fat percent- excess body weight for five years after surgery. age above 25 percent for men and 32 percent for Though many people may lose 100 pounds or women correlates with OBESITY. A high body fat more with bariatric surgery, they may remain percentage in combination with ABDOMINAL ADIPOS- overweight though at a healthier weight than ITY (the “apple” body shape) portends a particu- before surgery. larly high risk for CVD, HEART ATTACK, and STROKE. body mass index (BMI) 289

BODY FAT PERCENTAGE AND HEALTH RISK Health Status Men Women at risk for NUTRITIONAL DEFICIENCY < 4 percent < 12 percent lean (athlete or high fitness level), 4 to 15 percent 12 to 22 percent no increased health risk healthy, no increased health risk < 20 percent < 27 percent overweight, moderate increase 20 to 25 percent 27 to 32 percent in health risk

OBESITY, significant increase in health risk > 25 percent > 32 percent

Methods for measuring or approximating body OSTEOPOROSIS, also provides calculations of body fat fat percentage include percentage and lean tissue mass. No single method provides an absolute measure of body fat percent- • BODY MASS INDEX (BMI), a mathematical formula age. based on weight and height See also DIET AND HEALTH; EXERCISE AND HEALTH; • skinfold calipers, which measure the thickness FITNESS LEVEL; UPPER ARM CIRCUMFERENCE; WEIGHT of a fold of SKIN (typically at the triceps on the LOSS AND WEIGHT MANAGEMENT. back of the upper arm) to determine the amount of subcutaneous fat body mass index (BMI) A mathematical meas- ure of total body size and its correlation to health • bioelectrical impedance, which measures the risk. BMI values derive from height (without resistance a mild electrical current encounters shoes) and weight (without clothes) measures, when passed through the body with mathematical calculations that convert those • hydrostatic weighing, which uses water dis- measures to a value that reflects overall body size. placement to determine body mass BMI represents the mass of the body in kilograms per meter squared (kg/m2) though the common Additional measures that improve the precision presentation of BMI is simply the numeric value. of body fat percentage estimates include WAIST CIR- A low or a high BMI corresponds with increased CUMFERENCE and WAIST TO HIP RATIO, as these meas- risk for numerous health conditions. A BMI of 25 ures increase with excessive body fat. Dual-energy or greater is overweight; a BMI of 30 or greater is X-RAY absorptiometry (DEXA), an X-ray procedure OBESITY. BMI values apply to men or women who to determine BONE DENSITY as an assessment of have the same measurements. For example, a

BMI AND HEALTH RISK BMI Classification Health Risk Due to Weight > 18.5 underweight may indicate EATING DISORDERS or undernutrition 19 to 24.9 healthy weight no increased health risk 25 to 29.9 overweight moderate health risk 30 to 34.9 OBESITY, class 1 significant health risk 35 to 39.9 obesity, class 2 high health risk; INSULIN RESISTANCE or CARDIOVASCULAR DISEASE (CVD) likely 40+ obesity, class 3 severe health risk; DIABETES, CVD, or HYPERTENSION likely 290 Lifestyle Variables: Smoking and Obesity man who is 5 feet 8 inches tall and weighs 175 BMI values may not be accurate in children, pounds has the same BMI as a woman who is 5 the elderly, and performance athletes because feet 8 inches tall and weighs 175 pounds. body mass may not correctly reflect body compo- For most people a high BMI indicates increased sition. The elderly may have more body fat than body fat. The higher the BMI is above the BMI indicates, with a correspondingly higher “healthy” range, the greater the health risk for health risk. Performance athletes (amateur or pro- HYPERTENSION (high BLOOD PRESSURE), type 2 DIA- fessional) typically have higher LEAN MUSCLE MASS BETES, and forms of CARDIOVASCULAR DISEASE (CVD) (large skeletal muscles) and lower body fat per- such as HYPERLIPIDEMIA, ATHEROSCLEROSIS and CORO- centages than less physically active people of the NARY ARTERY DISEASE (CAD). Risk for these condi- same weight; the increased MUSCLE mass raises the tions further increases when WAIST CIRCUMFERENCE BMI even though body fat is lower. also is greater than 40 inches for men and 35 See also ABDOMINAL ADIPOSITY; CHILDHOOD OBESITY; inches for women, though waist circumference is DIET AND HEALTH; EXERCISE AND HEALTH; LIFESTYLE AND itself an independent risk factor for the same HEALTH; NUTRITIONAL ASSESSMENT; NUTRITIONAL NEEDS; health conditions. Losing weight drops BMI and OBESITY AND HEALTH; WEIGHT LOSS AND WEIGHT MAN- reduces health risk. AGEMENT.

BODY MASS INDEX (BMI) BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 Height (inches) Body Weight (pounds) 58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167 172 177 181 186 191 196 201 205 210 215 59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 178 183 188 193 198 203 208 212 217 222 60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179 184 189 194 199 204 209 215 220 225 230 61 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185 190 195 201 206 211 217 222 227 232 238 62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 196 202 207 213 218 224 229 235 240 246 63 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197 203 208 214 220 225 231 237 242 248 254 64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 209 215 221 227 232 238 244 250 256 262 65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210 216 222 228 234 240 246 252 258 264 270 66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216 223 229 235 241 247 253 260 266 272 278 67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223 230 236 242 249 255 261 268 274 280 287 68 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230 236 243 249 256 262 269 276 282 289 295 69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236 243 250 257 263 270 277 284 291 297 304 70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 250 257 264 271 278 285 292 299 306 313 71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 257 265 272 279 286 293 301 308 315 322 72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258 265 272 279 287 294 302 309 316 324 331 73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 272 280 288 295 302 310 318 325 333 340 74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 280 287 295 303 311 319 326 334 342 350 75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279 287 295 303 311 319 327 335 343 351 359 76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287 295 304 312 320 328 336 344 353 361 369

Adapted from U.S. National Heart, Lung, and Blood Institute (NHLBI) Obesity Education Initiative (2005) C childhood obesity The development of Diagnosing Childhood Obesity unhealthy body weight due to excessive body fat Conventional methods of assessing BODY FAT PER- before adulthood (age 18). Childhood OBESITY has CENTAGE and BODY MASS INDEX (BMI), the standard numerous health consequences that affect METAB- measures of obesity, are somewhat different for OLISM, physical growth and development, and children from those used for adults. A child’s body PUBERTY. Childhood obesity jumped significantly fat varies with developmental stages and growth between 1970 and 2000. Currently 15 percent of cycles. Correspondingly, a child’s BMI varies US children have obesity. Another 20 percent are according to age and developmental stage. As overweight, which places them at risk for obesity. well, boys and girls have different body fat compo- Health experts attribute the rise in childhood sition through the end of ADOLESCENCE. obesity primarily to EATING HABITS and physical In 2001 the US Centers for Disease Control and inactivity. Ongoing health assessment monitoring, Prevention (CDC) developed gender-specific BMI- such as the periodic National Health and Nutrition for-age charts to provide guidelines for assessing Examination Survey (NHANES) and the Behav- underweight, healthy weight, and overweight in ioral Risk Factor Surveillance System (BRFSS), children between the ages of 2 and 20. The charts reveals a steady decline in the level of physical correlate BMI to percentile, a measure of relative activity among young people, including through comparison that allows monitoring of BMI physical education programs in the schools. through the entire course of childhood. The Increasing the physical activity of children as a boundary for overweight is the 85th percentile (85 mechanism for improving long-term health is percent of children who are the same age and among the objectives of HEALTHY PEOPLE 2010, the gender have a lower BMI) and for obesity the US government’s agenda for community health. 95th percentile (95 percent of children who are Researchers also continue to explore other factors the same age and gender have a lower BMI). that may contribute to obesity. Much attention focuses on the role of genetics and regulation of Health Implications of Obesity in Childhood metabolic processes within the body such as the Doctors are seeing INSULIN RESISTANCE, type 2 DIA- release and activity of hormones. BETES, HYPERTENSION (high BLOOD PRESSURE), HYPER-

BMI FOR AGE FOR CHILDREN AND TEENS: KEY PERCENTILE MARKERS BMI for Age: Boys/Girls BMI for Age Percentile Health Status for Body Weight 2 years 7 years 15 years 20 years 14.8/14.4 13.7/13.4 16.6/16.3 19.1/17.8 5th underweight

18.2/18.0 17.4/19.2 23.4/24.0 27.1/26.5 85th overweight or at risk for overweight

19.3/19.1 19.1/19.6 26.8/28.1 30.6/31.8 95th obesity

291 292 Lifestyle Variables: Smoking and Obesity

LIPIDEMIA, OSTEOARTHRITIS, and the beginnings of for long-term weight management. However, obe- ATHEROSCLEROSIS in an increasing number of chil- sity is a complex condition that requires individu- dren, especially adolescents, who have obesity. alized assessment and a treatment approach that These conditions may require treatment with accommodates the various factors relevant for a medications and other interventions, the long- child. Counseling and SUPPORT GROUPS may help term health consequences of which remain address DEPRESSION, emotional issues, and family unknown. Emotional, social, and self-esteem dynamics. issues also are common among children who have obesity. The stigma of being “fat” is a difficult chal- Positive reinforcement must frame lenge for children who are forming their sense of treatment approaches for OBESITY in self and are especially sensitive to peer acceptance children. Punitive approaches such as and rejection. Obesity may result in a young per- withholding food, criticizing the child, son feeling ostracized in school and having diffi- and forcing exercise are inappropriate culty forming friendships. and can have serious emotional and psychologic consequences for the child. Health Implications of Childhood Obesity in Adulthood Established obesity is a more difficult challenge Increasing evidence points to long-term health for treatment, though lifestyle modifications consequences for people who enter adulthood with remain the mainstay of therapeutic approaches. obesity. Childhood obesity correlates with Nutrition education and BEHAVIOR MODIFICATION increased risk for earlier onset in adulthood of THERAPY are helpful for older children, especially insulin resistance and type 2 diabetes, osteoarthri- adolescents. Many health experts recommend tis, hypertension, hyperlipidemia, atherosclerosis, involving the entire family in the effort to shift to CORONARY ARTERY DISEASE (CAD), STROKE, and certain healthful lifestyle habits. Older adolescents who cancers. An increased risk for these conditions may struggle with obesity may benefit from medica- exist even among people who had childhood obe- tions intended to suppress APPETITE. Many eating sity yet achieve relatively healthy weight as adults. disorder treatment programs offer comprehensive These health conditions account for significant treatment that targets the child’s individual cir- physical disability and further complications result- cumstances and needs. BARIATRIC SURGERY, a treat- ing from co-morbidities (the cascading conse- ment option for adults who are otherwise unable quences of co-existing, multiple health conditions). to treat their obesity, is not usually an option for young people. Treatment Approaches and Outlook There is every reason to believe the health out- Prevention of obesity is the first line of treatment. look for children who achieve healthy weight and Routine childhood health examinations monitor a enter adulthood at healthy weight is excellent. child’s growth and development. Intervention for Health experts are hopeful that lifestyle modifica- children who have BMI-for-age values near or at tions implemented early in life will carry through the 85th percentile can head off obesity. Lifestyle adulthood, helping reduce adult obesity as well. modifications—nutritious eating habits and See also DIET AND HEALTH; EXERCISE AND HEALTH; increased physical exercise—presented in a posi- OBESITY AND HEALTH; QUALITY OF LIFE; WEIGHT LOSS AND tive context represent the most effective approach WEIGHT MANAGEMENT. D–E

diet aids Products that claim to expedite weight Weight loss as a component of long-term weight loss. Diet aids may be products proclaimed as management requires lifestyle modifications that APPETITE suppressants (decrease the urge to eat) or dieting does not accommodate, such as increased products or electronic devices advertised to “burn physical exercise and EATING HABITS that foster away” fat. Though most such diet aids have lim- healthful food choices. ited or no value, the diet aid industry in the Dieting tends to focus on restricting foods that United States generates about $30 billion in are high in calories, such as carbohydrates and fat. annual sales. Depriving the body of CALORIE intake forces it to Over-the-counter appetite suppressants typi- draw from stored energy sources such as glycogen cally contain diuretics (drugs that increase URINA- and body fat, though severe calorie restriction TION), STIMULANTS such as pseudoephedrine (a (less than 800 calories a day) results in protein decongestant) and CAFFEINE, or bulking agents that METABOLISM and loss of LEAN MUSCLE MASS because draw water after consumption and purport to protein is easier for the body to convert to GLUCOSE instill a sense of fullness. These kinds of products to meet its energy needs. Restrictive dieting is may have a limited effect to decrease appetite likely to deprive the body of other needed NUTRI- though may have undesired side effects such as ENTS such as vitamins and minerals, and com- agitation and mucous membrane dryness. monly results in food cravings for items the diet Devices that claim to burn energy by stimulat- does not allow. ing MUSCLE fibers to contract may indeed stimulate Some dieting approaches are detrimental to muscle contraction but do not generate enough health over time. High-fat, low-carbohydrate diets energy to affect the body’s metabolic balance. may achieve short-term weight loss but are likely Wraps, creams, and other substances applied to to result in increased levels of cholesterol and the SKIN that proclaim to “melt away” fat lack sci- triglycerides in the BLOOD circulation, raising the entific basis for their claims. Many diet aids come risk for HYPERLIPIDEMIA and ATHEROSCLEROSIS regard- with diet plans that advise increased exercise and less of weight loss. As well, low-carbohydrate diets reduced food intake—the only proven method for cause the body to excrete more water than usual, weight loss. resulting in weight loss but not loss of body fat. See also DIET AND HEALTH; DIETING; “FAT BURNERS”; “Yo-yo” dieting, in which weight continually fluc- NUTRITIONAL NEEDS; WEIGHT LOSS AND WEIGHT MANAGE- tuates, is particularly harmful not only for long- MENT. term weight management but also for the glucose–INSULIN balance, generating increased risk dieting The practice of temporarily altering one’s for INSULIN RESISTANCE. There is also the tendency to food intake to achieve weight loss. Dieting regain the lost weight as well as additional weight approaches typically restrict calories and often as somewhat of a rebound response in the form of food types. Though such approaches are effective excessive eating when the restrictive diet ends. for short-term weight loss, they are not sustain- People who have class 2 or 3 OBESITY, in which able in the long term and many people regain the adverse health conditions are either imminent or lost weight in less time than it took to lose it. already exist because of excessive body weight, 293 294 Lifestyle Variables: Smoking and Obesity may benefit from a doctor-supervised, short-term stitutes a serving and underestimate how much restrictive diet as part of an overall weight man- food they eat. Product labels specify the number agement approach. However, the most effective size of servings the package contains. However, form of dieting for sustained weight loss and much packaging gives the appearance of a single improved health status is that which combines serving when the label specifies several servings. It moderately reduced caloric intake and increased is important to carefully read labels and to pur- daily exercise. Though weight loss is gradual with chase packaged products that truly contain a sin- such an approach (health experts recommend one gle serving, that several people can share, or that half to one pound a week), it is more likely to be are easy to store. permanent because it arises from lifestyle modifi- Portion sizes are especially difficult to assess for cations that are themselves sustainable. home-cooked meals. For example, a single serving See also APPETITE; DIET AND HEALTH; EATING DISOR- of meat is 3 ounces, about the size of a deck of DERS; EXERCISE AND HEALTH; HUNGER; NUTRITIONAL cards. Yet most people eat a portion that is 8 to 12 1 NEEDS; OBESITY AND HEALTH; WEIGHT LOSS AND WEIGHT ounces or more, which is equivalent to 2 ⁄2 to 4 MANAGEMENT. servings. A single serving portion of cooked rice or mashed potatoes is 1/2 cup, though the typical eating habits The ways in which an individual serving spoon dishes up more than that. A person approaches food consumption. Eating habits who pours a bowlful of cereal with milk for break- encompass factors such as food choices, the timing fast is likely eating 2 to 4 servings of each. Even a and frequency of meals and snacks, portion size, few handfuls of chips eaten from the bag likely and social practices around eating (such as sitting constitute 3 or 4 servings. As well, many people down as a family to eat meals at the table or eat- feel compelled to eat all the food on their plates. ing while watching television). Eating habits affect nutrition, body weight, and body composition. What People Eat Nutritional guidelines recommend the highest Why People Eat proportion of foods come from fruits, vegetables, Much eating occurs for reasons other than to bring whole grains and whole grain products, and low- energy and NUTRIENTS into the body. People may eat fat proteins. However, fats and carbohydrates • for emotional comfort make up the majority of dietary intake for many people. In the United States the frequency with • for something to do or social interaction, such which people eat in restaurants, sit down as well as going out to eat as fast food, is very high. Though a number of • out of habit, such as because it is meal time restaurants offer fresh vegetables and fruit and • because other people are eating feature “heart healthy” menu choices, restaurant • because a particular item of food smells or looks meals tend to be high in both fat and carbohy- good drate. The same is true of snack foods and pre- pared foods such as frozen dinners and boxed and • to satisfy a food craving canned products. These eating habits are not always easy to break. Recognizing them is the first step; changing When People Eat them often requires understanding the reasons Eating when hungry is the ideal timing for the behind them. Increasing physical activity helps body but is often fraught with challenge in real accommodate extra calories consumed and also life. Because APPETITE is as much a factor of desire provides diversion to direct interest elsewhere. to eat as a signal of the body’s need to acquire nutrients, most people have difficulty distinguish- How—and How Much—People Eat ing genuine hunger. The urge to eat, particularly Portion size is a key factor in healthy eating. Many when delayed, tends to manifest as overconsump- people overestimate the amount of food that con- tion. Some people try to eat only one meal as a food cravings 295 means of controlling how much they eat, though leaves these areas. As well, fat loss in these areas is this is a counterproductive effort because when more apparent because the fat collects in layers they eat they are so hungry that they eat too just underneath the SKIN. Fat loss from the cheeks much and often less than nutritious foods. Other and neck also appears noticeable early in the people may eat full meals at breakfast, lunch, and weight loss process. supper because it is the pattern of eating they See also DIET AIDS; DIETING; WEIGHT LOSS AND have always followed. Snacking between meals WEIGHT MANAGEMENT. and eating on the go are habits that often result in overeating as well as high-fat, high-carbohydrate food cravings The desire to eat particular foods, consumption. typically without correlation to HUNGER or APPETITE. Some people speculate that food cravings suggest Establishing and Maintaining certain substances are missing from the diet or Health-Oriented Eating Habits from consumption, such as salt when a person Planning for meals often instills a sense of calm craves salty foods. Others believe food cravings around the process of eating because the planning originate as signals the BRAIN sends to satisfy its helps take away the pressure of figuring out what pleasure centers. Changes in HORMONE levels in the to eat and how to make the meal happen. House- body, such as occur during PREGNANCY, appear to hold members can take turns being responsible for initiate cravings for foods in sometimes unusual meals, sharing both the responsibility and the combinations. Food aversions are also common in pleasure of the meal. Most people do better nutri- pregnancy. Pica is the condition of craving non- tionally when they eat five smaller meals spread food substances such as dirt or paper and may throughout the day, though personal schedules indicate an iron deficiency. may make such an approach impractical, or three Other food cravings appear emotionally driven, meals a day with nutritious snacks between. such as those for comfort foods during times of See also DIET AND HEALTH; FOOD CRAVINGS; NUTRI- emotional distress. For the most part, however, TIONAL NEEDS; WEIGHT LOSS AND WEIGHT MANAGEMENT. there are no clear scientific explanations for food cravings, and everyone experiences them at some “fat burners” Products—foods, drinks, supple- time. As long as a person continues to eat an over- ments, devices, and other items—that proclaim to all nutritious diet, succumbing occasional food reduce body fat without exercise or changes in cravings has no detrimental effect on health. diet. Such products are not effective in this man- However, uncontrolled response to food cravings ner; the only method for “burning” fat is for a per- may result in nutritional imbalances and often is a son to expend more energy through activity than key factor in overeating, overweight, and OBESITY. he or she consumes through eating. Some “fat- It may also signal underlying emotional or psy- burner” products contain diuretics (substances chological disturbances. that draw fluid from the body to increase URINE Controlling food cravings is challenging and output). Some “fat burners” claim to spot-reduce, highly personalized. Methods that are effective for or eliminate fat in a targeted fashion. For the most some people include part such claims are at best inaccurate and more often deceptive. The body does not draw fat from • diversionary activities that make succumbing to one location any more than another during the craving difficult (such as taking a walk or weight loss efforts. Rather the body draws fat from bicycle ride) fat stores throughout the body. Fat accumulates in • eating healthful alternatives to the desired food larger amounts in certain parts of the body (such as fresh fruit instead of candy or lemon because these areas have more fat cells to accept instead of salt for seasoning) lipid storage. These areas tend to be the abdomen, hips, buttocks, thighs, and upper arms. When • HYPNOSIS to fortify the resolve to resist the crav- weight loss occurs, correspondingly more fat ing 296 Lifestyle Variables: Smoking and Obesity

• eating regular meals throughout the day that • BEHAVIOR MODIFICATION THERAPY to gain insight contain a balance of nutritious foods and understanding about the reasons for crav- ing foods • eating a small serving or portion of the desired food, such as a mini-size instead of a full-size See also ANEMIA; EATING DISORDERS; EATING HABITS; candy bar MORNING SICKNESS; SATIETY. L–N

lean muscle mass The amount of body tissue weeks) the person takes decreasing doses to ease that is lean MUSCLE in contrast to the percentage the body’s dependence on the nicotine. Nicotine that is body fat. There is an inverse relationship replacement products include between lean muscle mass and BODY FAT PERCENT- • transdermal (SKIN) patches, which a person AGE, such that when one increases the other wears for 16 to 24 hours to deliver a steady decreases. Lean muscle mass increases with regu- trickle of nicotine absorbed through the skin lar physical exercise that challenges muscle fibers to expand. Serious illness or injury, such as signifi- • chewing gums, which deliver doses of nicotine with timed chewing and holding the gum cant BURNS or major trauma, may draw protein between the gum and cheek for absorption of from lean muscle mass to aid in HEALING, resulting in diminished lean muscle mass. A common the released nicotine through the tissues of the MOUTH and into the BLOOD circulation method for estimating lean muscle mass is UPPER ARM CIRCUMFERENCE, a measurement of the distance • lozenges, which release nicotine as they dissolve around the middle of the upper arm. It is also pos- in the mouth for absorption through the tissues sible, though less accurate, to approximate lean of the mouth and into the blood circulation muscle mass based on body fat percentage deter- • nasal sprays, which deliver nicotine to the minations. The X-RAY procedure dual-energy X- membranes inside the NOSE for rapid absorption ray absorptiometry (DEXA), a diagnostic test that into the blood circulation measures BONE DENSITY, also provides data for cal- • inhalers, small plastic mouthpieces that hold culating lean muscle mass. cartridges containing nicotine a person draws in See also BODY MASS INDEX (BMI); RESISTANCE EXER- through the mouth similar to smoking a ciga- CISE; WAIST CIRCUMFERENCE; WAIST TO HIP RATIO. rette; nicotine enters the blood circulation by absorption through the tissues of the mouth nicotine replacement Products intended to (not the LUNGS) wean a person from NICOTINE otherwise acquired through cigarette smoking. Nicotine is a highly addictive DRUG that occurs naturally in tobacco. Taking NICOTINE replacement products Though behavior is an important component of in combination with one another or smoking, the addictive quality of nicotine while still smoking cigarettes presents a accounts for the difficulty people have in quitting. major risk for nicotine toxicity. Symp- Nicotine replacement can be fairly effective as an toms of nicotine overdose include aid for SMOKING CESSATION. The premise is that the • PALPITATIONS nicotine in the product, though less than that in a • rapid or irregular HEART RATE cigarette, fulfills the body’s desire for nicotine • NAUSEA when the person stops smoking. • DIARRHEA Most nicotine replacement products come in diminishing strength doses so over the course of a Nasal sprays and inhalers require a doctor’s typical smoking cessation program (usually 12 prescription. Transdermal patches and chewing 297 298 Lifestyle Variables: Smoking and Obesity gums are available over the counter as well as by lozenges, and COUGH with any nicotine replace- prescription, depending on the strength (nicotine ment product except transdermal patches. Some DOSE). With all nicotine replacement products people may develop dependence on the nicotine nicotine OVERDOSE can occur if the person com- replacement product, which is more of a risk with bines nicotine products or continues to smoke or nasal sprays and inhalers because these methods use other tobacco products (such as chewing deliver nicotine rapidly to the blood circulation in tobacco or cigars) while using a nicotine replace- similar fashion as cigarette smoking. The typical ment product. It is important to keep nicotine course of smoking cessation therapy with nicotine replacement products, especially gums and replacement is 12 to 16 weeks and should not lozenges, out of the reach of children. extend longer than 6 months. Other possible side effects include local irrita- See also ADDICTION; ANTISMOKING EFFORTS; SMOK- tion of the tissues, HICCUPS with the gum or ING AND HEALTH. O obesity The circumstance of weighing 20 percent tors to leptin, reducing leptin’s effectiveness. or greater in excess of ideal or healthy weight as a Other mutations influence the production of lep- consequence of excessive body fat. Doctors con- tin. Leptin also influences the actions of another sider a BODY MASS INDEX (BMI) of 30 to be the bound- protein, neuropeptide Y (NPY), that stimulates ary of obesity. In the 1990s health experts classified appetite. Researchers believe mutations of the ob obesity as a clinical diagnosis as well as an inde- gene predispose individuals to obesity because pendent risk factor for numerous health condi- appetite control mechanisms within the body do tions, including DIABETES, GALLBLADDER DISEASE, not function properly. However, these mutations HYPERTENSION (high BLOOD PRESSURE), ATHEROSCLERO- do not unequivocally cause obesity. SIS, HEART FAILURE, HORMONE-DRIVEN CANCERS of the Social and cultural influences Many people BREAST and PROSTATE GLAND, and CORONARY ARTERY who meet the diagnostic criteria for obesity do not DISEASE (CAD). Obesity also interferes with INSULIN recognize that their weight has become a health sensitivity and with HEALING. Many researchers condition with serious consequences if untreated. believe obesity is as significant a risk factor as ciga- About two thirds of people who have obesity rette smoking for CARDIOVASCULAR DISEASE (CVD). identify themselves as such; one third perceive themselves as overweight but not to an extent Causes of Obesity that interferes with health or exceeds their ability The simple cause of obesity is more intake than to manage by losing weight at will. There is a outgo—energy from food consumed exceeds social tendency to joke about excessive weight, energy expended through physical activity. How- diminishing its significance as a health factor with ever, the circumstances that establish this imbal- a corresponding cultural shift toward accommo- ance are complex. Lifestyle factors—EATING HABITS dating larger body size. and physical inactivity—are key causes of obesity. Emotional and psychologic factors The reasons The extent to which genetic factors influence obe- people eat often have little to do with hunger or sity remains unknown, though researchers have nutritional need. Eating can provide a sense of identified gene-directed processes that regulate comfort during times of emotional stress. Overeat- many of the variables within the body responsible ing is an eating disorder that often has complex for how the body uses and stores energy. Social, psychologic foundations related to issues of self- cultural, emotional, and psychologic issues further esteem, control, or psychologic injury such as may influence the development of obesity. occur as a consequence of sexual, domestic, or Genetic factors Researchers have discovered a childhood abuse. number of genes that regulate body functions related to APPETITE and METABOLISM. One is the ob Symptoms and Diagnostic Path GENE, which regulates the production of the HOR- The primary symptom of obesity is significantly MONE leptin. Leptin suppresses the HUNGER, increased body size due to excessive body fat. The appetite, and SATIETY centers in the HYPOTHALAMUS diagnostic markers for obesity include and brainstem. Certain mutations of the ob gene result in diminished sensitivity of the leptin recep- • BMI of 30 or greater 299 300 Lifestyle Variables: Smoking and Obesity

• body fat percentage greater than 25 percent for The long-term success of treatment for obesity men or 32 percent for women requires ongoing and continuous management of • WAIST CIRCUMFERENCE greater than 40 inches for obesity’s numerous and often intertwined causes. men or 35 inches for women For some people weight management remains a lifelong challenge and sometimes a struggle Most people who have obesity meet all three of though others are able to achieve and maintain these diagnostic markers. People who have signifi- healthy weight. cantly increased MUSCLE mass, such as perform- ance athletes and bodybuilders, may have a higher Risk Factors and Preventive Measures BMI without having obesity. The key risk factors for obesity are physical inac- tivity and excessive food consumption. People Treatment Options and Outlook who are sedentary (get no physical exercise) are at The treatment for obesity is weight loss. Treatment highest risk for obesity. Nutritious eating habits options include lifestyle modifications, BEHAVIOR and daily physical exercise are preventive as well MODIFICATION THERAPY, medications to suppress as therapeutic. To prevent obesity health experts appetite, and BARIATRIC SURGERY. Many people recommend experience better results with a combination of treatments; lifestyle modifications are essential for • food (CALORIE) intake appropriate for age and sustained weight management, regardless of other physical activity level treatments. However, most people who have obe- • eating foods with high nutrient density, notably sity have tried many weight loss approaches with- fruits, vegetables, whole grains and whole grain out success. products, and low-fat proteins Noninvasive methods are more likely to suc- ceed for people who have class 1 obesity. The US • minimizing consumption of high-fat foods National Institutes of Health (NIH) recommends (such as fast foods and snack items) and empty aggressive noninvasive treatment for people who carbohydrates (such as sodas and sweets) have class 2 obesity but who have not yet devel- • a minimum 30 minutes a day of moderate oped significant co-morbidities (health conditions physical exercise such as walking resulting from and intertwined with obesity). For people who have class 2 obesity and two or more Preventive efforts are most likely to succeed comorbid conditions (such as hypertension and when all members of the household participate in diabetes) and for people who have class 3 obesity, them. the NIH recommends bariatric surgery. Though See also CHILDHOOD OBESITY; CULTURAL AND ETHNIC bariatric surgery entails significant risks, health HEALTH-CARE PERSPECTIVES; EATING DISORDERS; GENERA- experts believe the benefits of extensive weight TIONAL HEALTH-CARE PERSPECTIVES; HEALTHY PEOPLE loss that is possible outweigh the risks of the sur- 2010; INSULIN RESISTANCE; LIFESTYLE AND HEALTH; OBE- gery when body fat percentage exceeds 30 percent SITY AND HEALTH; PEER PRESSURE; SMOKING AND HEALTH; (class 3 obesity). WEIGHT LOSS AND WEIGHT MANAGEMENT.

CLINICAL CLASSIFICATIONS OF OBESITY Body Mass Index (BMI) Clinical Classification Health Risk 30 to 34.9 class 1 moderate

35 to 39.9 class 2 serious

40 and above class 3 severe or morbid obesity and health 301 obesity and health Obesity reached the status of condition INSULIN RESISTANCE), which requires health crisis in the United States in the 1990s. In increasingly higher levels of GLUCOSE in the BLOOD 2005, one third of Americans—nearly 60 million circulation to initiate an appropriate insulin people—weighed 20 percent or more above response. The high blood glucose levels essentially healthy body weight, the key clinical marker for “burn out” the cells that form delicate nerves and diagnosing obesity. An equal number were over- blood vessels, causing them to die. The resulting weight, weighing 5 to 20 percent above healthy irreversible damage manifests as PVD and NEU- body weight. Many health experts believe obesity ROPATHY. is as significant a health risk factor as cigarette In an effort to bring blood glucose levels down, smoking, complicit in a broad spectrum of health the ISLETS OF LANGERHANS in the pancreas, which conditions. contain the cells that produce insulin, pump out increasing amounts of insulin. The environment HEALTH CONDITIONS within the body reaches the state of type 2 dia- IN WHICH OBESITY CAN BE A FACTOR betes when the islet cells can no longer keep pace ATHEROSCLEROSIS BREAST CANCER with the body’s demands. The amount of glucose COLORECTAL CANCER CORONARY ARTERY DISEASE (CAD) in the blood circulation ultimately reaches levels ENDOMETRIAL CANCER ERECTILE DYSFUNCTION that cause symptoms such as excessive thirst and GALLBLADDER DISEASE GASTROESOPHAGEAL REFLUX URINATION that represent the body’s efforts to rid HEART FAILURE DISORDER (GERD) itself of the excessive glucose. Symptoms that HYPERTENSION INSULIN RESISTANCE reflect damage resulting from elevated blood glu- MENSTRUAL DYSFUNCTION OBSTRUCTIVE SLEEP APNEA cose also occur, such as vision changes, develop- OSTEOARTHRITIS OVARIAN CANCER ment of cataracts, tingling or loss of sensation in POLYCYSTIC OVARY SYNDROME PROSTATE CANCER the feet, and wounds that do not heal. (PCOS) SEXUAL DYSFUNCTION Obesity and cardiovascular disease (CVD) Obe- STEATOHEPATITIS type 2 DIABETES sity sets the stage for HYPERLIPIDEMIA, the pathologic circumstance of excessive lipids (fatty acids) in the How Obesity Affects the Body and Health blood circulation. Hyperlipidemia is the founda- Obesity has numerous negative influences on tion of occlusive forms of CARDIOVASCULAR DISEASE health. It is the leading cause of HYPERTENSION (CVD) such as CAD, atherosclerosis, and CAROTID (high BLOOD PRESSURE) and type 2 DIABETES and is STENOSIS. Obesity is also the primary cause of an independent risk factor for the development of hypertension, partly as a consequence of obstruc- ATHEROSCLEROSIS, CORONARY ARTERY DISEASE (CAD), tive CVD such as atherosclerosis and partly PERIPHERAL VASCULAR DISEASE (PVD), OSTEOARTHRITIS, because the pressure excessive body fat places on GALLBLADDER DISEASE, COLORECTAL CANCER, hormone- the arteries, veins, and organs increases the resist- driven BREAST CANCER, and PROSTATE CANCER. Health ance blood encounters as it flows through the cir- risk for these conditions and their complications culation and forces the HEART to work harder to or consequences increases moderately for over- pump blood. The increased workload of the heart weight and significantly for obesity. In addition to may lead to HEART FAILURE. its role as a key risk factor for numerous health Obesity and osteoarthritis Excessive body conditions, obesity is itself a health condition with weight places considerable stress on the structures significant and potentially fatal consequences of the musculoskeletal system, most notably the when it remains untreated. back, hips, knees, ankles, and feet. The CARTILAGE Obesity and type 2 diabetes More than 95 per- that pads and cushions the joints distorts under cent of people who have type 2 diabetes are over- such pressure, and over time sustains permanent weight and many have obesity. Increased body fat damage. Physical inactivity exacerbates the situa- decreases cell sensitivity to INSULIN, which sets in tion. Osteoarthritis symptoms dramatically motion a cascade of adaptations that ultimately improve with weight loss, however, and much of overwhelm the body’s normal metabolic balance. the temporary damage to the structures of the Cells become resistant to insulin (the prediabetes joints is able to heal. 302 Lifestyle Variables: Smoking and Obesity

Obesity and gallbladder disease Gallstones are healthy weight, has a measurably detrimental three times more common in people who have effect on QUALITY OF LIFE. This level of obesity pre- obesity. Lipids and fatty acids in the blood circula- sents challenges for finding clothing, seating on tion provide the LIVER with a supply of the material airplanes, sitting on chairs, riding in cars, navigat- it needs to manufacture cholesterol, a key ingredi- ing store aisles, and even simply being able to ent of BILE. Ironically, rapid weight loss in someone walk to get around for the activities of daily living. who has obesity (greater than three pounds per These challenges commonly result in social isola- week) also triggers formation of gallstones. tion and can be a problem for developing friend- Obesity and cancer Rates of certain cancers are ships and relationships. significantly higher in people who have obesity. Health conditions that have developed as a The correlation is strongest for hormonally driven consequence of obesity may hinder some weight cancers such as prostate cancer in men and breast management efforts, notably physical exercise. It cancer, OVARIAN CANCER, and ENDOMETRIAL CANCER is important to find activities that are enjoyable (cancer of the UTERUS) in women. Many health and to persist in them to the extent that they do experts believe obesity is a major risk factor for not worsen other health conditions. A person who colorectal cancer, particularly in men, though has painful osteoarthritis, for example, may studies are less conclusive than for obesity’s corre- choose to walk for 5-minute periods of time four lation with other cancers. to six times a day instead of walking for 20 or 30 Obesity as an independent health condition minutes at a time. The cumulative benefit of the Aside from its role as a contributing factor to short periods of exercise are as effective and easier numerous health conditions, which doctors call to accommodate. co-morbidity, obesity itself is a disorder with meta- bolic, cardiovascular, pulmonary, and muscu- OVERCOMING OBSTACLES loskeletal symptoms. The presence of obesity Health conditions that limit mobility may inter- alone, setting aside all correlating health condi- fere with activities such as grocery shopping, tions, shortens LIFE EXPECTANCY nearly as much as leading to relapses in EATING HABITS. Alternative cigarette smoking. People who weigh more than methods to obtain healthful foods might include 30 percent above healthy body weight are up to hiring a teenage neighbor who can drive to shop 10 times more likely to die prematurely of any on a regular basis or shopping through the cause. The excessive weight and body mass online services many grocery stores now offer. stresses all structures of the body, pressuring inter- For a small fee, such services select the items nal organs, including the LUNGS, and affecting their requested and deliver them to the home. ability to function. See also CHILDHOOD OBESITY; DEPRESSION; DIABETES Obesity and Quality of Life PREVENTION; DIET AND HEALTH; EATING DISORDERS; EXER- Obesity, notably class 3 (morbid) obesity in which CISE AND HEALTH; LIFESTYLE AND HEALTH; WEIGHT LOSS a person weighs 100 pounds or more above AND WEIGHT MANAGEMENT. S

smoking and health There are no health benefits in CENTRAL NERVOUS SYSTEM stimulation to produce and numerous health risks from cigarette smoking. a combined sense of exhilaration and alertness. In the 1940s few people, including doctors, recog- With each inhalation of cigarette smoke, tar nized the magnitude of health risks associated with makes its way to the delicate alveoli deep within cigarette smoking. But 20 years later cigarette the LUNGS, clogging them and preventing them smoking was a known and publicly identified risk from exchanging oxygen. Other chemicals in the factor for numerous health conditions and the pri- smoke irritate the bronchi, causing an increase in mary cause of HEART disease and LUNG CANCER. In the mucus production and narrowing of the bronchial 1965 cigarette smoking in the United States peaked openings. Carbon monoxide beats out oxygen to with about 45 percent of American adults being bind with HEMOGLOBIN in the red blood cells (ery- smokers; by the early 2000s, only 23 percent of throcytes), cutting by up to 60 percent the American adults smoked. However, that 23 percent amount of oxygen each breath carries into the represents 48 million people who have significantly blood circulation. The combined effects of these increased risk for CARDIOVASCULAR DISEASE (CVD), actions and the chemicals that enter the blood- chronic lung disease, and cancer. Cigarette smoking stream affect cellular METABOLISM in countless remains the leading cause of preventable disease in ways. Dozens of these chemicals are carcinogenic; the United States. they cause cells within the body to develop into cancers. Some of the effects linger for hours after PACK YEARS AND DISEASE RISK the cigarette and compound with further smoking. One method of representing the amount of ciga- Cigarette smoking and CVD The leading health rette smoke exposure an individual has had is consequence of cigarette smoking is CVD. the “pack year.” This calculation expresses the Repeated exposure to nicotine causes permanent number of packs of cigarettes a person smokes changes in the cells that form the lining of the each day times the number of years the person arteries, making the arteries vulnerable to ATHERO- has smoked. A person who has smoked for 10 SCLEROTIC PLAQUE deposits and, over time, ATHERO- pack years may have smoked half a pack a day SCLEROSIS, CORONARY ARTERY DISEASE (CAD), and for 20 years, one pack a day for 10 years, or two PERIPHERAL VASCULAR DISEASE (PVD). Persistent nico- packs a day for five years. The higher the number tine exposure also causes the arteries to stiffen and of pack years, the greater exposure and more sig- lose FLEXIBILITY. These changes lead to HYPERTENSION nificant the risk of pulmonary and cardiovascular (high blood pressure) and increased risk for HEART disease. ATTACK and STROKE. The strain on the heart can eventually cause HEART FAILURE. How Smoking Affects the Body and Health Cigarette smoking and cancer The primary Cigarette smoking affects every cell in the body form of cancer associated with cigarette smoking is beginning within seconds of the first inhalation lung cancer. However, cigarette smoking increases from a cigarette. NICOTINE contracts BLOOD vessels, the risk for various forms of cancer, including oral increases HEART RATE, raises BLOOD PRESSURE, and cancer, laryngeal cancer, ESOPHAGEAL CANCER, PAN- activates neurotransmitters in the BRAIN that result CREATIC CANCER, BLADDER CANCER, PROSTATE CANCER, 303 304 Lifestyle Variables: Smoking and Obesity

BREAST CANCER, RENAL CANCER, STOMACH CANCER, and Cigarette smoking, fertility, and pregnancy LIVER CANCER. The burning of a cigarette releases Cigarette smoking affects sperm production in smoke that contains more than 4,000 chemicals, men and OVULATION in women. Smoking during dozens of which are known carcinogens (sub- PREGNANCY limits the amount of oxygen the devel- stances that cause cancer). oping fetus receives, affecting fetal growth and development. The babies of women who smoke CARCINOGENS IN CIGARETTE SMOKE during pregnancy tend to be 10 to 20 percent acrolein acrylonitrile smaller at birth than the babies of women who do aminobiphenyl aromatic amines not smoke. Low birth weight is a health risk for aromatic nitrohydrocarbons arsenic the infant. benzene benzofluoranthene benzopyrene butadiene Smoking and Preventable Disease cadmium chromium Nearly all of the health consequences associated chrysene crotonaldehyde with cigarette smoking are preventable by not dimethylhydrazine dibenzacridine smoking. People who never smoke enjoy the dibenzanthracene dibenzocarbazole strongest preventive benefit. People who smoke dibenzopyrene ethylcarbamate and quit can, over time, restore their health risk formaldehyde hydrazine for many conditions to near normal. Health condi- hydrocarbons lead tions such as COPD, lung cancer, laryngeal cancer, methylamine methylchrysene and bladder cancer are rare in nonsmokers. Other naphthylamine nickel factors such as EATING HABITS and physical inactivity nitropropane nitrosamines contribute to CVD, though not smoking removes a nitrosonomicotine phenols significant factor from an individual’s health risk polonium-210 (radon) quinoline profile. tar toluidine See also ANTISMOKING EFFORTS; ENVIRONMENTAL urethane vinyl chloride CIGARETTE SMOKE; ERYTHROCYTE; LIFESTYLE AND HEALTH; NEUROTRANSMITTER; NICOTINE REPLACEMENT; SMOKING Cigarette smoking and chronic pulmonary con- CESSATION; TOBACCO USE OTHER THAN SMOKING. ditions Cigarette smoking is the primary cause of numerous chronic pulmonary conditions, includ- smoking cessation Efforts to stop smoking. ing CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD), Tobacco contains NICOTINE, the addictive quality of chronic BRONCHITIS, and nonallergic ASTHMA. The which is comparable to that of HEROIN. As well, damage that results from COPD is irreversible and cigarette smoking becomes a compelling behav- progressive, often leading to permanent disability. ioral element of daily life. Most smokers who Cigarette smoking and healing The changes attempt to quit make numerous efforts before suc- that take place in the cells with cigarette smoking ceeding for the long term and the risk for relapse slow cellular metabolism, limiting the ability of remains high for years. Of the 1.8 million Ameri- cells to grow and divide. These functions are can smokers who quit every year, 30 percent essential for HEALING after injury or surgery. As remain smoke free for one year. well, lungs damaged by cigarette smoking are Several medical interventions can help to unable to deliver adequate oxygen to the blood smokers break the grip of nicotine, including NICO- circulation, restricting a fuel source necessary for TINE REPLACEMENT products (such as chewing gums, cell function. The effects of cigarette smoking on transdermal patches, inhalers, and nasal sprays) healing are so significant that most surgeons will and the prescription medication bupropion not perform elective (nonemergency) operations (Zyban), which appears to diminish the desire to on people who smoke. It is necessary to be smoke smoke. Nonmedical interventions include HYPNOSIS free for two to four weeks to mitigate enough of and BEHAVIOR MODIFICATION THERAPY. Many smokers smoking’s deleterious action on cellular function are more successful with a combination of meth- to allow effective healing. ods than with a single approach; those who smoke smoking cessation 305 more than 25 cigarettes a day generally benefit The effect of nicotine remains active in the more from a structured smoking cessation pro- body for about 20 minutes after smoking a ciga- gram with ongoing support and encouragement rette. For many smokers the time between the last from a therapist or through a support group. cigarette and what would have been the next cig- arette is the most difficult, as the body exerts its TIPS FOR SUCCESSFUL SMOKING CESSATION demand for the next DOSE of nicotine. After 72 • Prepare to stop smoking by eliminating all items associated hours the nicotine urge subsides considerably. with smoking such as lighters, ashtrays, and cigarettes. Each day, week, and month without smoking • Identify places and circumstances where smoking is likely lessens the body’s sense of nicotine dependence. to be irresistible and plan alternatives. About 75 percent of people who make it one • Purchase NICOTINE REPLACEMENT products before quitting and month smoke free are able to stay smoke free for place them in former smoking places, such as in the bath- one year. Each year of remaining smoke free room, kitchen, and car. increases the likelihood of long-term smoking ces- • Plan a system of self-reward for success in meeting short- sation. It is important to take setbacks in stride, term goals. identify and eliminate the trigger for the setback, • Arrange with someone to be available around the clock to and quickly resume smoking cessation efforts. call when the urge to light up becomes intense. See also ANTISMOKING EFFORTS; SMOKING AND CAR- • Use stress management techniques such as meditation, DIOVASCULAR DISEASE; SMOKING AND HEALTH; TOBACCO yoga, and physical exercise to unwind and relax. USE OTHER THAN SMOKING. T–U

tobacco use other than smoking Forms of HYPERTENSION (high BLOOD PRESSURE). The changes tobacco such as chewing tobacco and smoking to the arterial wall’s structure also facilitate the cigars. Tobacco use other than cigarette smoking is accumulation of arterial plaque and atheroscle- the primary cause of oral cancers (cancers that rotic deposits, leading to ATHEROSCLEROSIS and involve structures of the MOUTH). The two primary increasing the risk for CORONARY ARTERY DISEASE forms of tobacco use other than cigarettes are (CAD). cigars and smokeless tobacco. Smokeless Tobacco Cigar and Pipe Smoking It is a common misperception, particularly among Cigar and pipe smoke contains many of the same young people, that smokeless tobacco is safe chemicals and carcinogens as cigarette smoke. because there is no smoke involved with its use. Because cigar and pipe smokers hold the smoke in This is not true. Smokeless tobacco contains nico- their mouths rather than inhaling it, the struc- tine, which is highly addictive. It can be as difficult tures of the mouth have intense exposure to these to quit using smokeless tobacco as it is to stop chemicals. Long-term exposure to tobacco smoke smoking. A pinch or dip of smokeless tobacco con- is detrimental to the gums and TEETH and increases tains as much nicotine as three cigarettes. Forms the risk for CARDIOVASCULAR DISEASE (CVD). of smokeless tobacco include snuff, which is pow- Though the risk of LUNG CANCER from smoking dery, and chewing tobacco (plugs, twists, and cigars or pipes is less than that from smoking ciga- loose leaf). rettes, it is notably higher than for people who do Smokeless tobacco is particularly damaging to not smoke at all and in people who smoke three the teeth and gums. After only a few years of reg- or more cigars a day. People who regularly smoke ular use, the gum tissue may become structurally cigars also have higher risk for PANCREATIC CANCER, unstable, unable to support the teeth. Tooth loss laryngeal cancer, and ESOPHAGEAL CANCER. The may be unpreventable in such circumstances. The most significant cancer risks from cigar smoking irritation of the tobacco against the gums and are cancers of the lips, tongue, cheeks, soft palate cheeks also causes sores that can be painful or can (roof of the mouth), floor of the mouth, and further erode the tissue around the base of the gums. teeth. Tobacco juice permanently stains the teeth Smoking two to three cigars or more a day yellow or brown and erodes the enamel outer raises the risk for CVD nearly as much as cigarette layer, increasing the risk for DENTAL CARIES (cavi- smoking. The NICOTINE in tobacco becomes rapidly ties) and weakening the teeth. absorbed into the BLOOD circulation through the About four times the concentration of nicotine mucous membranes in the mouth. Nicotine stim- enters the blood circulation from smokeless ulates the smooth MUSCLE that makes up the walls tobacco as from cigarette smoking. Nicotine that of the arteries, causing the arteries to stiffen. enters the blood circulation by being absorbed Chronic exposure to nicotine also alters the struc- through the tissues of the mouth has the same ture of the muscle fibers in the arterial walls, negative effects on the blood vessels as nicotine reducing their FLEXIBILITY. These changes cause that enters the blood circulation through the 306 upper arm circumference 307

LUNGS, raising the risk for atherosclerosis and CAD (5 percent body fat) indicating insufficient nutri- with prolonged use. As well, smokeless tobacco tion. contains carcinogens that release into the mouth See also BODY MASS INDEX (BMI); UPPER ARM CIR- and is the leading cause of oral cancers. Doctors CUMFERENCE; WAIST CIRCUMFERENCE; WAIST TO HIP diagnose 30,000 people with oral cancers due to RATIO. smokeless tobacco use each year in the United States; about 8,000 Americans die each year from upper arm circumference A measurement of such oral cancers. the distance around the center of the upper arm, which serves as an approximate measure of LEAN CARCINOGENS IN SMOKELESS TOBACCO MUSCLE MASS. Upper arm circumference, also called acetaldehyde arsenic mid-upper arm circumference (MUCA), is one benzopyrene cadmium method to estimate appropriate nutrition. The crotonaldehyde formaldehyde muscles store protein, thus measuring the size of hydrazine nitrosamine acids muscles provides an approximation of the body’s polonium-210 (radon) tobacco-specific protein supply. In undernutrition and MALNUTRI- volatile aldehydes nitrosamines (TSNAs) TION MUSCLE size shrinks because the body metabo- volatile nitrosamines lizes protein stores to generate energy. Overnutrition (overweight and OBESITY) results in See also CARCINOGEN; HALITOSIS; SMOKING AND exaggerated muscle size as a consequence of high CANCER; SMOKING AND HEALTH; SMOKING CESSATION. amounts of fat in the muscle fibers. RESISTANCE EXERCISE such as weightlifting enlarges the upper triceps skinfold A measure of the thickness of a arm muscles, which can make upper arm meas- fold of SKIN at the triceps (MUSCLE at the back of urement less accurate as an assessment of lean the upper arm), which indicates BODY FAT PERCENT- muscle mass. AGE. Triceps skinfold thickness is easy for doctors, nutritionists, and fitness professionals to measure UPPER ARM CIRCUMFERENCE AND HEALTH as a means of monitoring loss of body fat. A ten- Measurement Health Risk Correlation sioned caliper, placed over a segment of pinched (centimeters) skin at the triceps, measure the skinfold thickness <16 MALNUTRITION in millimeters. The thickness value corresponds 16.1 to 18.5 increased risk for undernutrition roughly to the body fat percentage. For example, a 18.6 to 22 no increased health risk triceps skinfold measurement of 10 millimeters 22.1 to 25 overweight, moderate health risk (mm) corresponds to approximately 10 percent > 25 OBESITY, significant health risk body fat; of 35 mm to approximately 35 percent body fat. The triceps skinfold measurement may See also BODY MASS INDEX (BMI); TRICEPS SKIN also serve as an indicator for adequate nutrition in FOLD; WAIST CIRCUMFERENCE; WAIST TO HIP RATIO; infants and young children, with less than 5 mm WEIGHT LOSS AND WEIGHT MANAGEMENT. W waist circumference The distance measured Waist circumference that exceeds 35 inches for around the waist. Doctors define the waist as the women or 40 inches for men when body weight is imaginary line that circles the body between the within the range of healthy (BMI of 18.5 to 24.9) umbilicus (belly button) and the crest of the hip indicates a body fat distribution pattern of ABDOMI- bones. Healthy waist circumference is less than 35 NAL ADIPOSITY, which reflects increased risk for inches for a woman and less than 40 inches for a heart attack and CVD even when no other risk man, regardless of age. Waist circumference is an factors for heart disease are present. Doctors rec- important measure of health risk for conditions ommend modest weight loss (5 to 10 percent), such as OBESITY, INSULIN RESISTANCE, type 2 DIABETES, with emphasis on increased physical activity, to and forms of CARDIOVASCULAR DISEASE (CVD) such as reduce waist circumference. HYPERTENSION (high BLOOD PRESSURE), HYPERLIPIDEMIA, See also HEALTH RISK FACTORS; WAIST TO HIP RATIO; ATHEROSCLEROSIS, and CORONARY ARTERY DISEASE WEIGHT LOSS AND WEIGHT MANAGEMENT. (CAD). Excessive waist circumference also dramati- cally increases risk for HEART ATTACK. waist to hip ratio The proportion between the Though waist circumference alone increases distance around the waist and the distance around the risk for health conditions, the risk compounds the hips (WAIST CIRCUMFERENCE divided by hip cir- when it occurs in combination with elevated BODY cumference). A waist to hip ratio of 0.9 in men MASS INDEX (BMI). Health risk rises moderately and 0.8 in women indicates an “apple” body when BMI reaches 25 and significantly when BMI shape, which reflects an elevated body fat percent- reaches 30. In combination with waist circumfer- age, heralds an increased risk for CARDIOVASCULAR ence that exceeds 35 inches for a woman or 40 DISEASE (CVD) and HEART ATTACK in particular. The inches for a man, health risk jumps to the next higher the waist to hip ratio, the greater the risk. level. Other risk factors for CVD, such as cigarette smoking and physical inactivity, further increase WAIST TO HIP RATIO AND HEALTH RISK the likelihood for heart disease, heart attack, and Health Risk Men Women STROKE. Weight loss sufficient to decrease waist cir- cumference also decreases BMI, improving the healthy, no increased risk 0.89 or less 0.79 or less health risk. moderate to significant 0.9 or greater 0.8 or less

WAIST CIRCUMFERENCE, BODY MASS INDEX (BMI), AND HEALTH RISK DUE TO WEIGHT Health Risk Moderate Significant Severe BMI overweight (25 to 29.9) X waist > 35 inches/40 inches X BMI overweight plus waist > 35/40 inches X BMI OBESITY class 1 (30 to 34.9) X BMI obesity class 1 plus waist > 35/40 inches X

308 weight loss and weight management 309

See also ABDOMINAL ADIPOSITY; BODY MASS INDEX Calorie intake below these levels activates the (BMI); BODY SHAPE AND CARDIOVASCULAR DISEASE; body’s starvation mechanisms, which result in UPPER ARM CIRCUMFERENCE. slower METABOLISM and efforts to conserve energy (calories). Daily exercise is essential to increase weight loss and weight management The the body’s energy expenditure. During weight loss approaches and methods to lose excessive weight efforts, increased activity and decreased food con- and maintain healthy weight after weight loss. sumption combine for the most efficient results. Two thirds of Americans weigh more than is healthy, with a corresponding increase in weight- 30 MINUTES A DAY = 15 POUNDS A YEAR related health conditions such as HYPERTENSION One pound of fat is the equivalent of 3,500 calo- (high BLOOD PRESSURE), type 2 DIABETES, ries. Physical exercise at the minimum recom- OSTEOARTHRITIS, ATHEROSCLEROSIS, and CORONARY mended level of 30 minutes daily typically ARTERY DISEASE (CAD). Americans also spend tens of consumes 150 calories a day. This adds up to 1 billions of dollars each year on diet programs, nearly 1 ⁄2 pounds a month, or 15 pounds a year, books, diet aids, and other weight-loss products. lost through exercise alone. Yet the premise of weight loss and weight man- agement is fairly simple: eat less and exercise Behavior modification therapy Behavior modi- more as a matter of lifestyle. fication therapy may incorporate techniques such as taking smaller portions with the understanding Losing Weight that one can have more if still hungry, extending A weight loss approach that balances decreased consumption of a meal over a certain period of food intake and increased exercise can provide time to encourage a slower pace of eating, eating steady, sustainable results. Health experts recom- only at the table without reading or watching tele- mend a rate of nonsurgical weight loss that targets vision, keeping a food and exercise journal, sched- no more than a 10 percent drop in weight over no uling exercise “appointments,” and shopping after less than six months for optimal success in keep- eating and only from a list. ing the weight off long term. Short-term weight Medication therapy Prescription APPETITE sup- loss goals help monitor progress and establish a pressants can help people follow portion size and sense of success. Methods for weight loss include eating recommendations to reduce the amount of lifestyle modifications, BEHAVIOR MODIFICATION THER- calories they consume. Medications tend to APY, medication therapy, and BARIATRIC SURGERY. become less effective over time. Researchers are Lifestyle modifications: eating habits and exer- uncertain whether this is an issue of physiologic cise Lifestyle is the cornerstone of weight man- tolerance (the body becomes resistant to the med- agement. Many people achieve greater success ication’s effect) or a matter of becoming accus- with their weight loss efforts when they join pro- tomed to the medication and more able to grams that incorporate nutritional control (such as overcome its effect. Medication may be an appro- prepared meals or stringent menus) and struc- priate treatment for people who have a BODY MASS tured physical exercise (such as group classes). INDEX (BMI) between 30 and 34.9 (class 1 OBESITY) However, fad diets that promise rapid weight loss and who have been unsuccessful with efforts to generally do not produce sustainable results. lose weight. The medications to suppress appetite It is important for people who need to lose may have significant side effects or DRUG interac- weight to understand portion sizes, NUTRIENT DEN- tions. SITY, NUTRITIONAL NEEDS, and nutritional food Over-the-counter (OTC) diet medications often choices that are also palatable. This understanding contain CAFFEINE or a decongestant such as pseu- is essential for incorporating healthy EATING HABITS doephedrine. These drugs may mildly suppress the into long-term lifestyle modifications. Unless appetite though their long-term use may result in under a doctor’s supervision and guidance, daily side effects such as agitation and PALPITATIONS. OTC CALORIE intake should never drop below 1,200 diet products generally provide no greater benefit calories for women and 1,600 calories for men. than diet and exercise alone. 310 Lifestyle Variables: Smoking and Obesity

MEDICATIONS TO SUPPRESS APPETITE Medication Actions Possible Side Effects orlistat (Xenical) blocks intestinal absorption of fat frequent or uncontrollable bowel movements deficiency of fat-soluble vitamins (A, D, E, and K) phentermine (Fastin) CENTRAL NERVOUS SYSTEM stimulant dependency increases NOREPINEPHRINE levels in the PALPITATIONS BRAIN, which suppresses the APPETITE and insomnia HUNGER centers DRUG INTERACTION with monoamine oxidase inhibitor (MAOI) antidepressants sibutramine (Meridia) increases norepinephrine and serotonin serotonin syndrome levels in the brain, an action that drug interaction with narcotic analgesics, selective suppresses the appetite and hunger serotonin reuptake inhibitor (SSRI) antidepressants, and centers and elevates mood MAOI antidepressants

Bariatric surgery Weight loss surgery is a dras- will support sustained weight management. Even tic measure that becomes a treatment option small progress makes a measurable difference in when an individual’s weight exceeds 100 pounds health and well-being. over healthy weight (class 3 obesity) or otherwise Social and family support Encouragement and directly and immediately threatens health. Most support for weight loss and weight management bariatric surgery operations either restrict the size from family and friends is crucial for long-term of the STOMACH to limit the volume of consumed success, though is often a complex dynamic. Some food or alter the flow of ingested food to curtail people find themselves alone in their weight loss absorption. Surgery for weight loss has numerous efforts because other family members do not want risks and potential complications, though may be to make the same changes in their own eating the therapeutic approach that succeeds for people habits and physical activity. Other people are able who have been otherwise unable to reach a to make weight loss and weight management a healthier weight. family endeavor or to join with friends to support and encourage one another. Positive reinforce- HEALTH BENEFITS OF WEIGHT LOSS ment for achievements, however small, is far decrease OSTEOARTHRITIS improve HYPERLIPIDEMIA more effective than criticism. symptoms improve HYPERTENSION Relapse and weight gain Relapses of regained improve INSULIN sensitivity improve LIBIDO and sexual weight are common and disheartening. However, relieve OBSTRUCTIVE SLEEP function the quicker a person recognizes that his or her APNEA improve self-esteem weight is slipping back toward obesity the easier it improve type 2 DIABETES improve FERTILITY is to stop the slide and return to the treatment increase energy and mobility reduce risk for cancer methods that were effective. Unfortunately many reduce risk for CARDIOVASCULAR reduce risk for type 2 people tend not only to regain lost weight but also DISEASE (CVD) diabetes to gain additional weight. Such a rebound or “yo- relieve chronic BACK PAIN relieve GASTROESOPHAGEAL yo” effect is especially detrimental to health. It is REFLUX DISORDER (GERD) important to get back on track with eating habits and exercise as quickly as possible to halt weight Maintaining Healthy Body Weight gain before it becomes overwhelming to confront. Weight loss that is gradual and steady generally See also DIET AND HEALTH; EATING DISORDERS; EXER- results from incorporating lifestyle changes that CISE AND HEALTH; OBESITY AND HEALTH. SUBSTANCE ABUSE

Substance abuse is the use of any DRUG, including ALCOHOL, or other psychoactive substances in ways that are harmful to a person or others whom the person’s actions may affect. Health-care practitioners who provide care for people who have substance abuse problems, alcohol or drug DEPENDENCE, and ADDICTION may be physicians (MDs or DOs), psychi- atrists (physicians who specialize in psychiatric disorders), psychologists (PhDs), social workers (LSWs), and clinical registered nurse practitioners (CRNPs). Practitioners may be certified substance abuse professionals (SAPs), designat- ing that they have additional education and experience in treating substance abuse (including ALCOHOLISM).

This section, “Substance Abuse,” presents an drugs, in the same year. Through concerted legal, overview discussion of the health implications of social, and medical efforts heroin abuse declined substance abuse and alcoholism and entries about significantly over the following 30 years, and in substances of abuse, health risks related to sub- 2004 the US Substance Abuse and Mental Health stance abuse, and treatment for substance abuse. Administration (SAMHA) estimated 166,000 peo- ple actively using heroin. From Tonic to Toxin: Opium’s Odyssey Opiates, and in particular morphine and its Many substances currently restricted because of direct derivatives, remain the mainstay of analge- their high potential for abuse were once in com- sia (pain relief) in medical treatment though mon use. For centuries cultures around the world under tight regulatory control. Tens of millions of used opium, the dried sap from the poppy plant, Americans use opiates for effective pain manage- Papaver somniferum, to relieve PAIN, induce sleep, ment. However, PRESCRIPTION DRUG ABUSE of opiate and provide INTOXICATION. In 1805 a young phar- NARCOTICS such as hydromorphone, hydrocodone, macist’s assistant, Freidrich Wilhelm Adam Ser- oxycodone, and codeine becomes problematic for turner (1783–1841), isolated morphine, opium’s about four million of them. most potent ingredient, from opium; 90 years later chemists at the Bayer Company created Health Implications of Substance Abuse HEROIN from morphine. For the next decade the Addiction is a condition that develops over time, most common use of heroin was to treat mor- regardless of the substance or behavior that is the phine addiction—clearly a circumstance, in retro- source of the addiction. Social factors compound spect, of leaping from the frying pan into the fire. the health issues of addiction; many people are By 1913 the Bayer Company stopped produc- afraid or reluctant to acknowledge a possible addic- ing heroin, and in the 1920s opium and heroin tion for fear of repercussions in all areas of their became illegal in the United States. Federal law lives. Despite advances in understanding addiction regulated the manufacture, sale, and possession of in recent years, the perception remains that addic- morphine and other medicinal OPIATES. Nonethe- tion is a matter of insufficient willpower. However, less heroin continued to make its way into the addiction arising from substance abuse (whether United States, and in 1970 its abuse peaked with alcohol, NICOTINE, illicit drugs, or prescription more than 750,000 Americans addicted. Perhaps drugs) represents a complex entanglement of phys- not so coincidentally the US Congress passed the iologic, psychologic, and social factors. Many peo- Controlled Substances Act, the first comprehen- ple abuse multiple substances though have a sive classification and enforcement legislation for primary substance of abuse. 311 312 Substance Abuse

DRUG SLANG Drug Name Slang Names ALKYL NITRITES rush, locker room, rave, poppers, snappers

AMPHETAMINES speed, go-pill, upper

BARBITURATES yellow jackets, reds, blues, rainbows, downers, barbs, goofballs

COCAINE coke, snow, flake, blow, big C, lady, nose candy, white, party favors

DEXTROMETHORPHAN DXM, skittles, candy, c-c-c, dex, DM, Drex, red devils, tussin, velvet

FLUNITRAZEPAM (Rohypnol) roofies, rophies, roach, rope, forget-me pill

GAMMA HYDROXYBUTYRATE (GHB) liquid ecstasy, soap, easy lay, vita-G, Georgia home boy

HEROIN smack, horse, brown sugar, junk, black tar, big H, bag

KETAMINE special K, vitamin K, super K, keets lysergic acid diethylamide (LSD) acid, blotter, trip, hit, sugar cube, microdot, tab, purple haze marijuana pot, weed, reefer, mary jane, aunt mary, boom, kif, skunk, herb, dope, gangster

METHAMPHETAMINE speed, crank, crystal, ice, glass, meth, crystal meth

METHYLENEDIOXYMETHAMPHETAMINE (MDMA) XTC, X, hug drug, ecstasy, ecstacy

PHENCYCLIDINE (PCP) angel dust, ozone, wack, rocket fuel, crystal supergrass, embalming fluid, killer joint

Often the break from the addictive behaviors herself injects illicit drugs or has sexual partners occurs as a consequence of intervention, either by who inject illicit drugs. Intravenous drug use is family members and friends or through legal also the leading means of transmitting infection processes such as court-imposed sentencing to a with HEPATITIS B, hepatitis C, and hepatitis D. Intra- substance abuse program. Unfortunately, such venous drug users face numerous other risks intervention all too often comes at the cost of including ENDOCARDITIS (bacterial infection of the injury to self or others. Alcohol is a factor in more HEART valves), damaged and destroyed veins, cel- than half of MOTOR VEHICLE ACCIDENTS in the United lulitis (infection of the skin and underlying tissue), States. Other substances that alter perception, MALNUTRITION, and poisoning from the unknown judgment, and reaction time further contribute to ingredients illicit drugs contain as fillers. traffic accidents, which are the leading cause of accidental injury and death. These substances Special Risks: Substance Abuse During Pregnancy include CANNABIS products (marijuana, hashish, Substance abuse during PREGNANCY poses unique hash oil), as well as STIMULANTS, BARBITURATES, BEN- risks for the developing FETUS, which may experi- ZODIAZEPINES, and HALLUCINOGENS. ence health crises at birth and lifelong health con- Two thirds of new HIV/AIDS INFECTION among sequences. Among the most toxic substances of women in the United States result directly or indi- abuse is alcohol, which is teratogenic at nearly rectly from injected drug use: either the woman every stage of pregnancy. FETAL ALCOHOL SYNDROME Substance Abuse 313

(FAS) is the most severe complication of maternal specific drugs. Psychiatric disorders also play roles alcohol use during pregnancy. FAS may involve in susceptibility to addiction. significant physical BIRTH DEFECTS, BRAIN damage, Some research has shown that more than 80 developmental delays, LEARNING DISORDERS, and percent of people diagnosed with SCHIZOPHRENIA psychologic conditions. are also heavy cigarette smokers—addicted to Infants of women who are addicted to drugs are nicotine—have other substance abuse problems or born addicted themselves, requiring intensive med- addictions. Researchers do not know whether the ical care after birth to wean them from the drugs addictions increase susceptibility for psychiatric ill- and restore normal body functions. These infants ness or psychiatric illness increases vulnerability are also often born prematurely, further compro- for addictions. mising their health and well-being. Though the ter- The multiplicity of factors that contribute to atogenic risks of drugs such as heroin and COCAINE addiction make its treatment all the more difficult. remain unclear, long-term health problems and Of the 20 million Americans who have substance learning disabilities later in childhood are common. abuse or addiction problems, fewer than 4 million Babies born to women who smoke cigarettes seek treatment. New medications that target spe- are characteristically of small birth weight, which cific neuroreceptors have vastly improved symp- researchers believe results from insufficient oxy- tom relief during DETOXIFICATION and help maintain gen in the mother’s BLOOD circulation. They also SOBRIETY after withdrawal for many people. Inte- have high risk for failure to thrive, a potentially grated efforts to educate students and employees lethal health circumstance in which the infant about the dangers of substance abuse, coupled does not grow and develop normally but for no with mandatory drug testing in a growing number discernible medical reasons. Such infants require of environments, appear to have significantly diligent care and frequent medical attention, and reduced substance abuse in certain settings. are more vulnerable to infection and illness. Focused therapy that helps people learn new behaviors (BEHAVIOR MODIFICATION THERAPY) and Advances in Knowledge and Treatment gain insight into the reasons they abuse drugs and Discovery of opiate receptors in the early 1970s alcohol (COGNITIVE THERAPY) seems to be improving was a huge leap forward in understanding how the success rate for maintaining sobriety. As well, narcotics work in the brain. Subsequent advances pharmacologic research is producing new kinds of allowed researchers to identify the roles of other narcotics that can target specific neuroreceptors in neuroreceptors and neurotransmitters and to dis- ways that provide therapeutic action (such as pain cover alterations in brain function that occur with relief) with low risk for addiction. A addiction A pattern of lifestyle that revolves who has the addiction recognizes them. Denial of around obtaining and using drugs. The behaviors addiction is itself a key symptom. Specific symp- of this pattern are compulsive and difficult to toms of addiction vary with the substance that is resist or overcome, particularly when there is the source of the addiction and may cover a broad physical DRUG DEPENDENCE. However, addiction can range of physiologic and psychologic characteris- occur with nearly any substance (such as drugs, tics. General symptoms of addiction may include ALCOHOL, and tobacco) or behavior (such as gam- bling) that a person feels he or she cannot live • agitation or anxiety without and is willing to take substantial risks to • obsessive interest in maintaining or obtaining keep the substance or behavior part of everyday access to the substance or behavior life. For most people addiction is a chronic condi- • loss of interest in work, family, and social activ- tion for which successful treatment often requires ities ongoing diligence, participation in SUPPORT GROUPS, and PSYCHOTHERAPY. • isolation from others Numerous health complications are associated • dramatic change in physical appearance, such with addiction. Key among them are HEPATITIS and as continuously runny NOSE, bloodshot eyes, or HIV/AIDS among people who inject drugs using weight loss shared needles and paraphernalia. MALNUTRITION is common among people who have addictions to Diagnosis of addiction is a complex process that alcohol, HEROIN, COCAINE, AMPHETAMINES, and often includes input from a physician, a psycholo- METHAMPHETAMINE. Prime health risks associated gist or psychiatrist, and a substance abuse special- with the leading addiction in the United States, ist. Though BLOOD and URINE tests may provide cigarette smoking, include CARDIOVASCULAR DISEASE evidence that a particular substance is in the body, (CVD) and LUNG CANCER. such test results alone do not establish a diagnosis of addiction. The diagnostic path includes physical SUBSTANCES FOR WHICH and psychologic examinations that look for indica- ADDICTION IS MOST COMMON tions of substance abuse, such as needle tracks ALCOHOL AMPHETAMINES (injected drugs) or rotted TEETH (methampheta- BARBITURATES BENZODIAZEPINES mine), and behaviors that suggest addiction (most CANNABIS compounds COCAINE possessions have disappeared, poor PERSONAL DESIGNER DRUGS HALLUCINOGENS HYGIENE, fired from multiple jobs or not able to get inhalants METHAMPHETAMINE a job, frequent arrests or other legal problems). methylphenidate NICOTINE OPIATES organic solvents Treatment Options and Outlook There are numerous approaches to treatment for Symptoms and Diagnostic Path addiction, most of which have short-term and Symptoms of addiction are often apparent to fam- long-term components. The treatment approach ily members and friends long before the person must meet the specific needs of the individual as 314 alcohol 315 well as address the physiologic and psychologic • intense feelings of anxiety, loneliness, and loss aspects of the substances to which the person has • PEER PRESSURE addictions. In the short term, SUBSTANCE ABUSE TREATMENT may require intensive psychologic sup- • family history of ALCOHOLISM or substance abuse port and therapy through an outpatient or inpa- tient substance abuse treatment program. Though genetic factors likely exist that con- Treatment may involve medical care for symp- tribute to an individual’s vulnerability to addic- toms of WITHDRAWAL SYNDROME resulting from drug tion, researchers believe such factors are multiple dependence, such as NICOTINE REPLACEMENT patches and affect numerous processes within the body. As for tobacco dependence, METHADONE or BUPRENOR- well, some drugs have higher potential for addic- PHINE for opiate dependence, and disulfiram for tion, notably those that produce an intense alcohol dependence. Medication therapy may also response to taking them. Such drugs include focus on treating underlying or accompanying methamphetamine, heroin, and cocaine. psychologic disorders such as DEPRESSION (ANTIDE- It often seems, to those outside looking in at PRESSANT MEDICATIONS) and anxiety (ANTIANXIETY addiction, that the simple solution to preventing MEDICATIONS). Treatment programs typically also addiction is making the choice not to use drugs or include intensive psychotherapy, BEHAVIOR MODIFI- alcohol. This is an effective solution in many cir- CATION THERAPY, COGNITIVE THERAPY, group therapy, cumstances; the person who is able to avoid the and peer support. These approaches attempt to substance does not develop addiction to sub- help people understand their motivations for seek- stances if not taking them. However, the health ing the effects of the substance of abuse, the condition of addiction is complex; one of its most behaviors they indulge in to achieve the sub- destructive features is its ability to impair a per- stance, and the ways in which they can replace son’s capability to make such choices. The conse- those behaviors with others that support nondrug- quences of addiction are often severe yet do not seeking behaviors. deter the pursuit of the addiction’s source. The Relapses are common among people who have most effective prevention efforts are those that addictions. Once established, an addiction remains combine education about substance abuse and its a powerful compulsion even with treatment and negative health effects with measures to help peo- methods to mitigate its strength. Absolute avoid- ple choose not to use substances of abuse the first ance of the substance or behavior (abstinence) is time. crucial; most addiction experts agree that people See also GENERALIZED ANXIETY DISORDER (GAD); who have addictions cannot experience “just a lit- ILLICIT DRUG ABUSE; NALTREXONE; OBSESSIVE–COMPUL- tle” of the addiction’s source without succumbing SIVE DISORDER (OCD); PRESCRIPTION DRUG ABUSE; SMOK- again to the addiction. Though researchers do not ING CESSATION; SCHEDULED DRUG; SUBSTANCE ABUSE fully understand the complexity of addiction’s PREVENTION; TOLERANCE. mechanisms, they do know that even small expo- sure to the source can reactivate the addiction. aerosols and glues See ORGANIC SOLVENTS. Long-term REMISSION requires persistence and determination in combination with a strong sup- alcohol In the context of health and substance port network of family, friends, and health-care abuse a fermented or distilled beverage containing providers. ethanol (also called ethyl alcohol) that, when Risk Factors and Preventive Measures ingested, has numerous effects on the body, rang- Multiple factors contribute to addiction. Among ing from mild relaxation to INTOXICATION. Alcohol the key risks are consumption is legal though regulated in the United States by federal and state laws and pro- • underlying psychologic conditions such as hibited by minors (those under age 21). Each state depression, ATTENTION DEFICIT HYPERACTIVITY DIS- establishes the laws and regulations that govern its ORDER (ADHD), and POST-TRAUMATIC STRESS DISOR- alcohol sales. However, access to alcohol is such DER (PTSD) that underage alcohol consumption is a significant 316 Substance Abuse health and social problem. In the United States, hol. Though alcohol METABOLISM varies among alcohol is a factor in more than one third of MOTOR individuals, in general the body takes 60 to 90 VEHICLE ACCIDENTS. Long-term alcohol abuse con- minutes to metabolize one standard drink’s worth tributes to numerous health conditions including of the alcohol. Men tend to metabolize alcohol permanent birth defects in children exposed to more quickly than women because they have alcohol during fetal development (FETAL ALCOHOL higher quantities of the enzyme acetaldehyde SYNDROME). Alcohol is the most commonly abused dehydrogenase, which breaks down acetaldehyde DRUG in the United States. (a harmful toxin) to acetic acid (a harmless waste product) that the body can excrete in the URINE. Alcoholic Beverages From the perspective of intoxication, a drink is Ingesting large quantities of ethanol merely the vehicle that carries alcohol into the (alcoholic beverages) or of alcohols body. The alcohol in a distilled beverage such as other than ethanol such as methanol gin is no different from the alcohol in beer or (wood alcohol) and isopropyl alcohol wine. What does differ is the concentration of (rubbing alcohol) is potentially fatal. alcohol within the drink. A distilled drink may contain 40 percent alcohol (represented as “80 Alcohol Intoxication proof” on the label); a beer is usually 4 percent Intoxication (drunkenness) occurs with alcohol and wine is 10 to 14 percent. Thus a 1-ounce shot consumption because alcohol, which is chemically of distilled spirits, 12-ounce glass of beer, and 5- a solvent, literally softens the neural membranes ounce glass of wine all contain roughly the same (the outermost structure of a NEURON), disrupting amount of alcohol. Each of these is a “standard” their ability to respond to electrical impulses drink for purposes of assessing alcohol consump- (action potential). The highest concentration of tion. Alcohol contains 7 calories per gram, 100 to neurons is in the brain; the brain neurons most 150 calories per standard drink. Mixers add addi- significantly affected appear to be those of the pre- tional calories. Other than energy, alcohol has no frontal cortex, a part of the brain responsible for nutritional value. coordinating numerous functions of cognition, judgment, memory, and inhibition. From a physi- Alcohol Absorption and Metabolism ologic perspective these changes and the behaviors Ethanol is a small molecule that the body rapidly that result define intoxication. The return to nor- absorbs through the STOMACH and SMALL INTESTINE mal follows the same path in reverse, with the less and that, once in the BLOOD circulation, readily complex functions returning first as the neural crosses the BLOOD–BRAIN BARRIER to affect the BRAIN membranes essentially “dry out.” directly. A person generally begins to feel the Alcohol also alters the presence and balance of effects of alcohol within 10 minutes of ingesting chemicals in the brain. Among them are an alcoholic drink; the amount of alcohol in the blood circulation peaks about 45 minutes after • gamma-aminobutyric acid (GABA), an consumption. Factors that influence the rate of inhibitory NEUROTRANSMITTER that carries NERVE absorption include carbonation and the presence impulses in the cerebral cortex to facilitate of food. The alcohol from carbonated alcoholic processes related to inhibitions beverages, such as beer and champagne, enters • DOPAMINE, a neurotransmitter that is key for the blood circulation more rapidly than from non- nerve impulses related to mood, emotion, and carbonated alcoholic beverages such as wine. the perception of pleasure Foods, particularly those high in fat and protein, • glutamate, an excitatory neurotransmitter that significantly slow the absorption of alcohol. increases activity among neurons Once in the blood circulation, however, alcohol metabolizes at a consistent, predictable rate Alcohol blocks the actions of GABA and gluta- regardless of its ingested form. The body metabo- mate, suppressing the mechanisms in the brain lizes alcohol far more slowly than it absorbs alco- that inhibit inappropriate behaviors and create a alcohol 317 sense of relaxation and calmness. At the same reducing blood pressure. However, health experts time alcohol increases the presence of dopamine, caution that people who do not currently drink resulting in feelings of pleasure or even euphoria. should not start; the potential health benefits do With continued, excessive alcohol consumption not sufficiently outweigh the risks. People who the brain becomes accustomed to these altered should not drink alcohol under any circumstances balances and develops reliance on the alcohol to include those who are in recovery from ALCO- maintain them. At the same time the brain devel- HOLISM and pregnant women. People who take ops TOLERANCE to the presence of alcohol in the prescription drugs should be cautious because blood circulation; it requires higher doses of alco- alcohol interferes with numerous medications. hol to elicit the same neurotransmitter responses. The physical and mental impairments typically Health Risks of Alcohol Consumption associated with intoxication begins with the most Alcohol toxicity is a serious risk with bouts of complex skills and progresses to the least complex heavy or binge drinking in which a person con- skills. Because judgment is among the complex sumes large quantities of alcohol in a short time. skills, by the time a person loses motor function A blood alcohol concentration twice the legally skills (such as balance and coordination) he or she defined level of intoxication, 0.16 percent, results is unable to perceive their deficiencies. Memory in the state of euphoria commonly associated with storage and retrieval are also high-level skills being intoxicated. At this concentration in the impaired early in intoxication, accounting for the blood circulation alcohol significantly impairs inability to remember events that happen during judgment, physical coordination, and reaction intoxication. Long-term, chronic alcohol abuse time. A blood alcohol level three times the typical (frequent, repeated intoxication) alters GENE legal limit—0.24 percent—causes extreme confu- expression within cells that may result in perma- sion and possibly stupor. With a blood alcohol nent changes in cell activity. level of 0.35 percent the average person is uncon- The uniform standard for legal intoxication in scious; 0.50 percent is often a point of no return the United States is a blood alcohol concentration leading to RESPIRATORY FAILURE and death. (BAC) of 0.08 percent, which represents a measure HEALTH RISKS OF ALCOHOL ABUSE 80 milligrams of alcohol per deciliter (100 milli- liters) of blood. This is the level of alcohol concen- Short Term tration in the blood circulation at which predictable ACCIDENTAL INJURIES acts of VIOLENCE impairments typically occur. However, individuals alcohol toxicity impaired cognitive function may appear more or less intoxicated than their impaired judgment impaired physical BACs suggest because response to alcohol varies. interaction with medications coordination reduced inhibition short-term memory Health Benefits of Alcohol Consumption sleep disturbances difficulties A number of research studies suggest that for most slowed reaction times slurred speech people regular, moderate alcohol consumption— Long Term no more than one alcoholic drink daily for women BERIBERI CARDIOMYOPATHY and two alcoholic drinks daily for men—can CIRRHOSIS FETAL ALCOHOL SYNDROME reduce the risk for CARDIOVASCULAR DISEASE (CVD) GASTRITIS GASTROINTESTINAL BLEEDING such as HYPERTENSION (high BLOOD PRESSURE) and HYPERTENSION LIVER CANCER ATHEROSCLEROSIS (fatty deposits in the walls of the LIVER DISEASE OF ALCOHOLISM NUTRITIONAL DEFICIENCY arteries). Alcohol affects lipid metabolism, raising PANCREATIC CANCER PANCREATITIS levels of high-density lipoprotein (HDL) choles- STEATOHEPATITIS STOMACH CANCER terol—the “good” cholesterol. It also influences COAGULATION processes, altering the activation of The primary health consequence of chronic, certain coagulation factors in ways that slightly excessive alcohol consumption is alcoholism. slow blood clotting. Alcohol appears to help relax Alcoholism is an addiction to alcohol (physiologic the smooth MUSCLE of the walls of the arteries, and psychologic dependence on alcohol) and is a 318 Substance Abuse leading health problem in the United States. Sec- This reduced enzyme access extends the amount ondary to alcoholism is a high risk for LIVER dis- and length of time other drugs are active in the ease. Because it metabolizes alcohol, the liver is BLOOD circulation. The result may be an intensified the organ most vulnerable to alcohol’s toxic effect of the drug or an ADVERSE REACTION. For effects. Long-term excessive alcohol consumption example, drinking while taking antihypertensive also increases the risk for LIVER CANCER, STOMACH medications to treat HYPERTENSION (high BLOOD CANCER, COLORECTAL CANCER, BREAST CANCER, CORO- PRESSURE) may cause blood pressure to drop lower NARY ARTERY DISEASE (CAD), hypertension, and than intended, resulting in dizziness or unsteadi- NUTRITIONAL DEFICIENCY. ness, especially when standing up after lying See also ALCOHOLIC HALLUCINOSIS; CELL STRUCTURE down (orthostatic HYPOTENSION). AND FUNCTION; DELIRIUM TREMENS; HEPATOTOXINS; In the long term, chronic alcohol abuse causes ILLICIT DRUG ABUSE; PRESCRIPTION DRUG ABUSE; SUB- the liver to increase activation of CYP450 STANCE ABUSE PREVENTION; SUBSTANCE ABUSE TREAT- enzymes, resulting in more rapid metabolism of MENT. drugs. The result may be lower levels of drugs in the blood circulation than are necessary to provide alcohol interactions with medications The therapeutic effects. With antihypertensive medica- numerous ways in which ALCOHOL intensifies or tions, for example, this might mean blood pres- inhibits the actions and side effects of prescription sure remains elevated beyond the level expected and OVER-THE-COUNTER (OTC) DRUGS. Alcohol also for the DOSE of medication. The alteration of interacts with illicit drugs though often unpre- enzyme activity may also metabolize drugs in dictably because of their uncertain composition. ways that cause toxicity. Adverse reactions are a As well, some drugs interact with alcohol in ways particular risk among people who regularly drink that alter alcohol’s METABOLISM and actions in the alcohol but do not divulge the information to their body. Alcohol-medication interactions are of doctors or often to family members because denial increasing concern as more than 70 percent of is a hallmark of ALCOHOLISM. Altered enzyme activ- Americans take regular medications and at least ity may continue for weeks to months after stop- 10 percent of them drink alcohol daily. ping alcohol consumption and may be a permanent state when alcohol abuse has been Liver Enzymes and Drug Metabolism exceptionally long term (over decades). The LIVER produces CYTOCHROME P450 (CYP450) ENZYMES that metabolize (break down into their Direct Interactions chemical components) most drugs that enter the between Alcohol and Other Drugs body. The enzymes act at predictable rates for spe- Consumed alcohol may also directly compete for cific substances, one of the key factors in establish- or bind with neuroreceptors in the BRAIN in ways ing appropriate DRUG dosages. Alcohol–medication that interfere with drugs that act on the CENTRAL interactions occur in two general ways: through NERVOUS SYSTEM such as anesthetic agents, ANAL- competition for the enzymes that metabolize them GESIC MEDICATIONS (PAIN relievers), ANTIDEPRESSANT (short-term or acute alcohol consumption) and MEDICATIONS, ANTIANXIETY MEDICATIONS, MUSCLE through changes in the way the liver produces RELAXANT MEDICATIONS, antiseizure medications, these enzymes (long-term or chronic alcohol con- ANTIPSYCHOTIC MEDICATIONS, ANTIHISTAMINE MEDICA- sumption). Because the primary interaction TIONS, and hypnotics. The interaction often inten- between alcohol and medications occurs at this sifies side effects such as sleepiness, confusion, and enzyme level, alcohol affects in some way the cognitive dysfunction. actions of nearly all medications. In the short term, acute alcohol consumption Increased Risk for Liver Damage (drinking alcoholic beverages) engages the As the body’s clearinghouse for drugs, the liver is CYP450 enzymes available in the liver. Conse- especially vulnerable to damage from toxic quently fewer enzymes are then available to byproducts of drug metabolism. Though the liver metabolize other substances such as medications. has great capacity to restore itself, the double alcoholism 319 onslaught of hepatotoxic drugs and alcohol may whom have alcohol addiction (alcoholism). Alco- overwhelm its renewal mechanisms. Alcohol is a holism has extensive health and social conse- potent hepatotoxin; it is a poison that destroys quences. liver cells. Many medications are also hepatotoxic and in combination with alcohol consumption can Symptoms and Diagnostic Path result in significant liver damage and LIVER FAILURE. A significant factor with alcoholism is hiding the Some of the most dangerous drugs in combination amount of drinking the person is doing. Indica- with alcohol are those in such common use that tions of excessive drinking are often behaviors many people fail to recognize their potential risks that might appear normal in isolation but that in or the frequency with which they take them: acet- aggregate are problematic. These indications may aminophen and the NONSTEROIDAL ANTI-INFLAMMA- include TORY DRUGS (NSAIDS). These drugs are common ingredients in numerous products to relieve symp- • establishing rituals around drinking toms of COLDS, sinus congestion, menstrual • changing plans or missing appointments to drink cramps, arthritis pain, and general pain (such as in • denying drinking or that drinking is a problem prescription analgesic medications). It is important to minimize or avoid drinking alcohol when tak- • drinking alone or seeking ways to drink in ing products that contain these drugs. Various pre- secret scription medications are also hepatotoxic • hiding bottles of alcohol in odd places themselves or in combination with alcohol. • needing double shots or multiple drinks to feel See also COGNITIVE FUNCTION AND DYSFUNCTION; the effects of the alcohol DRUG INTERACTION; HEPATOTOXINS; ILLICIT DRUG ABUSE; LIVER DISEASE OF ALCOHOLISM; MEDICINAL HERBS AND Indications of problem drinking that others BOTANICALS; MILK THISTLE; OVERDOSE; SUBSTANCE ABUSE notice may include PREVENTION; SUBSTANCE ABUSE TREATMENT. • frequent absences from work or school alcoholic hallucinosis A state of temporary PSY- • forgetting people, conversations, or events CHOSIS that may occur after sudden withdrawal of • unexplained changes in personality or interests ALCOHOL in a person who has heavily consumed alcohol for an extended time. Typical symptoms • disappearing at times throughout the day include auditory and sometimes visual HALLUCINA- • out-of-control drinking episodes that the per- TIONS, PARANOIA, and vivid nightmares. However, son denies thought processes remain clear, and the person • frequent illness or health complaints, especially remains fully alert and aware of his or her sur- gastrointestinal conditions roundings. Symptoms do not usually require treatment beyond reassurance that they will soon The diagnostic path includes physical and psy- end, though some people benefit from short-term chologic examinations with an initial screening treatment with a BENZODIAZEPINES such as chlor- questionnaire about alcohol use. Health-care diazepoxide. Most people recover in 10 to 14 days providers who treat alcoholism use a variety of though some symptoms may linger up to 3 weeks. such screening and assessment tools. Further test- See also ALCOHOLISM; ANTIANXIETY MEDICATIONS; ing may include diagnostic procedures to diagnose DELIRIUM TREMENS; SCHIZOPHRENIA; WITHDRAWAL SYN- physical health problems associated with alcohol DROME. abuse such as LIVER disease, CARDIOVASCULAR DISEASE (CVD), and gastrointestinal disorders. The doctor alcoholism A health condition resulting from may also want to test for DIABETES, as chronic alco- ADDICTION to ALCOHOL. As with other addictions, hol consumption interferes with the alcoholism is a combination of physiologic, psy- GLUCOSE–INSULIN balance. However, there are no chologic, behavioral, and social factors. About 20 BLOOD tests or other procedures to conclusively million Americans abuse alcohol, at least half of diagnose alcoholism. The doctor makes the final 320 Substance Abuse diagnosis on the basis of the aggregate findings, See also ALCOHOLIC HALLUCINOSIS; DELIRIUM including the best determination of the person’s TREMENS; FETAL ALCOHOL SYNDROME; HEPATITIS; SUB- drinking patterns and history. STANCE ABUSE PREVENTION; SUBSTANCE ABUSE TREAT- MENT. Treatment Options and Outlook Alcoholism is a chronic, lifelong condition that alkyl nitrites Inhaled drugs that rapidly relax requires ongoing management to maintain com- smooth MUSCLE and dilate the BLOOD vessels. The plete abstinence from alcohol. DETOXIFICATION—the alkyl nitrite with therapeutic application is amyl process the body goes through to completely elim- nitrite, a treatment for ANGINA PECTORIS (CHEST PAIN inate alcohol—takes 5 to 7 days. Medications to resulting from constriction of the CORONARY ARTER- ease the symptoms of WITHDRAWAL SYNDROME may IES). Amyl nitrite requires a physician’s prescrip- include BENZODIAZEPINES and NALTREXONE, which tion in the United States. Other alkyl nitrites have calm anxiety and reduce cravings for alcohol, legitimate uses in products such as room deodoriz- respectively. After the body is free of alcohol, ers, adhesive removers, and various types of maintaining sobriety often requires a combination cleaners. Medicinal amyl nitrite comes in small of approaches that may include glass ampules encased in fabric. To use the vial the person snaps or pops the vial within its protective • medications such as disulfiram, which prevents fabric, releasing and breathing the vapors. the body from metabolizing alcohol, and nal- As substances of abuse, alkyl nitrites produce trexone to mitigate alcohol cravings euphoria, reduced inhibition, and a sensation of • individual PSYCHOTHERAPY to gain insight and excitement. Inhaled alkyl nitrites also are reputed understanding of the factors that contribute to to intensify sexual experiences because they relax the desire to drink sphincter muscles such as those in the VAGINA and • group therapy or SUPPORT GROUPS such as Alco- the ANUS. The primary users of alklyl nitrites are holics Anonymous to provide opportunity to adults between the ages of 30 and 50. Abuse of talk about alcoholism with others who have the alkyl nitrites has moderate risk for psychologic condition and to reinforce behaviors to remain DEPENDENCE. OVERDOSE of alkyl nitrites can result in drink free ARRHYTHMIA (irregular heartbeat). Alkyl nitrites may aggravate HYPERTENSION (high BLOOD PRESSURE) For nearly everyone who has alcoholism, main- or intensify the effects of nitrite-based medications taining sobriety (absolute abstinence) requires to treat cardiovascular conditions such as hyper- continued diligence. It is important to seek appro- tension and HEART FAILURE. priate intervention to return to sobriety as quickly as possible when relapses do occur. Most alcohol COMMON ALKYL NITRITES treatment centers and programs also offer support amyl nitrite butyl nitrite groups and sometimes counseling for family mem- cyclohexyl nitrite ethyl nitrite bers. isobutyl nitrite isopropyl nitrite methyl nitrite pentyl nitrite Risk Factors and Preventive Measures Persistent, regular drinking is the most significant Long-term use of alkyl nitrites can cause METHE- risk for developing alcoholism, because over time MOGLOBINEMIA, a condition in which the HEMOGLO- the body acquires both alcohol TOLERANCE and alco- BIN cannot properly bind with oxygen. Ingestion hol DEPENDENCE. Additive risks include beginning to or injection of alkyl nitrites carries high risk for drink at a young age, family history of alcoholism, death. Because alkyl nitrites use tends to encour- genetic composition (separate from family history), age high-risk sexual behavior their use results in and history of psychologic conditions such as ATTEN- increased risk for HEPATITIS and SEXUALLY TRANSMIT- TION DEFICIT HYPERACTIVITY DISORDER (ADHD), DEPRES- TED DISEASES (STDS) including HIV/AIDS, though alkyl SION, and BIPOLAR DISORDER. As well, three in four nitrites do not directly cause such infections. people who have alcoholism are men. Long-term, chronic alkyl nitrites abuse also causes anabolic steroids and steroid precursors 321 changes in the function of the IMMUNE SYSTEM that PARANOIA, SLEEP DISORDERS, DEPRESSION, ARRHYTHMIA, may make users more susceptible to INFECTION. and aggressive behavior. Amphetamines and See also CLUB DRUGS; CORONARY ARTERY DISEASE amphetamine-like drugs have high risk for psy- (CAD); DRUG INTERACTION; SUBSTANCE ABUSE PREVEN- chologic DEPENDENCE and ADDICTION with chronic TION. abuse. amphetamines Drugs that stimulate the CENTRAL COMMON AMPHETAMINES NERVOUS SYSTEM. Amphetamines belong to the AND AMPHETAMINE-LIKE DRUGS phenylethylamine class of drugs, a large DRUG fam- amphetamine benzphetamine ily that also includes amphetamine-like drugs with cathinone dextroamphetamine similar actions and effects. Amphetamines and diethylpropion mazindol amphetamine-like drugs are SCHEDULED DRUGS in METHAMPHETAMIN Emethcathinone the United States, requiring a physician’s prescrip- methylphenidate phendimetrazine tion for legal use and possession. Those that are phentermine schedule 2 drugs further must meet narrowly defined treatment criteria. Methcathinone and See also BARBITURATES; CAFFEINE; HYPNOTICS; NAR- cathinone, though ingredients of schedule 2 and COTICS; NICOTINE; OPIATES; PERFORMANCE-ENHANCING schedule 3 drugs, are schedule 1 drugs in their SUBSTANCES; SUBSTANCE ABUSE TREATMENT. pure forms and do not have therapeutic uses. Amphetamines and amphetamine-like drugs anabolic steroids and steroid precursors Hor- have dual activity in the BRAIN: They increase the mones or hormonelike substances taken to release of serotonin, DOPAMINE, and NOREPINEPHRINE; increase MUSCLE mass and STRENGTH. Anabolic and they block the reuptake of dopamine, norepi- steroids are class 3 SCHEDULED DRUGS in the United nephrine, and monoamine oxidase (MAO). These States, legally available only with a physician’s neurotransmitters have numerous roles in brain prescription. As substances of abuse, anabolic activities in regard to mental focus, concentration, steroids and steroid precursors (substances the and mood. Consequently amphetamines and body metabolizes into anabolic steroids) are popu- amphetamine-like drugs increase alertness, reduce lar among athletes, bodybuilders, people who APPETITE, and establish a sense of confidence and work in jobs that require physical strength, and well-being. Therapeutic uses include treatment for people who desire a particular physique. Anabolic NARCOLEPSY, ATTENTION DEFICIT HYPERACTIVITY DISOR- steroids are available in injectable forms and oral DER (ADHD), weight loss in morbid OBESITY, and tablets. alertness in military pilots. Abuse of amphetamines and amphetamine-like Therapeutic Uses drugs occurs to take advantage of the euphoria, Therapeutic uses for anabolic steroids are very heightened alertness, and diminished need for limited; many anabolic steroid products are illicit. sleep. As well, the stimulant effects of these drugs Though most anabolic steroids are androgenic may intensify LIBIDO (sex drive), though ERECTILE (increase the production of ANDROGENS, the male DYSFUNCTION is a common SIDE EFFECT of chronic sex hormones), anabolic steroids that are nonan- abuse. TOLERANCE develops quickly, escalating the drogenic (increase muscle mass without intensify- amount of drug necessary to produce the desired ing masculine traits) became available in the late effects. Because dopamine is also essential for 1990s for therapeutic uses. Anabolic nonandro- movement, its presence in excess results in invol- genic steroids appear to have fewer undesirable untary movements (DYSKINESIA). Short-term side side effects, though the full extent of any long- effects that usually go away when the drug leaves term consequences remains unknown. the body include trembling, HALLUCINATION, Most commonly doctors prescribe a TESTOS- increased perspiration, and HEADACHE. Side effects TERONE product for androgen supplementation or with long-term use that may be long lasting or therapy and a nonandrogenic anabolic steroid permanent include SCHIZOPHRENIA-like PSYCHOSIS, to treat growth-related disorders in children. 322 Substance Abuse

Therapeutic uses for anabolic androgenic steroids • INFERTILITY or sterility include treatment for certain kinds of BREAST CANCER • LIVER damage and TESTICULAR CANCER, and endocrine disorders in • LIVER CANCER which the body does not produce normal levels of testosterone and other androgens. Therapeutic uses • left ventricular hypertrophy (enlarged left ven- for anabolic nonandrogenic steroids include disor- tricle of the HEART) ders of the PITUITARY GLAND and other conditions • ATHEROSCLEROSIS and CORONARY ARTERY DISEASE (such as chronic RENAL FAILURE) in childhood that (CAD) result in smaller than normal stature, and circum- stances of muscle loss associated with long-term In young people who are still growing, anabolic chronic health conditions such as AIDS. androgenic steroids cause the growth plates in the long bones to close, ending their growth. Other Abusive Uses risks of anabolic steroid use may include INFECTION Most anabolic steroid abusers are men ages 20 to with HEPATITIS, HIV/AIDS, and other diseases 40, though anabolic steroid use among teens (boys acquired through sharing needles to inject the and girls) and women, especially athletes, is grow- steroids. ing. However, athletic organizations worldwide prohibit the use of anabolic steroids and steroid COMMON ANABOLIC STEROIDS precursors at all levels of competition from high AND STEROID PRECURSORS school through professional. At elite levels of com- Anabolic Androgenic Steroids petition, sanctioning organizations use URINE and boldenone chlorotestosterone BLOOD tests to detect anabolic steroid use among clostebol dehydrochlormethyltestosterone competing athletes. dihydrotestosterone drostanolone There is some use of anabolic steroids, both ethylestrenol fluoxymesterone androgenic and nonandrogenic, as antiaging ther- formebolone mesterolone apies. These are unproven uses. methandienone methandienone methandriol methandrostenolone Adverse Health Risks and Consequences methenolone methyltestosterone Short-term, adverse health consequences of ana- mibolerone nandrolone bolic androgenic steroids are usually reversible (go norethandrolone oxandrolone away after stopping the DRUG) and may include oxymesterone oxymetholone stanolone stanozolol • enlarged breasts (GYNECOMASTIA), testicle shrink- testolactone TESTOSTERONE age, reduced body HAIR, and other feminization trenbolone characteristics in men • facial hair, increased body hair, lowered voice, Anabolic Androgenic Steroid Precursors and other masculinizing characteristics in androstenediol androstenedione women DEHYDROEPIANDROSTERONE norandrostenediol • mood swings, emotional volatility, and out- (DHEA) bursts of rage norandrostenedione

• moderate to severe DEPRESSION Anabolic Nonandrogenic Steroids • DELUSION human growth hormone insulinlike growth factor 1 • ACNE (hGH) (IGF-1)

Long-term, adverse health consequences of See also AGING, ENDOCRINE CHANGES THAT OCCUR anabolic androgenic steroids are often permanent WITH; ANTIAGING APPROACHES; GAMMA HYDROXYBU- (continue when no longer taking the drug) and TYRATE (GHB); HORMONE; INJECTING DRUGS, RISKS OF; may include PERFORMANCE-ENHANCING SUBSTANCES. B

barbiturates DRUGS that depress the functions of ence and activity of gamma aminobutyric acid the CENTRAL NERVOUS SYSTEM. Barbiturates are (GABA), a NEUROTRANSMITTER that regulates many SCHEDULED DRUGS in the United States, requiring a of the brain’s inhibitory functions. physician’s prescription for legal use and posses- Excessive amounts of barbiturates in the blood sion. Some barbiturates are schedule 2 drugs, circulation suppress the respiratory centers in the which strictly limits the reasons for which physi- brain. Barbiturates also slow HEART RATE and lower cians may prescribe them. BLOOD PRESSURE. Combining barbiturates with alco- Barbiturates readily cross the BLOOD–BRAIN BAR- hol is particularly hazardous, as these drugs act in RIER once in the BLOOD circulation and act similarly the same ways to depress neurologic function. to ALCOHOL in the ways they affect BRAIN neurons. Though researchers do not know the precise Barbiturate OVERDOSE is life threatening mechanisms through which barbiturates alter and requires emergency medical care. brain function, they believe these drugs cause Signs of barbiturate overdose include changes in the cell membranes of neurons in a UNCONSCIOUSNESS, dilated pupils, shallow way that alters their action potential (ability to BREATHING, and slow PULSE. transmit electrical impulses). Researchers do know barbiturates also potentiate (enhance) the pres- Barbiturates have numerous therapeutic uses, including sedation during diagnostic and minor THE TRUTH ABOUT TRUTH SERUM surgical procedures, suppression of seizures, and Thiopental, better known by its trade name Pen- relief of severe anxiety. However, because barbitu- tothal, is a fast-acting barbiturate that produces a rates have high potential for ADDICTION and abuse, trancelike state of semiconsciousness. One effect they are seldom the first line of therapy for most of this state is the blockade of inhibition, allow- conditions except certain seizure disorders. As ing a person to do and say what the conscious drugs of abuse barbiturates are popular for the mind might block. Psychiatrists first used sodium sense of calm and well-being they can provide and pentothal expressly for this purpose when treat- their effectiveness to induce sleep. ing what was then called battle fatigue in sol- diers returning from World War II. Psychiatrists COMMON BARBITURATES were able to learn the details of the traumatic amobarbital aprobarbital experiences the soldiers endured and provide butabarbital butalbital therapy to help them cope with their memories. mephobarbital methohexital However, a person under Pentothal’s influence pentobarbital phenobarbital does not necessarily answer questions truthfully secobarbital thiopental and indeed may sometimes tell lies once the effect of medication removes the inhibition that would otherwise prevent him or her from doing Suddenly stopping barbiturates after long-term so. use can result in serious or lethal complications, resulting from neurotransmitter imbalance in the 323 324 Substance Abuse brain that causes erratic and extreme NERVOUS SYS- doping are BLOOD TRANSFUSION and ERYTHROPOIETIN TEM responses affecting brain function as well as (EPO) supplementation. Doctors may use either of vital functions such as regulation of blood pres- these methods therapeutically to treat certain sure, heart rate, and body temperature. types of ANEMIA and to maintain the level of or See also ALCOHOL INTERACTIONS WITH MEDICATIONS; hasten the return of blood cells after AMPHETAMINES; BENZODIAZEPINES; HYPNOTICS; PRESCRIP- CHEMOTHERAPY. Blood doping is an abuse of these TION DRUG ABUSE; SUBSTANCE ABUSE PREVENTION; SUB- methods done to improve athletic performance by STANCE ABUSE TREATMENT. increasing AEROBIC CAPACITY, typically among ath- letes who compete in ENDURANCE events. However, benzodiazepines Drugs that depress CENTRAL athletic organizations worldwide prohibit blood NERVOUS SYSTEM functions. In large part benzodi- doping at all levels of competition, and many rou- azepines have replaced BARBITURATES in many ther- tinely test athletes for evidence of it. apeutic applications and have numerous therapeutic uses including as MUSCLE relaxants, Blood Transfusions antianxiety medications, and sleep aids. Doctors Blood transfusion is usually of packed red blood also prescribe benzodiazepines to relieve the cells and may be homologous (from a donor) or symptoms of WITHDRAWAL SYNDROME. Benzodi- autologous (the person’s own blood). For autolo- azepines are class 4 SCHEDULED DRUGS in the United gous transfusion, the person may undergo HEMO- States, requiring a physician’s prescription for legal PHORESIS, in which blood withdrawn from the use and possession. As drugs of abuse, benzodi- body undergoes cell separation; the components azepines are popular for easing the symptoms of other than the red blood cells are returned to the “coming down” from other drugs. They may also blood circulation. The concentrated red blood cells cause sensations similar to moderate ALCOHOL collected via hemophoresis are then refrigerated INTOXICATION. Benzodiazepines are among the most or frozen to store them until a few days before a frequently abused prescription medications. Risks competition. The athlete receives his or her own of long-term, chronic abuse may result in ADDIC- red blood cells back via transfusion, boosting the TION and symptoms such as HALLUCINATION, trem- number of red blood cells in the blood. For bling, and confusion. homologous transfusion, the athlete receives a transfusion of red blood cells collected from COMMON BENZODIAZEPINES donors. alprazolam chlordiazepoxide clobazam clonazepam Erythropoietin (EPO) clorazepate clorazepate EPO is a natural HORMONE the body produces to diazepam estazolam stimulate the BONE MARROW to produce erythro- flurazepam halazepam cytes. EPO supplement, which became available in lorazepam midazolam the late 1980s, is a recombinant hormone that oxazepam prazepam intensifies this action. Injections of EPO thus cause quazepam temazepam the bone marrow to produce extra red blood cells, triazolam increasing their presence in the blood. Because it is far easier than blood transfusion to use in secret, See also GENERALIZED ANXIETY DISORDER (GAD); EPO is the favored method of blood doping. HYPNOTICS; PRESCRIPTION DRUG ABUSE. Health Risks and Complications blood doping Actions to boost the ability of the Risks of blood doping include blood clots that can BLOOD to carry oxygen by increasing the volume of cause HEART ATTACK or STROKE and increased viscos- red blood cells in the blood circulation. Red blood ity (thickness) of the blood, which strains the cells (erythrocytes) contain HEMOGLOBIN, protein HEART and can cause CARDIOMYOPATHY and HEART molecules that bind with oxygen molecules in the FAILURE. Homologous blood transfusions carry the LUNGS. The two commonly used methods of blood risk of contracting a bloodborne INFECTION such as buprenorphine 325

HEPATITIS B and hepatitis C, particularly when tablets and mix them with water for injection, donation circumvents usual donor screening and which results in a “high” similar to that of HEROIN collection procedures to minimize detection of the or other OPIATES. To prevent this, doctors prescribe transfusions. the buprenorphine with naltrexone formulation See also ANABOLIC STEROIDS AND STEROID PRECUR- (brand name Suboxone in the United States) to SORS; ERYTHROCYTE; PERFORMANCE-ENHANCING SUB- help maintain SOBRIETY after initial detoxification STANCES; RECOMBINANT DNA. when drug cravings may intensify. Very little nal- trexone enters the blood circulation through sub- buprenorphine A DRUG administered therapeuti- lingual absorption. However, high amounts enter cally to treat opiate ADDICTION. Buprenorphine is the blood circulation when dissolved and injected. available in two formulations: buprenorphine Buprenorphine is a synthetic drug that partially alone for use during DETOXIFICATION; and buprenor- binds with opiate receptors, which is enough to phine in combination with NALTREXONE, an opiate activate an opiate response in the body without an antagonist, for long-term use to help prevent intoxication effect. Because of this binding, it is recurrence. In the United States buprenorphine is possible to develop a physical DEPENDENCE to one of the SCHEDULED DRUGS, available only by pre- buprenorphine. Substance abuse treatment pro- scription from a physician who has completed an grams taper the dosage over a period of time to approved program for its appropriate use in SUB- wean the body from dependence. Buprenorphine STANCE ABUSE TREATMENT. is also available as an analgesic medication (PAIN Buprenorphine for opiate addiction treatment reliever), which doctors prescribe primarily for is available as sublingual tablets that dissolve pain relief after surgery. Undesired side effects under the tongue, releasing buprenorphine for associated with buprenorphine include drowsi- absorption into the BLOOD circulation through the ness, NAUSEA, CONSTIPATION, and HYPOTENSION (low mucosa of the MOUTH. Administered in this way, BLOOD PRESSURE). Buprenorphine OVERDOSE can buprenorphine has an extraordinarily long HALF- cause potentially fatal respiratory depression. LIFE in the body. Because of this, dosing is often See also CYTOCHROME P450 (CYP450) ENZYMES; every other day in the maintenance phase of LEVO-ALPHA ACETYLMETHADOL (LAAM); METHADONE; treatment. However, it is possible to crush the PRESCRIPTION DRUG ABUSE. C

caffeine A CENTRAL NERVOUS SYSTEM stimulant. Cannabis sativa is among several species of Though not commonly perceived as a DRUG of Cannabis cultivated in many parts of the world for abuse, caffeine is the most widely used psychoac- hemp, the tough fibers of the plant’s stem, for use tive drug in the world. The primary sources of caf- in making rope, floor coverings, nets, and some- feine are coffee, tea, and colas. Chocolate also times clothing. Stems and hemp fibers do not con- contains some caffeine. A typical cup of coffee tain THC. However, in the United States growth, contains 100 to 150 milligrams (mg) of caffeine; cultivation, and possession of Cannabis are illegal tea and cola drinks contain 60 to75 mg per serv- (schedule 1 drug) no matter the reason. ing. Many OVER-THE-COUNTER (OTC) DRUGS, notably those for PAIN relief and relief of menstrual cramps, Medical Uses contain caffeine. Chocolate may contain 3 to 5 mg At present the only accepted medical use of THC is of caffeine per ounce. Though researchers disagree the synthetic formulation dronabinol (Marinol), as to whether caffeine is addictive, many people which doctors may prescribe to treat NAUSEA asso- experience mild withdrawal symptoms when ciated with CHEMOTHERAPY and to improve APPETITE stopping caffeine after long-term consumption of in people who have AIDS. Dronabinol is a sched- caffeinated beverages. Such symptoms may ule 3 drug in the United States; possession and use include HEADACHE, irritability, difficulty concentrat- requires a physician’s prescription. ing, and cravings for the beverage. Excessive caf- Considerable research has explored the ability feine consumption may cause PALPITATIONS, of THC to decrease INTRAOCULAR PRESSURE (pressure agitation, and feelings of anxiety. within the EYE) as a treatment for GLAUCOMA. How- See also ANALGESIC MEDICATIONS; DYSMENORRHEA; ever, research results have been inconclusive. NICOTINE; PERFORMANCE-ENHANCING SUBSTANCES; STIM- Though THC (in therapeutic use often referred to ULANTS. as medical marijuana) does lower intraocular pressure the effect lasts only as long as THC is cannabis The plant Cannabis sativa, the source active in the body, about five hours. THC’s psy- for marijuana, hashish, and hash oil. Cannabis is choactive effects make the drug impractical for the most widely used illicit DRUG in the Western glaucoma treatment. world; more than 80 million Americans have used marijuana, the most common form of cannabis, Actions and Effects in the Body at least once and about 15 million use it regu- THC produces euphoria, heightened or altered larly. The primary psychoactive chemical in sensory perceptions, and a sensation of calm and cannabis substances is delta-9-tetrahydrocannabi- relaxation. It exerts its psychoactive actions by nol, commonly called THC. THC has moderate binding with cannabinoid receptors in the BRAIN. risk for DEPENDENCE and ADDICTION. ALCOHOL Ordinarily the NEUROTRANSMITTER anandamide potentiates (enhances and alters) the effects of binds with these receptors, which are abundant in THC when a person consumes the two drugs certain parts of the brain, including the hippocam- together. pus, cerebellum, and basal ganglia. The hippocam-

326 chloral hydrate 327 pus regulates memory storage and retrieval for similar carcinogenic characteristics because it con- short-term memory. The cerebellum and basal tains many of the same chemicals. ganglia coordinate and control voluntary motor movement. Hashish and Hash Oil THC also binds with neuroreceptors in the Hashish is the dried and compressed resin extracted brain that affect sensations of pleasure, notably from the tops of the Cannabis plant. As with mari- those associated with food and eating. Recent juana, the most common methods of consumption research suggests long-term, chronic use of sub- are smoking (though typically in pipes) and cook- stances containing THC results in permanent ing in foods. Its THC content is 5 to 7 percent. Hash changes to the cannabinoid receptors. Those in oil is an extract of the THC and other cannabinoids the hippocampus seem particularly vulnerable, (cannabis chemicals) pulled from the flowers of which researchers believe may account for the Cannabis plants using a solvent. The resulting liquid long-lasting difficulties chronic marijuana abuses is thick and concentrated, with a THC content of have with short-term memory. about 15 percent. The user may place a few drops on an ordinary cigarette or in foods. The effects and Marijuana their duration for both hashish and hash oil are Marijuana is a product formed from the dried similar to marijuana. leaves and buds of the Cannabis plant, which are usually then smoked like cigarettes or in pipes. HEALTH RISKS OF CANNABIS ABUSE The psychoactive ingredients, primarily THC, Short Term enter the BLOOD circulation rapidly through the altered judgment and anxiety LUNGS. The effect lasts about two hours, though relaxed inhibition cognitive dysfunction THC remains detectable in the blood and URINE for delayed reaction time dizziness at least 24 hours and up to 10 days after smoking heightened sensory perceptions impaired balance and marijuana. Some people mix marijuana with food, increased APPETITE coordination in which case THC more slowly enters the blood panic attack circulation via absorption through the intestinal mucosa (mucous lining of the SMALL INTESTINE). Long Term Most marijuana has a THC content of 5 to 7 per- apathy and disinterest in life delusions cent. A cultivation method that removes the seeds DEPRESSION IMMUNE SYSTEM suppression from the plants in their early stages of develop- loss of short-term memory PSYCHOSIS ment results in a particularly potent form of mari- functions juana called sinsemilla, which has a THC content of 10 to 15 percent. See also COGNITIVE FUNCTION AND DYSFUNCTION; Aside from the neurologic risks of THC, a sig- ILLICIT DRUG USE; MEMORY AND MEMORY IMPAIRMENT; nificant health concern with marijuana is its SCHEDULED DRUGS; SUBSTANCE ABUSE TREATMENT. smoke. Burning marijuana releases more than 400 chemicals, many of which are the same carcino- chloral hydrate A hypnotic drug used therapeu- gens (cancer-causing agents) found in cigarette tically as a sleep aid. Chloral hydrate is a schedule smoke. As well, the smoke is an irritant to the 4 drug in the United States, requiring a physician’s bronchial structures and the lungs. Long-term prescription for legal use and possession. As a drug smoking of marijuana can result in some of the of abuse chloral hydrate may be taken alone or same health problems that result from long-term mixed with ALCOHOL (“Mickey Finn”). The latter cigarette smoking such as COUGH, chronic BRONCHI- produces a potent sedative as well as amnesiac TIS and CHRONIC OBSTRUCTIVE PULMONARY DISEASE effect. Such a mixture gained notoriety as a “date (COPD). Whether long-term marijuana smoking rape” concoction in the early decades of the 20th increases the risk for LUNG CANCER remains century. When taken at therapeutic dosage chloral unknown, though many researchers believe it has hydrate is very safe. However, at high doses, chlo- 328 Substance Abuse ral hydrate may produce potentially fatal respira- lar drug of abuse, and an estimated 35 million tory depression. Americans have used it at least once. Extracted from the leaves of the Erythroxylum HEALTH RISKS OF CHLORAL HYDRATE ABUSE coca plant, cocaine as a drug of abuse produces Short Term intense euphoria, energy, and a sense of physical and mental infallibility. The most common method ARRHYTHMIA disturbed balance and of use is to snort (rapidly inhale) the powdered dizziness coordination form of the drug into the NOSE, where absorption HALLUCINATION impaired motor function through the nasal mucosa (mucous membrane lin- irritability slurred speech ing of the nose) allows the drug to enter the BLOOD Long Term circulation within a few minutes for an effect that HEART damage kidney damage lasts two to three hours. Crack cocaine—created by LIVER damage sleep disturbances mixing cocaine powder with sodium bicarbonate and water, then igniting the dried mixture and See also FLUNITRAZEPAM; GAMMA HYDROXYBUTYRATE inhaling the smoke—gets the drug into the blood (GHB); HEPATOTOXINS; HYPNOTICS; SCHEDULED DRUGS; circulation even more rapidly through the LUNGS. SEXUAL ASSAULT. Some people dissolve the powder in water and inject the solution intravenously for an instant and club drugs Drugs popular for illicit use in set- intense though short (20 to 30 minutes) effect. tings such as “rave” clubs and at parties. Most club The key risk of cocaine abuse is ADDICTION; drugs are designer drugs though some are conven- about 10 percent of people who try cocaine even- tional drugs used illicitly. The key risks with club tually become addicted. Crack cocaine is particu- drugs are not knowing what they are when taking larly addictive. The compulsion to use cocaine is them and combining them with ALCOHOL. so intense for many people who are addicted that Among the most popular club drugs are HALLU- they resort to extraordinary actions to acquire the CINOGENS such as KETAMINE and METHYLENE- drug. The person trying to quit cocaine often DIOXYMETHAMPHETAMINE (MDMA), commonly called needs short-term medical support to mitigate ecstasy, and HYPNOTICS such as FLUNITRAZEPAM symptoms of withdrawal and long-term family (Rohypnol), commonly called rophies or roofies, and social support to stay off cocaine. and GAMMA HYDROXYBUTYRATE (GHB). Flunitrazepam and GHB, which are odorless and tasteless, have HEALTH RISKS OF COCAINE ABUSE gained notoriety as “date rape” drugs because they Short Term produce amnesia of events that occur during the anxiety diminished ability to feel PAIN time of the drug’s effectiveness in the body. Other elevated body temperature HEART ATTACK drugs sometimes popular as club drugs include HYPERTENSION PARANOIA LSD and METHAMPHETAMINE. rapid HEART RATE restlessness, irritability, or Mixing any of these drugs with alcohol is par- agitation ticularly hazardous and can result in potentially Long Term fatal respiratory depression. ADDICTION ARRHYTHMIA See also DESIGNER DRUG; MEMORY FUNCTION AND chronic nasal congestion DYSPNEA (difficulty BREATHING) IMPAIRMENT; SCHEDULED DRUGS. HALLUCINATION MALNUTRITION PSYCHOSIS runny NOSE (RHINORRHEA) cocaine A DRUG that acts as a CENTRAL NERVOUS seizures SUDDEN CARDIAC DEATH SYSTEM stimulant. Cocaine is highly addictive and is a schedule 2 drug in the United States, subject- Though the effects on fetal development when ing its legal use to stringent requirements. The pri- a pregnant woman uses cocaine are uncertain the mary therapeutic use of cocaine is as a topical infant can be born with cocaine addiction, espe- anesthetic applied to the mucous membranes for cially if the mother is using crack cocaine. Because dental and surgical operations. Cocaine is a popu- many women who abuse cocaine also drink ALCO- cocaine 329

HOL and smoke cigarettes, both of which affect HEART ATTACK in users of any age and during any fetal development, health consequences for use of the drug, including the first time. infants born to cocaine-addicted mothers are often Researchers do not know what causes such car- multiple and complex. Infants born addicted to diovascular changes or their precise nature, cocaine require extensive medical care until their though speculate the cardiovascular effect is a bodies are free from the effects of the drug. They combination of conductive (ARRHYTHMIA) and are also more likely to be born prematurely, ischemic (severely decreased blood flow and oxy- increasing the need for medical care during early gen supply to the HEART MUSCLE) circumstances infancy as well as the risk for lifelong health prob- that collude to cause the heart to suddenly stop lems, including developmental delays and LEARN- beating. ING DISORDERS later in life. See also AMPHETAMINES; ANESTHESIA; ILLICIT DRUG Cocaine abuse may also cause changes in car- USE; SCHEDULED DRUGS; STIMULANTS; SUBSTANCE ABUSE diovascular function that can result in sudden PREVENTION; SUBSTANCE ABUSE TREATMENT. D delirium tremens A serious medical condition The doctor may desire other tests to evaluate spe- that may develop during withdrawal from ALCOHOL cific symptoms, such as ELECTROCARDIOGRAM (ECG) ADDICTION (ALCOHOLISM). The symptoms of delirium for palpitations and tachycardia. Treatment is gen- tremens are both physical and psychologic; the erally intravenous administration of BENZODI- physical symptoms can be life threatening without AZEPINES, such as chlordiazepoxide and diazepam, prompt medical treatment. Most people who to produce sedation and to help stabilize the NEU- experience delirium tremens (also called DTs) are ROTRANSMITTER balance in the brain because benzo- long-term heavy drinkers who suddenly quit diazepines also bind with GABA neuroreceptors. drinking. However, delirium tremens may also Without treatment delirium tremens may so sig- occur after a single episode of extreme alcohol nificantly disrupt brain function as to cause death. consumption in a person who does not often With appropriate and timely treatment, symptoms drink heavily. end in about 72 hours and most people recover Delirium tremens develops as a consequence of completely in 7 to 10 days. the BRAIN’s inability to restore the balance among See also ALCOHOL HALLUCINOSIS; NALTREXONE; SUB- the neurotransmitters gamma-aminobutyric acid STANCE ABUSE TREATMENT; WITHDRAWAL SYNDROME. (GABA), DOPAMINE, and glutamate. Instead the imbalance that resulted from alcohol DEPENDENCE dependence The physiologic or psychologic spirals out of control, producing a spectrum of need to continue taking a particular DRUG. In autonomic dysfunctions that affect multiple body physiologic dependence, predictable changes occur systems. within the body that reconfigure or adapt a partic- Symptoms begin within a few to 48 hours of ular facet of function and result in the body’s alcohol cessation and are often severe from the reliance on the substance to maintain that func- onset. Symptoms may include tion. Often the body then reacts in unpleasant ways (WITHDRAWAL SYNDROME) when the person • tremors and seizures stops taking the substance. Physiologic depend- • hyperactive reflexes ence ends when the body completely clears all • confusion, DELUSION, and HALLUCINATION chemical traces of the drug. Drugs often subject to abuse that cause physiologic dependence include • anxiety, irritability, restlessness, and agitation ALCOHOL, HEROIN, and opiate NARCOTICS such as • tachycardia (rapid HEART RATE), TACHYPNEA (rapid morphine, hydrocodone, and oxycodone. BREATHING), diaphoresis (excessive sweating), In psychologic dependence taking the drug and PALPITATIONS results in pleasurable sensations and the desire • elevated body temperature and BLOOD PRESSURE (craving, when intense) to take the substance to • NAUSEA and VOMITING obtain them. Though the drug causes chemical changes in the body that result in temporary alter- Diagnostic tests may include BLOOD tests to ations of function, the drug does not establish any measure blood alcohol concentration, LIVER physiologic adaptation. Psychologic dependence enzyme levels, and complete blood count (CBC). can be intense and does not correlate to the drug’s 330 depressants 331 presence in the body. Because the body develops there is also substance abuse or addiction, exten- TOLERANCE to many drugs taken on a long-term sive support and treatment such as PSYCHOTHERAPY basis (requiring a higher DOSE to achieve the same are also essential. Though physiologic dependence effect), the longer the person uses the substance ends when the drug is no longer present in the the more likely he or she may experience some body, psychologic dependence can persist for physiologic and psychologic symptoms when stop- weeks, months, or even years after stopping the ping the substance, representing the body’s adap- drug. tation to the drug’s absence. The nature of such symptoms depends on the drug. Drugs often sub- Risk Factors and Preventive Measures ject to abuse that cause psychologic dependence The primary risk factor for drug dependence is include COCAINE, AMPHETAMINES, BENZODIAZEPINE taking repeated doses of the drug. When doing so drugs, and HALLUCINOGENS. is to achieve therapeutic outcomes, drug depen- Though drug dependence is often a key factor dence is desired and appropriate. When the pur- in substance abuse and ADDICTION, it is not synony- pose of taking a drug is other than therapeutic, mous with either. Substance abuse and addiction not only is dependence possible but there is a high encompass the ways in which people use the likelihood for substance abuse or addiction. As drugs and the behaviors in which they engage to such use is detrimental to health, prevention obtain the drugs. Physiologic dependence occurs efforts include restricting access to the drug along in numerous therapeutic applications—for exam- with education and therapy, if appropriate, to ple, with therapies involving systemic CORTICO- understand the health consequences of continued STEROID MEDICATIONS, ANTIDEPRESSANT MEDICATIONS, dependence and behavioral approaches to avoid and antihypertensive medications. As well, a per- use of the drug. son may develop dependence on a substance com- See also ANALGESIC MEDICATIONS; ILLICIT DRUG USE; monly abused (such as a narcotic PAIN reliever or PRESCRIPTION DRUG ABUSE; SCHEDULED DRUGS; SUB- antianxiety medication) when taking it to legiti- STANCE ABUSE PREVENTION; SUBSTANCE ABUSE TREAT- mately treat a health condition and yet not abuse MENT. or have an addiction to that substance. depressants Chemicals that slow the activity of Symptoms and Diagnostic Path the CENTRAL NERVOUS SYSTEM. The primary thera- Indications of drug dependence vary according to peutic purpose of depressants is to cause sedation the drug. In a therapeutic context such symptoms or sleep. Most work through actions that directly reflect achievement of the desired effect of the affect the function of BRAIN neurons, neurotrans- drug—for example, suppression of the IMMUNE mitters, and neuroreceptors. Many do so by RESPONSE with corticosteroid medications or relief increasing the activity of gamma aminobutyric of symptoms with antidepressant medications or acid (GABA), a NEUROTRANSMITTER that slows brain pain relief medications. In the context of sub- function. Depressants have high potential for stance abuse or addiction, indications of drug DEPENDENCE and ADDICTION. Abruptly ending their dependence may include attempts to obtain use may cause WITHDRAWAL SYNDROME that, with increasing quantities of the drug, taking the drug certain drugs, has the potential to be life threaten- inappropriately, and obvious differences in behav- ing when symptoms are serious and untreated. ior between when taking the drug and when not Types of prescription drugs that are depressants taking the drug. include ANTIANXIETY MEDICATIONS, HYPNOTICS, BARBI- TURATES, and BENZODIAZEPINES. Drugs in these classi- Treatment Options and Outlook fications are SCHEDULED DRUGS in the United States, Treatment for undesired or unintentional drug which require a physician’s prescription for legal dependence, such as with corticosteroid or antide- possession and use. Doctors may prescribe them to pressant medications, consists of controlled wean- treat GENERALIZED ANXIETY DISORDER (GAD), panic ing from the drug, a process that may take several attacks and PANIC DISORDER, SLEEP DISORDERS, and weeks to complete. In circumstances in which POST-TRAUMATIC STRESS DISORDER (PTSD). 332 Substance Abuse

As substances of abuse, depressants produce tion). Many people undergoing treatment for INTOXICATION with initial euphoria and subsequent addiction receive medications to mitigate with- diminished cognitive function. Those who abuse drawal symptoms. Detoxification may take as long depressants often do so to dull the effects of coming as 14 days, though the most severe symptoms down from other drugs such as METHAMPHETAMINE occur within the first 3 to 5 days for most addic- and COCAINE. The most commonly abused depres- tions. Successful recovery from addiction requires sants are ALCOHOL and benzodiazepines, notably further, and often ongoing, treatment that may alprazolam and diazepam. Other commonly abused include PSYCHOTHERAPY, BEHAVIOR MODIFICATION THER- depressants include the illicit drugs FLUNITRAZEPAM APY, COGNITIVE THERAPY, and intensive family and and GAMMA HYDROXYBUTYRIC ACID (GHB). peer support. See also ALCOHOLISM; ILLICIT DRUG USE; PRESCRIP- See also ALCOHOLIC HALLUCINOSIS; ALCOHOLISM; TION DRUG ABUSE; STIMULANTS. INTOXICATION; SOBRIETY; WITHDRAWAL SYNDROME. designer drugs Illicit drugs created by altering dextromethorphan A COUGH suppressant, also the molecular structure of existing drugs, usually called an antitussive, that is a common ingredient drugs that are legal but restricted. The designer in numerous OVER-THE-COUNTER (OTC) DRUGS. These drug is typically similar to the derivative drug in products are the most common sources for abuse, its actions and effects, though both are often though other sources include illicit dextromethor- enhanced or intensified in some way. Because phan powder or capsules that contain dex- “street chemists” (commonly called cookers) man- tromethorphan powder. Though not a narcotic, ufacture designer drugs in casual settings, these dextromethorphan binds with certain opiate drugs are often of inconsistent potency and purity. receptors in the BRAIN and SPINAL CORD (CENTRAL There are often dozens of variations on a particu- NERVOUS SYSTEM) and has an opioid effect in sup- lar formula, each somewhat different molecularly pressing the cough REFLEX. Dextromethorphan has but all touted as the same drug. low risk for DEPENDENCE or ADDICTION. Most designer drugs are CLUB DRUGS produced At the recommended DOSAGE in cough and cold solely for the purpose of creating an intoxicating relief products dextromethorphan effectively or hallucinogenic experience, though some relieves cough without significant side effects. designer drugs are substances people take to When taken in amounts that exceed the recom- improve physical or athletic performance. The risk mended dosage dextromethorphan causes NAUSEA, for OVERDOSE, either from a single unexpectedly disorientation, HALLUCINATION, and dissociation potent dose or through combining drugs, is very (perceptions of separating from the physical high. Designer drugs have no therapeutic use. body). In very high doses, dextromethorphan See also AMPHETAMINES; BLOOD DOPING; HALLU- causes confusion, slurred speech, disturbed vision, CINOGEN; METHAMPHETAMINE; PERFORMANCE-ENHANC- tachycardia (rapid HEART RATE), and peripheral ING SUBSTANCES; SUBSTANCE ABUSE PREVENTION. PARESTHESIA (tingling and numbness of the fingers and toes). Seizures or fatal ARRHYTHMIA (irregular detoxification The process of eliminating from HEART beat) may also occur with very high doses. the body a substance to which a person is Chronic dextromethorphan abuse may result in addicted. Detoxification causes physiologic PSYCHOSIS and permanent neurologic damage to changes that restore to normal the way the body the brain. functions, reversing the changes that occurred as Other ingredients in multisymptom products DEPENDENCE and ADDICTION developed. This process that contain dextromethorphan, such as aceta- of restoration can cause symptoms such as ABDOM- minophen (an analgesic and antipyretic) and INAL PAIN, JOINT and MUSCLE PAIN, NAUSEA, VOMITING, guaifenesin (an expectorant), may cause other “shakes” (tremors), and sometimes seizures. undesired side effects. Chronic acetaminophen use Controlled detoxification, also called medically or acetaminophen OVERDOSE has high risk for per- supervised withdrawal, is the first stage of treat- manent LIVER damage, LIVER FAILURE, kidney dam- ment for DRUG addiction (including ALCOHOL addic- age, and RENAL FAILURE. disulfiram 333

HEALTH RISKS OF DEXTROMETHORPHAN ABUSE • blurred vision Short Term • HYPERVENTILATION and DYSPNEA (shortness of confusion disorientation breath) double vision HALLUCINATION NAUSEA and VOMITING seizures Symptoms typically begin about 10 minutes sudden death tachycardia (rapid HEART beat) after consuming alcohol and last 60 to 90 minutes. Though disulfiram can be very effective in helping Long Term maintain SOBRIETY in people who stringently com- ARRHYTHMIA BRAIN damage ply with the conditions of treatment, it can cause chronic hallucinations neuromotor dysfunction severe and potentially life threatening symptoms when alcohol consumption is substantial. Such See also ANALGESIC MEDICATIONS; HALLUCINOGENS; severe symptoms require emergency medical HEPATOTOXINS; NARCOTICS; OPIATES; PRESCRIPTION DRUG attention. Among them are tachycardia (rapid ABUSE. HEART RATE), ARRHYTHMIA (irregular HEART rate), seizures, and RESPIRATORY FAILURE. disulfiram A medication that blocks the action of the enzyme acetaldehyde dehydrogenase in the Because so many products and sub- second stage of ALCOHOL METABOLISM. This inhibi- stances, including medications, can con- tion prevents the conversion of acetaldehyde, a tain ALCOHOL, health-care providers potent toxin, to relatively harmless acetic acid. recommend that anyone taking disulfi- The consequence is rapid accumulation of ram carry a wallet card that identifies acetaldehyde in the BLOOD circulation, causing an them as on disulfiram therapy and the array of extremely unpleasant symptoms similar contact information for the prescribing to severe hangover. The intensity of symptoms physician. correlates directly to the DOSE of disulfiram and the amount of alcohol consumed. Abstinence from alcohol prevents symptoms. It Disulfiram, better known by its trade name is essential to avoid all products that contain alco- Antabuse, may be among the treatments for ALCO- hol. Common sources of alcohol include alcoholic HOLISM. Though disulfiram is very effective for beverages (beer, wine, mixed drinks), salad dress- controlling alcohol consumption, it does not cure ings, food sauces, cough and cold preparations, alcoholism. Symptoms that occur with the combi- any medicinal preparations labeled elixirs, mouth- nation of disulfiram and alcohol, called the disulfi- washes, and some COLD SORE treatments. Topical ram–alcohol reaction, include products that contain alcohol, such as aftershave lotion, may also activate the disulfiram–alcohol • throbbing HEADACHE reaction. Ingesting alcohol in any quantity in the 12 hours before the first disulfiram dose or up to • intense thirst and profuse VOMITING 14 days after the last disulfiram dose will produce • excessive sweating symptoms. • PALPITATIONS and CHEST PAIN See also INTOXICATION; METHADONE; NALTREXONE. E–G

ecstasy See METHYLENEDIOXYMETHAMPHETAMINE major operations such as OPEN HEART SURGERY or to (MDMA). treat significant CHRONIC PAIN such as may occur with terminal cancer. Fentanyl is a schedule 2 ethchlorvynol A sedating hypnotic DRUG, similar DRUG in the United States, strictly regulating its in physiologic action and effects to BARBITURATES, legitimate use. Numerous analogs (pharmacologic doctors may prescribe as a sleep aid to treat derivations) of fentanyl are available illicitly, insomnia. Ethchlorvynol (brand name Placidyl) though only a few are available for legitimate use. has high potential for physical DEPENDENCE and As a drug of abuse fentanyl produces effects ADDICTION, however, and is seldom the medication similar to those of HEROIN though is significantly of first choice in a therapeutic setting. It is a more potent. The most common method of schedule 4 drug in the United States; possession administration, as with heroin, is intravenous and use are legal only with a doctor’s prescription. injection (using a needle to inject the drug directly TOLERANCE to ethchlorvynol develops after about into a VEIN). Other forms of fentanyl subject to one week of taking it regularly, which means the abuse are transdermal patches (Duragesic) and a body requires a higher DOSE to achieve the same “lollipop” that allows the drug to enter the BLOOD effect. Taking ethchlorvynol for three weeks or circulation by being absorbed through the mucous longer often establishes physical dependence; membrane of the MOUTH (transmucosal absorp- abruptly stopping the drug after this time is likely to tion). The risk for OVERDOSE is very high with result in withdrawal symptoms such as NAUSEA, agi- abuse of these forms of fentanyl, as their structure tation, HALLUCINATION, tremors (“shakes”), and pos- releases a consistent amount of the drug over an sibly seizures. It is important to taper the amount of extended period of time and consuming them drug over days to weeks to stop taking it. As a drug faster than intended releases excessive amounts of of abuse, ethchlorvynol produces an intoxicating the drug. Fentanyl has a high risk for DEPENDENCE effect. As with other hypnotics, combining the drug and ADDICTION, with significant withdrawal symp- with ALCOHOL enhances the sedating effect and can toms when stopping the drug. result in OVERDOSE. People who abuse substances See also ANALGESIC MEDICATIONS; ANESTHESIA; such as METHAMPHETAMINE or COCAINE may use ILLICIT DRUG USE; KETAMINE; OPIATES; PHENCYCLIDINE ethchlorvynol to ease the transition between the (PCP); PRESCRIPTION DRUG ABUSE; SCHEDULED DRUGS; “high” of the stimulant and the “crash” of returning WITHDRAWAL SYNDROME. to normal state. See also CHLORAL HYDRATE; DEPRESSANTS; HYP- fetal alcohol syndrome A constellation of BIRTH NOTICS; PRESCRIPTION DRUG ABUSE; SCHEDULED DRUGS; DEFECTS that may occur as a result of a woman’s STIMULANTS; WITHDRAWAL SYNDROME. ALCOHOL consumption during the early stages of PREGNANCY. About 6,000 infants are born with fetal fentanyl A narcotic PAIN reliever about 80 times alcohol syndrome (FAS) each year in the United more potent than morphine. Fentanyl’s primary States. Up to five times as many more infants are therapeutic uses are for intravenous anesthetic born with symptoms of alcohol exposure during during surgery and for analgesia (pain relief) after prenatal development, although they do not have 334 fetal alcohol syndrome 335 full-blown FAS. Doctors may call incomplete the affirming factor, though the collective charac- forms of FAS alcohol-related neurodevelopmental teristics of FAS are relatively unique to the effects disorder (ARND) when symptoms are primarily of alcohol. Mild symptoms are sometimes difficult behavioral and alcohol-related birth defects to detect and diagnose, especially when health- (ARBD) when symptoms are primarily physical. care providers do not know the mother’s alcohol People sometimes refer to the entire range of consumption during pregnancy (as is common in these conditions as fetal alcohol spectrum disor- many adoption circumstances). From initial estab- ders (FASDs), though this is a general rather than lishment of FAS criteria, the diagnostic path a clinical term. includes further neurologic and psychologic test- Researchers first identified FAS in 1981 and are ing to more concisely define the extent of the still unable to determine any safe level of drinking damage. during pregnancy. Alcohol is highly teratogenic, meaning it has strong capability to cause damage Treatment Options and Outlook to cells of all types during fetal development. The Treatment attempts to manage symptoms and the highest risk for severe birth defects occurs with effects of the damage that has occurred. The ear- heavy drinking during the first eight weeks of lier diagnosis takes place and interventions can pregnancy, the time when body systems and begin, the more successful treatment usually is in organs are developing. The BRAIN and NERVOUS SYS- helping the child reach his or her full potential. TEM are particularly vulnerable to alcohol toxicity; Children who have FAS are more likely also to exposure during any stage of pregnancy may have psychologic conditions such as ATTENTION affect whatever neurologic development is occur- DEFICIT HYPERACTIVITY DISORDER (ADHD) and CONDUCT ring at the time. The result may be a range of DISORDER. The first children diagnosed as having intellectual, emotional, and behavioral dysfunc- FAS are only now entering adulthood, so doctors tions that become apparent as the child grows up. do not know the long-term consequences of FAS. People who have mild symptoms and receive Symptoms and Diagnostic Path aggressive, targeted intervention are often able to A collaboration of US health-care agencies con- function in society with relative success. Those vened as the National Task Force on Fetal Alcohol who have severe symptoms may need ongoing Syndrome and Fetal Alcohol Effects issued diag- care even in adulthood. nostic criteria and guidelines in 2004, under man- date from the US Congress to establish consistent Risk Factors and Preventive Measures diagnosis. These criteria include The only risk for fetal alcohol syndrome is a woman’s consumption of alcohol during preg- • small head (microcephaly) with structural brain nancy. FAS is entirely preventable if the woman abnormalities apparent with diagnostic imaging completely abstains from alcohol during preg- procedures nancy, from CONCEPTION to birth. Because more • three unique and characteristic craniofacial than half of pregnancies in the United States are anomalies, also called facial dysmorphias: unplanned, the greatest risk exists for women smooth philtrum (no ridges in the upper lip); who are not planning pregnancy but become narrowly placed eyes with short slits (palpebral pregnant. fissures); and narrow, thin upper lip Extensive education efforts have increased • impaired growth (height or weight that awareness of the dangers of alcohol during preg- remains below the tenth percentile for age) nancy, among them warning labels placed on • mental delays and functional deficits (varied alcoholic beverage containers and posted in estab- and numerous intellectual, cognitive, and lishments that serve alcoholic beverages such as behavioral problems) restaurants, lounges, taverns, and bars. However, many people, including some health-care Some infants who have FAS also have other providers, still erroneously believe it is safe to birth defects. Prenatal exposure to alcohol may be drink in moderation during pregnancy. The US 336 Substance Abuse

Surgeon General in 2005 issued an advisory stat- action. Combining GHB with ALCOHOL greatly ing that there is no safe threshold for alcohol con- intensifies this action, resulting in rapid and deep sumption during pregnancy and that the risk for sleep with amnesia; the person does not remember FAS and related conditions increases with the events that occur during the INTOXICATION period. As amount and frequency of alcohol a woman con- a consequence GHB has acquired notoriety as a sumes during pregnancy. “date rape” drug, used to unknowingly intoxicate See also ALCOHOLISM; PRENATAL CARE; SUBSTANCE others for the purpose of SEXUAL ASSAULT. ABUSE TREATMENT. GHB is a schedule 1 drug in the United States, indicating that it has no known therapeutic use. A flunitrazepam A hypnotic DRUG with sedative legal, uncontrolled GHB precursor to is 1,4- actions and effects similar to those of other BENZO- butanediol, a chemical commonly available as an DIAZEPINES. Flunitrazepam, better known by its industrial solvent. 1,4-butanediol metabolizes to brand name Rohypnol or its slang names ropies GHB after ingestion and has the same effects in and roofies, is not legal in the United States, the body. Efforts are under way in the United though it is manufactured as a legal drug in other States to reclassify 1,4-butanediol to restrict its countries. As a drug of abuse flunitrazepam is availability as well. popular at parties and in clubs. Taken alone it pro- See also ANABOLIC STEROIDS AND STEROID PRECUR- duces a euphoric INTOXICATION. When combined SORS; CLUB DRUGS; DEPRESSANTS; HYPNOTICS. with ALCOHOL flunitrazepam causes incapacitation and amnesia of events that take place while the glutethimide A hypnotic DRUG first used as a drug combination is active in the body. Because of substitute for BARBITURATES to treat insomnia and this interaction flunitrazepam has gained notori- other SLEEP DISORDERS. Glutethimide (brand name ety as a “date rape” drug. The risks for DEPENDENCE Doriden) is highly addictive, and, like barbiturates, and ADDICTION are moderate. poses a significant risk for life-threatening symp- See also CLUB DRUGS; DEPRESSANTS; DETOXIFICATION; toms when taken in excessive amounts. TOLERANCE SCHEDULED DRUGS; WITHDRAWAL SYNDROME. to the drug (increased amount necessary to pro- duce the same effect) occurs after about a week of gamma hydroxybutyrate (GHB) An illicit DRUG regular use; DEPENDENCE may develop after three with depressant and anabolic effects in the body, weeks of regular use. Stopping the drug suddenly depending on the amount and frequency taken. after three weeks or longer of regular use often GHB originally gained popularity among body- results in withdrawal symptoms that may require builders and athletes for whom STRENGTH and MUS- medical treatment. Because of its high risk for CLE mass are important. Though not a HORMONE, ADDICTION and OVERDOSE, glutethimide is a schedule GHB has anabolic effects—that is, it causes an 2 drug in the United States and requires a physi- increase in both the number and size of voluntary cian’s prescription for legal possession and use. muscle cells. Its sedative qualities also make GHB Few physicians prescribe glutethimide, however, an effective sleep aid for people also using other because other sedatives and hypnotics are as effec- anabolic steroids, which tend to cause sleep distur- tive with fewer side effects and lower risk for bances. addiction. As a CENTRAL NERVOUS SYSTEM depressant, GHB See also HYPNOTICS; PRESCRIPTION DRUG ABUSE; SUB- functions as a hypnotic with moderate sedating STANCE ABUSE TREATMENT; WITHDRAWAL SYNDROME. H hallucinogens Psychoactive substances that alter bear out this potential. Through incidental inges- the BRAIN’s perceptions of sensory experiences. tion, LSD’s developer, Swiss chemist Albert Hof- Auditory and visual HALLUCINATION, time disorien- mann (b. 1906), discovered the drug’s tation, and altered depth perception are common hallucinogenic capabilities. Because the effects of with hallucinogen abuse. However, not all people taking LSD could be remarkably similar to the who take hallucinogens experience hallucinations. some types of SCHIZOPHRENIA, researchers subse- Researchers do not know the precise mechanisms quently used LSD in clinical research as an effort of hallucinogens though believe many of them to better understand this psychiatric disorder. affect the presence of serotonin, a NEUROTRANSMIT- However, LSD proved unable to provide the TER in the brain. Most hallucinogens are illicit sub- insights researchers hoped it would. In the 1960s stances; many come from natural sources such as LSD became popular as an illicit hallucinogen. mushrooms and cacti and others are synthesized LSD is a very potent hallucinogen that can (created in clandestine laboratories using chemi- remain active in the body up to 12 hours. High cals). In the United States hallucinogens are doses often generate unpleasant or frightening SCHEDULED DRUGS; most are schedule 1 drugs experiences and tend to produce flashbacks for because there are no therapeutic applications for two to three days after its use. Common initial their use and they have such high abuse potential. effects include rapid HEART RATE, NAUSEA, low body Short-term, adverse health consequences of temperature, and diaphoresis (cold sweat). Hallu- hallucinogen use include distortions of reality that cinations begin about an hour after ingestion and may lead to irrational decisions and actions. Rapid may result in bizarre behavior as the person reacts mood swings and corresponding changes in to distorted sensory perceptions. Some people behavior are common. The effective action of experience intense anxiety and DEPRESSION after some hallucinogens may be 10 hours or longer. the effect of the LSD wears off. Long-term, adverse health consequences of chronic hallucinogen use include possible neuro- Natural Hallucinogens toxicity and death of brain neurons. Some people Natural sources of hallucinogenic substances are experience flashbacks—hallucinatory experiences abundant and include plants such as cacti, which that repeat days, weeks, and sometimes months contain mescaline, and numerous types of mush- after hallucinogen use. Occasionally PSYCHOSIS rooms, which contain tryptamines such as psilocy- develops in a person who uses hallucinogens bin. Some natural hallucinogenic substances are extensively. Hallucinogen use does not typically potentially lethal even in small doses. Tryptamine- result in DEPENDENCE though may result in ADDIC- containing mushrooms grow abundantly in hot, TION (desire to take the DRUG). moist environments around the world, including in the United States. The peyote cactus Lysergic Acid Diethylamide (LSD) (Lophophora williamsii) grows abundantly in the The original purpose of lysergic acid diethylamide southwestern United States and northern Mexico. (LSD), first synthesized in 1938, was as a treat- The peyote’s crowns contain high concentrations ment to prevent seizures. However, testing did not of mescaline. The most common methods of 337 338 Substance Abuse ingestion are chewing or eating dried plants or nent immediately on waking in the morning and mushrooms or drinking liquid brewed from them. may include The potency and effect of natural hallucinogens are unpredictable. • significant HEADACHE • NAUSEA Other Drugs with Hallucinogenic Effects • VOMITING Many substances can generate hallucinatory expe- riences, particularly when taken in high doses. • dizziness and VERTIGO Hallucinations, especially visual, are common with • PHOTOPHOBIA (aversion to bright light) abuse of many types of AMPHETAMINES and NAR- COTICS. Among such drugs are Though many remedies profess to prevent or cure hangover, the only prevention is avoiding • METHYLENEDIOXYMETHAMPHETAMINE (MDMA), better excessive alcohol consumption and the only cure known by its slang name ecstasy, a popular is time. The folk remedy of consuming an alco- amphetamine-based club drug that produces a holic drink to relieve hangover does not really end combination of euphoria and excitation the hangover but instead induces mild INTOXICA- • KETAMINE, an anesthetic agent seldom used for TION. In a person who is addicted to alcohol (ALCO- ANESTHESIA in people because it produces hallu- HOLISM) this restores the effect of alcohol on the cinations and sometimes DELIRIUM balance of neurotransmitters in the BRAIN. How- • PHENCYCLIDINE (PCP), a veterinary anesthetic ever, hangover is an indication that the LIVER’s agent that produces intense hallucinations, METABOLISM of alcohol has not been able to keep DELUSION, delirium, and other psychoactive pace with the body’s consumption, allowing responses in people higher concentrations of aldehyde (a toxin that is the first step of alcohol metabolism) to circulate in These drugs also produce primary effects such the BLOOD. There is some evidence that the herb as CENTRAL NERVOUS SYSTEM stimulation, analgesia MILK THISTLE (silymarin) improves liver function so (PAIN relief), and anesthesia (unawareness of sen- the liver can more efficiently metabolize alcohol. sation). When used as drugs of abuse, the overall See also DETOXIFICATION; LIVER DISEASE OF ALCO- effects are often unpredictable. Illicit chemists HOLISM; WITHDRAWAL SYNDROME. often mix different drugs together to create varia- tions of these drugs, which are particularly harm- hashish See CANNABIS. ful because their actions are unknown in such combinations. hash oil See CANNABIS.

COMMON HALLUCINOGENS heroin A narcotic DRUG derived from morphine. alpha ethyltryptamine (AET) bufotenine Widely used to relieve PAIN when it first became diethyltryptamine (DET) dimethyltryptamine (DMT) available in the early 1900s, heroin even appeared KETAMINE lysergic acid diethylamide (LSD) in over-the-counter pain remedies (as did other mescaline peyote OPIATES) marketed to relieve various aches and dis- PHENCYCLIDINE (PCP) psilocybin comforts. Today, however, heroin has no thera- peutic uses and is a schedule 1 drug in the United See also CLUB DRUGS; ILLICIT DRUG USE; HYPNOTICS; States, making it legally available only for clinical NEURON; NEUROTRANSMITTER; SCHEDULED DRUGS; SUB- research. Heroin has very high risk for DEPENDENCE STANCE ABUSE PREVENTION; SUBSTANCE ABUSE TREAT- and ADDICTION; heroin addiction presents signifi- MENT. cant health and social problems in the United States and throughout the world. hangover Unpleasant physical symptoms that Heroin absorbs poorly through the gastroin- occur as a toxic reaction after excessive consump- testinal mucosa; thus its classic method of admin- tion of ALCOHOL. These symptoms are most promi- istration is intravenous injection (injected with a hypnotics 339 needle directly into a VEIN). Other means of using NEUROTRANSMITTER that conveys NERVE impulses heroin are injecting it—intramuscular (into a MUS- among BRAIN neurons to slow brain activity. BARBI- CLE) or under the SKIN (subcutaneous, also called TURATES, most BENZODIAZEPINES, and some ANTIHISTA- “skin popping”)—snorting it into the NOSE, or MINE MEDICATIONS have hypnotic actions. smoking it mixed with tobacco or marijuana. Short-term health risks of hypnotic use include These other methods are no less addictive, though snorting and smoking do reduce the risk for con- • excessive drowsiness or difficulty waking up in tracting bloodborne diseases such as HEPATITIS and the morning HIV/AIDS. Such infections are significant risks with • sense of sluggishness the next day injected drugs of abuse, particularly when users share needles, syringes, and other paraphernalia. These consequences and side effects usually go The risk for OVERDOSE is high because heroin’s away after the drug is no longer present in the potency and other ingredients are uncertain from body. Health risks of continued or long-term use DOSE to dose. Most powder sold as heroin is 10 to of hypnotics may include 70 percent heroin. The remainder may be other number of other substances from sugar to aceta- • DEPENDENCE on the drug to fall asleep minophen to other illicit drugs or even poisons. • ADDICTION Exceptionally pure heroin is also hazardous • severe withdrawal symptoms when suddenly because it is more narcotic than the person is stopping the drug, including possible PSYCHOSIS accustomed to using. • profound DEPRESSION HEALTH RISKS OF HEROIN ABUSE • increased potential for OVERDOSE Short Term Because the body develops TOLERANCE for hyp- CONSTIPATION delayed reactions notics, the margin between a safe amount of the drowsiness inability to concentrate drug and the amount necessary to produce the NAUSEA and VOMITING OVERDOSE desired effect narrows with long-term use. This is Long Term particularly hazardous with barbiturates and can ADDICTION ENDOCARDITIS and other result in unintended fatal overdose. HEPATITIS, HIV/AIDS, and other bacterial INFECTION viral infection scarring and damage to BLOOD COMMON HYPNOTICS vessels BARBITURATES BENZODIAZEPINES CHLORAL HYDRATE diphenhydramine See also INJECTING DRUGS, RISKS OF; NARCOTICS; doxcylamine ethchlorvynol SCHEDULED DRUGS; SMOKING AND HEALTH; WITHDRAWAL GAMMA HYDROXYBUTYRIC ACID (GHB) GLUTETHIMIDE SYNDROME. meprobamate methaqualone METHYPRYLON paraldehyde hypnotics DRUGS that induce sleep or cause zaleplon zolpidem heavy sedation. Hypnotics are CENTRAL NERVOUS SYSTEM DEPRESSANTS that act primarily to elevate See also SCHEDULED DRUGS; SLEEP DISORDERS; SUB- levels of gamma aminobutyric acid (GABA), a STANCE ABUSE TREATMENT; WITHDRAWAL SYNDROME. I illicit drug use Any use of substances not legal other significant risk with illicit drugs is the legal to possess. Many illicit drugs are “underground” consequence for their possession, which may drugs that individuals manufacture specifically for result in jail sentences, fines, and serious conse- illicit use. Some of these drugs may be legal in quences for a person’s career, family, and lifestyle. other countries though are not legal in the United In the United States the 1970 Controlled Sub- States or in the country in which the person is stances Act (CSA) and its subsequent revisions using them. As well, illicit drugs may be drugs that establish the legality of drugs. Other countries are legal but the person possessing them does not have comparable legislative guidelines. have legal authorization, such as a physician’s pre- scription. COMMONLY ABUSED ILLICIT DRUGS A significant health concern with illicit drugs is ANABOLIC STEROIDS AND STEROID COCAINE their production. Many drugs that come in loose PRECURSORS FLUNITRAZEPAM form (such as HEROIN, COCAINE, METHAMPHETAMINE, GAMMA HYDROXYBUTYRIC ACID hashish and marijuana) are “cut” with various and often (GHB) HEROIN unknown substances, including other drugs and LSD marijuana sometimes chemicals not intended for human mescaline METHAMPHETAMINE consumption. These fillers, which dilute the DRUG’s METHYLENEDIOXYMETHAMPHETAMINE (MDMA) peyote strength, may alter the actions of the drug or themselves cause effects in the body that are See also ADDICTION; CLUB DRUGS; DESIGNER DRUGS; unexpected or toxic. The manufacture of illicit STIMULANTS; HALLUCINOGENS; NARCOTICS; OPIATES; PRE- drugs in pill form is also questionable, with SCRIPTION ABUSE; SCHEDULED DRUGS; SUBSTANCE ABUSE potency and ingredients varying certainly from PREVENTION. batch to batch and often from pill to pill. Many people who manufacture illicit drugs such as injecting drugs, risks of The potential health methamphetamine have little knowledge of consequences of sharing needles and DRUG para- chemistry beyond that required to produce the phernalia. Sharing needles allows the passing of drugs, and produce the drugs in less than ideal BACTERIA and viruses that are in the BLOOD among and often unsanitary conditions. all individuals who use the needles. Rinsing with Other illicit drugs are produced in countries water or cleaning with bleach is not enough to where their use is legal; they are smuggled into prevent INFECTION with many bloodborne the United States and other countries. The pro- pathogens. duction circumstances may or may not be of Intravenous drug users who share needles and acceptable standards in terms of the drug’s purity drugs have particularly high risk for infection with and consistency and the cleanliness of the manu- bloodborne viruses such as HEPATITIS B, hepatitis C, facturing environment. Manufacturing inconsis- HIV/AIDS, and for acquiring bacterial infections tencies, sanitation, and impurities may all pose such as TUBERCULOSIS and MENINGITIS. It is also pos- health risks for people who use drugs smuggled sible to acquire infection with some SEXUALLY into the United States from other countries. The TRANSMITTED DISEASES (STDS). 340 intoxication 341

Needle exchange programs have become effec- intoxication The presence of ALCOHOL or other tive public health tools for reducing communica- DRUG in the body in an amount that alters percep- ble disease transmission among intravenous drug tion, behavior, thought processes, motor skills, users. Local health departments administer such judgment, and other physical or psychologic activi- programs, which give the person a sterile needle ties in ways that are dysfunctional or disruptive. and syringe in exchange for a used one. Though it From a health perspective intoxication is a state of is a common perception that such needle poisoning. Slang terminology for intoxication exchange programs inherently encourage intra- includes drunkenness (alcohol intoxication), venous drug abuse, there is little clinical evidence stoned, high, and buzzed. The primary objective of that this is the case. Many substance abuse experts substance abuse is to achieve a state of intoxication, believe needle exchange programs, though they which continues for as long as the substance do not overtly encourage users to stop using responsible for it remains active in the body. In the drugs, do provide regular access to information United States and most countries laws define the about treatment programs that allow users who legal boundaries of intoxication, beyond which want to stop to find the help they need to do so as intoxication while participating in certain activities well as reduce the risk for disease. such as driving becomes a criminal offense. See also SEXUAL HEALTH; SEXUALLY TRANSMITTED DIS- See also DETOXIFICATION; ILLICIT DRUG USE; OVER- EASE (STD) PREVENTION; SUBSTANCE ABUSE PREVENTION; DOSE; POISON PREVENTION; PRESCRIPTION DRUG ABUSE; SUBSTANCE ABUSE TREATMENT; WITHDRAWAL SYNDROME. SOBRIETY; SUBSTANCE ABUSE TREATMENT. K–M

ketamine An intravenous anesthetic agent used BRAIN in the same way as does morphine, though primarily in veterinary medicine that has euphoric methadone’s chemical structure differs from that and hallucinogenic effects when used as a sub- of morphine and methadone’s effects last up to 24 stance of abuse. Ketamine causes a sense of disso- hours. ciation (separation of one’s self from PAIN and Methadone has similar risk as OPIATES for other physical sensations associated with surgery), DEPENDENCE and ADDICTION. In the United States amnesia for events that occur while it is effective methadone is a schedule 2 DRUG doctors prescribe in the body, and primarily visual HALLUCINATION primarily to treat HEROIN addiction. It works by that are often quite vivid. Users sprinkle ketamine blocking opiate receptors in the brain, which pre- powder on cigarettes or marijuana and smoke it, vents other opiates such as heroin from doing so. snort the powder, or dissolve the powder and Though methadone is itself addictive, withdrawal inject it intravenously. Excessive doses result in symptoms are less severe than withdrawal from anesthesia-like loss of CONSCIOUSNESS. In the United heroin. As a drug of abuse methadone has effects States ketamine is a schedule 3 drug. similar to those of heroin. Doctors also occasion- See also ANESTHESIA; CANNABIS; ILLICIT DRUG USE; ally prescribe methadone as an analgesic, often to NARCOTICS; PHENCYCLIDINE (PCP); SCHEDULED DRUGS. treat CHRONIC PAIN. See also ANALGESIC MEDICATIONS; DETOXIFICATION; levo-alpha acetylmethadol (LAAM) An oral DRUG ILLICIT DRUG USE; SCHEDULED DRUGS; SUBSTANCE ABUSE to treat narcotic ADDICTION, primarily HEROIN addic- TREATMENT; WITHDRAWAL SYNDROME. tion. LAAM is a synthetic product similar in chem- ical composition as well as action in the body to methamphetamine A very potent DRUG that is a METHADONE, though a single DOSE is effective for up CENTRAL NERVOUS SYSTEM stimulant. Though one to 72 hours. In the United States LAAM is a sched- formulation of methamphetamine is available for ule 2 drug. However, a rare but serious SIDE EFFECT therapeutic use to treat a certain type of NAR- of LAAM is damage to the HEART and BLOOD vessels. COLEPSY, in the United States methamphetamine is Because of this, doctors use LAAM primarily when primarily illicit and classified as a schedule 2 drug; treatment with methadone is not effective. its possession and therapeutic uses are extremely See also NALTREXONE; SCHEDULED DRUGS; SUB- limited. Highly addictive, methamphetamine pro- STANCE ABUSE TREATMENT. duces euphoria and a sense of invincibility. The drug stays active in the body for an extended time, LSD See HALLUCINOGENS. making repeated use dangerously toxic; fatal OVER- DOSE is a significant risk. marijuana See CANNABIS. Though relatively simple from a chemistry per- spective, which gives rise to proliferate clandestine methadone A synthetic analgesic (PAIN medica- “meth labs,” the manufacture of methampheta- tion) originally developed as an oral substitute for mine is also quite toxic. Meth labs require only morphine, a narcotic analgesic, during World War rudimentary equipment and supplies. However, II. Methadone binds with opiate receptors in the the methamphetamine production process is so 342 methylenedioxymethamphetamine (MDMA) 343 harmful that it renders uninhabitable or unusable lar to amphetamine, a stimulant, and mescaline, a any structures (including homes, apartments, and hallucinogen. The drug’s risks for DEPENDENCE and motels) used for meth labs. ADDICTION are very high. In the United States Chronic, long-term methamphetamine abuse MDMA is a schedule 1 drug with no therapeutic causes serious and permanent damage to many uses. body systems. Classic indications of such abuse The desired effects of MDMA are euphoria, include rotted and missing TEETH, emaciated increased energy, heightened sensory perceptions, appearance, open sores on the face, and patchy and intensified sexual interest and experiences. HAIR loss. Continuous picking at the SKIN reflects The undesired side effects of MDMA may have damage to BRAIN neurons; PARANOIA and SCHIZO- long-lasting or permanent consequences, includ- PHRENIA are common with chronic methampheta- ing ARRHYTHMIA, organ damage or failure, and mine abuse. DETOXIFICATION and maintaining damage to BRAIN neurons. Cravings for MDMA can SOBRIETY are difficult. continue long after stopping the drug. As well, because MDMA is an illicit drug it is often con- HEALTH RISKS OF METHAMPHETAMINE ABUSE taminated with other drugs, commonly ampheta- Short Term mine compounds, though underground chemists use a variety of substances as fillers. These sub- altered reactions and disordered thinking stances may interact with each other or have toxic reaction time DYSPHORIA as effect wears off consequences of their own. excitability and hyperactivity rapid mood swings unpredictable and violent behavior HEALTH RISKS OF MDMA (ECSTASY) ABUSE Long Term Short Term ADDICTION HALLUCINATION disturbed thought processes erratic body temperature MALNUTRITION PSYCHOSIS HYPERTENSION hyperthermia rotted TEETH SCHIZOPHRENIA increased or irregular HEART memory impairment sores on the face and body unhealthy weight loss RATE (ARRHYTHMIA)

See also HALLUCINOGENS; ILLICIT DRUG USE; SCHED- Long Term ULED DRUGS; STIMULANTS; SUBSTANCE ABUSE TREATMENT; ADDICTION BRAIN damage WITHDRAWAL SYNDROME. cognitive dysfunction organ damage methylenedioxymethamphetamine (MDMA) See also AMPHETAMINES; CLUB DRUGS; COGNITIVE An illicit DRUG that acts on the CENTRAL NERVOUS FUNCTION AND DYSFUNCTION; HALLUCINOGENS; MEMORY SYSTEM to produce hallucinogenic and stimulant AND MEMORY IMPAIRMENT; NEURON; SCHEDULED DRUGS; effects. A designer drug, MDMA is best known by STIMULANTS; SUBSTANCE ABUSE PREVENTION; SUBSTANCE its slang name ecstasy. MDMA is chemically simi- ABUSE TREATMENT. N

naltrexone A medication to treat opiate ADDIC- brain’s perceptions about and responses to pain TION. Naltrexone binds with opiate receptors in the signals as well as certain aspects of mood and con- BRAIN, preventing opiate drugs from binding. This sciousness. Opiate receptor binding also influences action can block further effect of OPIATES already in the rate of BREATHING (respiratory rate). The gas- the body or prevent the effect of opiates taken trointestinal tract contains some opiate receptors, after naltrexone is in the body. Naltrexone is a which is why certain types of narcotics are useful treatment for addiction to opiates including pre- for treating diarrhea and others cause CONSTIPATION scription NARCOTICS and illicit drugs such as HEROIN. as an undesired SIDE EFFECT. Naltrexone also helps reduce ALCOHOL cravings in There are two general classifications of nar- some people who are recovering from ALCOHOLISM. cotics: OPIATES, which come from natural sources, Naltrexone is most effective in people who have and synthetics, which are produced from chemi- strong desire to remain abstinent from DRUG or cals in laboratories. Opiates derive from opium, alcohol use and when starting DETOXIFICATION as the sap from the Papaver somniferum poppy plant. part of a comprehensive SUBSTANCE ABUSE TREAT- Synthetic narcotics, sometimes called opioids MENT program. because they act in an opiate-like manner in the See also ILLICIT DRUG USE; LEVO-ALPHA ACETYL- body, are chemical formulas designed in the labo- METHADOL (LAAM); METHADONE; PRESCRIPTION DRUG ratory to bind with specific types of opiate recep- ABUSE; WITHDRAWAL SYNDROME. tors for a lower risk of dependence and addiction. Opiate receptors rapidly become tolerant to the narcotics Drugs that produce insensitivity to actions of narcotics, resulting in higher doses physical sensation, often altering perception and being necessary to achieve the same effect. the level of CONSCIOUSNESS. Many narcotics subject Narcotics come in forms for all ROUTES OF ADMIN- to abuse are legitimate drugs that have therapeutic ISTRATION: oral (liquids, tablets, capsules), rectal uses such as to relieve PAIN, stop COUGH, and treat (suppositories), sublingual (under the tongue), DIARRHEA. Anesthesiologists use some narcotics to intravenous injection (with a needle into a VEIN), initiate or provide ANESTHESIA. Some narcotics are intramuscular injection (with a needle into a MUS- illicit, produced in clandestine labs by people who CLE), subcutaneous (with a needle under the SKIN), have rudimentary knowledge of chemistry. All transdermal (patches, for absorption through the narcotics have high risk for DEPENDENCE and skin), and mucosal (sprays or lozenges, for absorp- ADDICTION. Accordingly narcotics are SCHEDULED tion through the mucous membranes of the MOUTH DRUGS in the United States and many other or NOSE). Some narcotics do not absorb well countries, restricting their legal use and posses- through the gastrointestinal tract and are available sion. only for injection, whereas for other narcotics Narcotics act on neuroreceptors in the CENTRAL injection offers the most rapid effect. The most NERVOUS SYSTEM (BRAIN and SPINAL CORD) called opi- commonly used methods for abuse are oral and ate receptors, which researchers discovered in injectable. As well, in circumstances of narcotic 1973. These specialized proteins regulate the abuse a person may add a powdered narcotic to a

344 nicotine 345 cigarette and smoke it, which allows absorption needle exchange programs See INJECTING DRUGS, through the LUNGS. RISKS OF. The short-term health risks of narcotic use include nicotine The primary psychoactive DRUG in tobacco and SMOKING CESSATION products. Nicotine • drowsiness has stimulant as well as vasoconstrictive effects • reduced alertness or consciousness and is highly addictive. Many health experts con- sider nicotine at least as addictive as COCAINE and • NAUSEA, VOMITING, and constipation HEROIN. Most tobacco users, particularly smokers, attempt to quit numerous times before they Health risks that may occur with long-term use achieve long-term success. Nicotine crosses the of narcotics include BLOOD–BRAIN BARRIER within seconds of tobacco use, where it affects the presence and activity of • TOLERANCE, dependence, and addiction several BRAIN neurotransmitters, notably DOPAMINE • INFECTION through shared needles among those and acetylcholine. These actions set in motion a who inject the drugs cascade of events throughout the body that affect • depressed respiration and RESPIRATORY FAILURE multiple functions, ranging from mood to cardio- leading to death as the boundary between vascular activity. effective and toxic dosages grows increasingly Common sources of nicotine include narrow • cigarettes Narcotic antagonists are drugs that have greater • cigars affinity for opiate receptors than do narcotics; they • NICOTINE REPLACEMENT products are able to “bump” opioids from the receptors. These drugs are often effective for treating nar- • smokeless (chewing) tobacco cotic OVERDOSE and addiction. DETOXIFICATION from •snuff narcotic addiction often entails numerous with- drawal symptoms that are more severe the longer HEALTH RISKS OF NICOTINE ABUSE a person has taken or abused the drugs. Short Term activation of STRESS RESPONSE HORMONAL CASCADE COMMON NARCOTICS elevated BLOOD PRESSURE increased HEART RATE Opiates (Narcotics of Natural Origin) vasoconstriction codeine HEROIN hydrocodone hydromorphone Long Term morphine oxycodone ADDICTION paregoric (opium) thebaine ARTERIOSCLEROSIS chronic HYPERTENSION Synthetics (Opioids) health complications associated with tobacco use BUPRENORPHINE butorphanol inability to focus without nicotine in the BLOOD circulation dextropropoxyphene fentanyl meperidine METHADONE As a stimulant nicotine can heighten a person’s pentazocine mental focus and cognitive capability. However, tolerance develops rapidly such that with contin- See also ANALGESIC MEDICATIONS; ILLICIT DRUG USE; ued use (nicotine ADDICTION) this effect diminishes. NARROW THERAPEUTIC INDEX (NTI); PRESCRIPTION DRUG Nicotine, through its effect on acetylcholine in the ABUSE; SUBSTANCE ABUSE PREVENTION; SUBSTANCE ABUSE brain, activates the STRESS RESPONSE HORMONAL CAS- TREATMENT; WITHDRAWAL SYNDROME. CADE, increasing the flow of EPINEPHRINE and NOR- 346 Substance Abuse

EPINEPHRINE in the body. This causes immediate DROME) and of the blood flow to the PENIS, result- changes in the walls of the arteries, causing them ing in ERECTILE DYSFUNCTION. The only therapeutic to stiffen and narrow. With long-term use of nico- use for nicotine is in nicotine replacement prod- tine-containing substances these changes become ucts to treat nicotine addiction (SMOKING CESSA- permanent and alter cardiovascular function, con- TION). tributing to serious HEART conditions such as HYPER- See also ANTISMOKING EFFORTS; CANCER RISK FAC- TENSION (high BLOOD PRESSURE) and HEART FAILURE. TORS; CARCINOGEN; ENVIRONMENTAL CIGARETTE SMOKE; The cardiovascular changes also affect the body’s NEUROTRANSMITTER; SMOKING AND CANCER; SMOKING tiniest arteries, which can result in restricted cir- AND CARDIOVASCULAR DISEASE (CVD); SMOKING AND culation in the fingers and toes (RAYNAUD’S SYN- HEALTH; WITHDRAWAL SYNDROME. O–R

opiates Drugs derived from opium, the dried sap LEVO-ALPHA ACETYLMETHADOL (LAAM); NALTREXONE; of the Papaver somniferum poppy plant. P. som- PRESCRIPTION DRUG ABUSE; SUBSTANCE ABUSE PREVEN- niferum is the only one of about 120 species in the TION; SUBSTANCE ABUSE TREATMENT; WITHDRAWAL SYN- Papaver family of poppy plants that produces DROME. opium; other species are common ornamental flowering annuals or perennials. In the United organic solvents Petroleum distillates found in States opiates are SCHEDULED DRUGS, restricting legal gasoline and some paints, paint thinners, aerosols, use and possession to physician prescription. household cleaners, and glues. When inhaled in HEROIN, which derives from morphine, is a sched- small quantities organic solvents produce a sense ule 1 drug, a classification that prohibits posses- of INTOXICATION and mild HALLUCINATION. Inhaling sion and use. Opiates have moderate to high risk the vapors into the LUNGS allows rapid absorption for TOLERANCE, DEPENDENCE, and ADDICTION. into the BLOOD circulation. However, the margin Most opiates are NARCOTICS used for analgesia between intoxication and neurologic toxicity is (PAIN relief) or ANESTHESIA (loss of sensation). very narrow and inhaled solvents can cause rapid Opium is the main ingredient in the medication death. The highest rate of organic solvent abuse is paregoric, sometimes used to treat DIARRHEA. among children between 9 and 13 years of age. Because opiates suppress the COUGH REFLEX, pre- Short-term health risks of inhaling organic sol- scription antitussive medications often contain vents include them (notably codeine and hydrocodone). The most effective opiate for significant pain relief, • slurred speech and uncoordinated movement such as pain after surgery or terminal pain, is mor- • HEADACHE phine, which became available in sustained- • NAUSEA and VOMITING release tablets in the 1990s. The most commonly • panic attacks used opiates are hydrocodone and codeine, which appear in numerous products to relieve moderate • erratic mood and behavior pain and also for cough relief. • DEPRESSION • ASPIRATION of the substance into the lungs COMMON OPIATES • asphyxiation (suffocation) resulting in death alfentanil butorphanol codeine dextropropoxyphene Long-term abuse of inhalants has significant fentanyl HEROIN health risks including hydrocodone hydromorphone meperidine METHADONE • RENAL FAILURE morphine oxycodone • LIVER damage pentazocine sufentanil • cognitive dysfunction

See also ANALGESIC MEDICATIONS; DEXTROMETHOR- • memory impairment PHAN; ILLICIT DRUG USE; INJECTING DRUGS, RISKS OF; • HEART FAILURE 347 348 Substance Abuse

Because numerous products contain organic CAFFEINE is perhaps the most commonly used solvents, preventing inhalant abuse is challenging. performance-enhancing substance. Coffee, tea, The very fact that these products are ordinary and and cola drinks contain caffeine as do many common perpetuates the mistaken belief that energy drinks, gels, and food bars. Energy prod- inhaling them is harmless. Many parents are ucts also commonly contain GINSENG and other unaware of the practice of sniffing or huffing such herbs that act as STIMULANTS. Some contain ma products. Substance abuse experts urge parents to huang, a Chinese herb whose active ingredient is read product labels to identify those products that ephedra, a stimulant that is no longer legal in the contain organic solvents to minimize the amount United States. Other commonly available products of such products in the home. Indications a child used for their stimulant actions to enhance per- may be abusing substances containing organic sol- formance are decongestants such as pseu- vents include doephedrine. Illicit performance-enhancing substances include ANABOLIC STEROIDS AND STEROID • RASH around the NOSE and MOUTH PRECURSORS, ERYTHROPOIETIN (EPO), human growth • wheezing and coughing (new and unrelated to hormone (hGH), and prescription stimulants. upper respiratory INFECTION) See also BLOOD DOPING; DESIGNER DRUGS; HOR- • red, teary eyes MONE; MUSCLE. • unpredictable and erratic behavior phencyclidine (PCP) A veterinary anesthetic that causes varied and unpredictable effects when COMMONLY ABUSED ORGANIC SOLVENTS used as a substance of abuse. A single use may acetone benzene result in long-term psychiatric disorders such as methanol methyl butyl ketone PARANOIA, PSYCHOSIS, mood disorders, and SCHIZO- methyl ethyl ketone methylene chloride PHRENIA. Though the risks for DEPENDENCE and toluene trichloroethane ADDICTION are high with chronic use, the unpre- trichloroethylene dictability and unpleasantness of PCP’s effects tend to limit its use. PCP is a schedule 2 drug in the See also ALKYL NITRITES; ILLICIT DRUG USE; PANIC United States. However, no manufacturers cur- DISORDER. rently produce it so it is nearly always an illicit drug. The most common method of use is to performance-enhancing substances Drugs, hor- sprinkle the powder on a cigarette or onto mari- mones, herbs, and nutritional supplements an juana and smoke it. individual takes to improve athletic capability or that results in an unfair competitive advantage. HEALTH RISKS OF PHENCYCLIDINE ABUSE Performance-enhancing substances present health Short Term risks because they alter the body’s functions or amnesia dissociation structure. extreme anxiety HALLUCINATION Athletic organizations in the United States and involuntary MUSCLE activity loss of physical coordination internationally prohibit the use of performance- slurred speech violent behavior enhancing substances at all levels of participation and competition, though the kinds of substances Long Term banned varies with the sport and level of competi- GENERALIZED ANXIETY DISORDER mood disorders tion. However, use and abuse of performance- (GAD) movement disorders enhancing substances remains a particular PARANOIA PSYCHOSIS concern among younger athletes who compete at SCHIZOPHRENIA levels where testing for banned substances is infrequent or does not occur. PEER PRESSURE and See also ILLICIT DRUG USE; HALLUCINOGENS; KETA- perceptions that such substances are necessary to MINE; STIMULANTS; SUBSTANCE ABUSE PREVENTION; SUB- excel (win) may also be factors. STANCE ABUSE TREATMENT. Rohypnol 349 prescription drug abuse The misuse of drugs means of obtaining the drugs is illicit, such as prescribed for therapeutic purposes. Most prescrip- through altered or forged prescriptions, or obtain- tion DRUG abuse begins unintentionally and may ing drugs through unlicensed sources. become intentional as psychologic DEPENDENCE or See also ANALGESIC MEDICATIONS; ILLICIT DRUG USE; ADDICTION develops. The most commonly abused OPIATES; SCHEDULED DRUG; SUBSTANCE ABUSE PREVEN- prescription drugs are NARCOTICS, BENZODIAZEPINES, TION; SUBSTANCE ABUSE TREATMENT. and STIMULANTS. In the context of abuse, possession and use of the drugs may be illicit when the Rohypnol See FLUNITRAZEPAM. S

sobriety The state of abstinence from ALCOHOL • NICOTINE, the primary active ingredient of and drugs. Sobriety is a marker of success in SUB- tobacco STANCE ABUSE TREATMENT. Individuals who are in • pseudoephedrine and phenylephrine, decon- recovery keep track of the length of time they gestants found in OTC cold remedy and allergy remain sober. When treatment and sobriety are relief products ordered through the courts, such as in connection • GINSENG, guarana, and kola nut, which are com- with the breaking of laws in regard to use or pos- mon ingredients in energy products session of alcohol or drugs, it may be necessary for the person to prove sobriety through BLOOD and Though OTC and herbal products containing URINE tests that check for the presence of prohib- stimulants are readily available, they are not ited substances. Sobriety begins when the body is inherently safe. Herbal products, which are not clear of alcohol or drugs, which may take days to subject to regulation as drugs in the United States, weeks, depending on the substance, and continues often contain numerous and sometimes poorly for as long as it remains so. identified ingredients that may interact with each See also DETOXIFICATION; ILLICIT DRUG USE; INTOXI- other or are of inconsistent potency and purity. CATION; PRESCRIPTION DRUG ABUSE. Ephedrine and phenylpropanolamine are formerly common decongestants that are now banned in stimulants Drugs that stimulate the CENTRAL the United States, though herbal products manu- NERVOUS SYSTEM, producing heightened awareness factured in other countries sometimes contain and alertness. Stimulants have therapeutic uses as them. Ma huang, a common Chinese herb, is a treatments for ATTENTION DEFICIT HYPERACTIVITY DIS- natural source of ephedra, an ephedrine alkaloid. ORDER (ADHD), NARCOLEPSY, sinus congestion, and Many states also limit the sale of pseu- weight loss. All central NERVOUS SYSTEM stimulants doephedrine, once the most commonly used belong to the same general DRUG classification, decongestant, because of its use in illicitly manu- sympathomimetic amines, and elicit the same facturing METHAMPHETAMINE, to which it has key kinds of responses though at varying levels. Stim- chemical similarities. ulants have moderate to high risk for DEPENDENCE and ADDICTION. Prescription and Illicit Stimulants Federal law in the United States regulates most Over-the-Counter Stimulants stimulant drugs as SCHEDULED DRUGS; possession Numerous stimulants are commonly available and use require a physician’s prescription. Pre- without a doctor’s prescription, such as scription stimulants most commonly abused include AMPHETAMINES, dextroamphetamine, and • CAFFEINE, found in coffee, tea, cola, and energy methylphenidate. Illicit stimulants most com- drinks, gels, and food bars as well as in OVER- monly abused are COCAINE and METHAMPHETAMINE. THE-COUNTER (OTC) DRUGS for weight loss, alert- These drugs all have high risk for psychologic ness, and PAIN relief dependence and addiction as well as for with-

350 substance abuse treatment 351 drawal symptoms when stopping them. A unique A fundamental tenet of the 12-step approach is risk of cocaine use is that of SUDDEN CARDIAC DEATH anonymity for members within a structure of reg- due to the drug’s unpredictable effects on the ular meetings that provide consistent peer sup- HEART and cardiovascular system. port. There are no requirements for membership in 12-step groups other than agreement to follow COMMON STIMULANTS the 12 steps; and there are no fees, charges, or AMPHETAMINES benzphetamine dues. Each group determines the ways in which CAFFEINE COCAINE its members support the group’s functions and dextroamphetamine diethylpropion expenses. There are also 12-step support pro- ephedra ephedrine grams, such as Al-Anon, for the family members mazindol METHAMPHETAMINE and friends of people who have addictions. methcathinone methylphenidate modafinil NICOTINE Behavior Modification Therapy phendimetrazine phentermine Behavior modification therapy is formally struc- phenylephrine pseudoephedrine tured care through a licensed psychologist or sub- stance abuse professional and takes the approach See also ILLICIT DRUG USE; PRESCRIPTION DRUG that a person can change the ways he or she ABUSE; SUBSTANCE ABUSE PREVENTION; SUBSTANCE ABUSE thinks and acts in regard to alcohol and drugs of TREATMENT. abuse. Methods may include incentives, setting and then working to meet goals, behavior substi- substance abuse treatment A method for help- tution skills, PSYCHOTHERAPY to help the person ing people stop abusing drugs (including ALCOHOL), understand his or her reasons for abusing drugs or overcome ADDICTION, and maintain SOBRIETY. The alcohol, education about drugs and addiction, and acute stage of substance abuse treatment is DETOXI- techniques for coping with situations that present FICATION, which is most often a health circum- high risk for relapse. Behavior modification ther- stance that requires medical care until the person’s apy builds on the premises that the individual is body is completely free from the drug (typically 72 responsible for his or her behavior, behaviors are hours to 10 days). This stage of treatment is often learned, and learning new behaviors is always inpatient though may be outpatient. possible. The follow-up treatment may last weeks to months, depending on the nature of the addiction Related Health Care and Lifestyle Issues and the person’s individual situation. This stage Many people recovering from addiction have may have require inpatient treatment with follow- other health conditions that need appropriate up outpatient care or may be entirely outpatient. medical attention, from NUTRITIONAL DEFICIENCY to There are numerous methods for substance abuse damage resulting from abused drugs or alcohol. treatment. The two main structured approaches Recovery from substance abuse must also include are the 12-step programs and BEHAVIOR MODIFICA- treatment for such health conditions. Some condi- TION THERAPY. tions, such as HEPATITIS or other bloodborne infec- tions, may require medications or extended 12-Step Programs treatment. Other conditions, such as LIVER disease The original 12-step program, started in the 1930s, or CARDIOVASCULAR DISEASE (CVD), may need ongo- is Alcoholics Anonymous, which today has more ing medical care. than two million members worldwide. As well Nutritional eating is particularly important there are numerous similar programs for other because nutritional deficiencies are common. addictions. The basic premise of the 12-step pro- Many people need vitamin and mineral supple- gram is that addiction is an incurable disease from ments. Eating foods that are enjoyable provide a which a person is in ongoing recovery no matter source of pleasure. Regular physical exercise is how long he or she has maintained sobriety. also important to maintain overall health as well 352 Substance Abuse as help stabilize mood, reduce cravings for drugs more likely he or she will also create long-term or alcohol, and provide a sense of purpose and success with treatment. routine. Support from family members and friends is also essential. Many people who relapse do so Long-Term Outlook because they do not separate from the circum- Though many people successfully maintain sobri- stances and relationships that supported their ety and a drug-free lifestyle, relapse into addiction addictions. Underlying or co-existing psychiatric is not uncommon. Maintaining sobriety is an disorders or psychologic conditions often con- ongoing effort that requires continuous attention tribute to relapse. When considering and evaluat- that many people find more challenging than they ing potential substance abuse treatment programs, can manage. The more skills a person acquires for it is important to ask what about the program’s finding alternatives to drugs and alcohol—jobs, rate of success and how the program measures it. education, community involvement, sports and See also ALCOHOLISM; EXERCISE AND HEALTH; ILLICIT athletics, and other activities that provide a pro- DRUG USE; NUTRITION AND HEALTH; PRESCRIPTION DRUG ductive, fulfilling experience of everyday life—the ABUSE; SUBSTANCE ABUSE PREVENTION; SUPPORT GROUPS. T–W

tobacco A plant cultivated as a crop in the key role in addiction not only to nicotine but to southern United States and regions around the most psychoactive drugs. Acetylcholine affects the world with similar climate. In the United States release of other neurotransmitters in the brain and federal and state laws regulate the sale and posses- hormones in the body, notably EPINEPHRINE and sion of tobacco products, with most states restrict- NOREPINEPHRINE. These chemicals stimulate brain ing sales to people age 18 or older (age 19 in a few activity as well as increase BLOOD PRESSURE and states). Further restrictions on smoking affect the HEART RATE. Though cigarette smoking provides the use of tobacco throughout the United States. most rapid release of nicotine with tobacco use, Though tobacco releases hundreds of chemicals oral forms of tobacco (chewing tobacco and snuff) when it burns, its primary psychoactive ingredient deliver significantly higher concentrations of nico- is NICOTINE, a powerful stimulant and vasoconstric- tine into the blood circulation and thus have high tor (narrows and stiffens the BLOOD vessels). Nico- risk for addiction though many people perceive tine enters the blood circulation within seconds of them to have fewer health risks. the first inhalation of cigarette smoke and remains Dozens of the chemicals in tobacco are carcino- active in the body for up to two hours after the genic (cause cancer). Many are most potent when person finishes smoking the cigarette. Its primary burning, such as smoking a cigarette or cigar, route is via absorption in the LUNGS, though the releases them. Tobacco use, primarily cigarette mucous membranes of the MOUTH (oral mucosa) smoking, is the leading cause of CARDIOVASCULAR and NOSE also absorb nicotine from the smoke. DISEASE (CVD), LUNG CANCER, laryngeal cancer, and Mucosal absorption is the primary route for nico- CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD). tine and tobacco’s other chemicals to enter the Chewing tobacco and snuff cause nearly all oral blood circulation with cigar smoking and forms of cancers (cancers of the mouth); cigar smoking tobacco other than cigarettes, such as chewing also causes oral cancers. Smoked forms of tobacco tobacco and snuff. also expose other people to carcinogenic chemi- cals. No form of tobacco or tobacco product See also ANTISMOKING EFFORTS; CANCER RISK FAC- is safe to use. Any use of tobacco, TORS; CARCINOGEN; ENVIRONMENTAL CIGARETTE SMOKE; smoked or oral, can cause numerous SMOKING AND CANCER; SMOKING AND CARDIOVASCULAR health conditions. Smoking tobacco fur- DISEASE (CVD); SMOKING AND HEALTH; SMOKING CESSA- ther exposes others to health risks. TION; WITHDRAWAL SYNDROME.

Nicotine is one of the most addictive substances tolerance The need for increasing amounts of a known. It rapidly crosses the BLOOD–BRAIN BARRIER DRUG to reach the same level of effectiveness. Tol- to act directly on neurotransmitters and neurore- erance is an expected physiologic effect with many ceptors in the BRAIN, affecting primarily DOPAMINE drugs; for some, the therapeutic benefits rely on it. and acetylcholine. Dopamine has numerous func- Tolerance accounts for the ability of long-time tions related to mood, emotion, and sensations of users to take doses of drugs that might otherwise pleasure; researchers believe dopamine plays a be harmful. 353 354 Substance Abuse

In the context of substance abuse, tolerance is a ALCOHOL withdrawal, especially from long-term factor in the development of DEPENDENCE, in which alcohol abuse, may result in DELIRIUM TREMENS, a body biochemistry changes in response to the severe and potentially fatal complex of symptoms drug’s presence so that the body depends on the that requires medical treatment and monitoring drug for a particular way of functioning, and in until the body completely detoxifies from alcohol. ADDICTION, in which the drive to use the drug (irre- Withdrawal from BARBITURATES also requires close spective of dependence) is all-consuming so that medical supervision and usually medications to most efforts in daily life focus on obtaining and relieve withdrawal symptoms; suddenly stopping using the drug. Dependence and addiction may barbiturates can result in lethal complications, have physiologic or psychologic components, or resulting from NEUROTRANSMITTER imbalances in the both; tolerance is physiologic and may occur with- BRAIN. Withdrawal from STIMULANTS typically out dependence or addiction. causes profusely runny NOSE because stimulants Tolerance develops at an unpredictable rate have a decongestant action through constricting with psychoactive drugs (drugs that affect the the BLOOD vessels in the nose. Withdrawal from mind, mood, and emotions) and NARCOTICS. It may OPIATES results in sometimes severe coughing be necessary to wean from, or gradually taper the because opiates suppress the COUGH REFLEX; remov- DOSAGE of, these drugs so a person may stop taking ing this suppression causes rebound coughing them without adverse effects. until opiate receptors re-acclimate. See also DETOXIFICATION; ILLICIT DRUG USE; PRE- Doctors typically use medications such as BEN- SCRIPTION DRUG ABUSE; SUBSTANCE ABUSE TREATMENT; ZODIAZEPINES to ease withdrawal symptoms until WITHDRAWAL SYNDROME. detoxification is complete. Subsequent treatment to maintain SOBRIETY may include medications withdrawal syndrome The physical and psycho- such as disulfiram and NALTREXONE for alcohol logic symptoms that may occur with DETOXIFICATION addiction and METHADONE, NALTREXONE, or LEVO- from substance abuse, DEPENDENCE, or ADDICTION. ALPHA ACETYLMETHADOL (LAAM) for narcotic addic- The symptoms of withdrawal vary, depending on tion. Many people trying to stop smoking benefit the substances of dependence and addiction. from NICOTINE REPLACEMENT products to wean from Because substance abuse often involves multiple NICOTINE addiction. When PRESCRIPTION DRUG ABUSE drugs, there is wide variation in the specific symp- of NARCOTICS for CHRONIC PAIN relief results in toms individuals experience during detoxification. dependence or addiction, subsequent treatment Among the more common symptoms are incorporates alternative methods of pain relief. Though withdrawal symptoms end when the sub- • NAUSEA and VOMITING stances of abuse are no longer present in the body, • shivering or trembling (“the shakes”) continued treatment for addiction remains key for preventing relapse. • abdominal cramping or PAIN See also ALCOHOLISM; ILLICIT DRUG USE; SMOKING • intense cravings for the drugs of abuse CESSATION; SUBSTANCE ABUSE PREVENTION; SUBSTANCE • HALLUCINATION ABUSE TREATMENT. EMERGENCY AND FIRST AID

This section, “Emergency and First Aid,” provides areas, the 911 network coordinates response to all brief and basic instructional information for com- emergencies. mon health emergencies, directed at the average When calling 911 to report an emergency and person who has minimal medical knowledge or request aid, certain basic information helps get the training. The structure and presentation of the right assistance to the right location in the short- content in this section differs from other sections est amount of time. of The Facts On File Encyclopedia of Health and Medi- cine in having such an instructional focus. Other • Where is the site or scene? If a home, provide sections contain content that gives detailed infor- the address. If a business, provide the name mation about the health conditions. and address. When at a home or business, call- ing 911 from a land line (regular telephone) This content does not substitute for displays location information for 911 dispatch- appropriate and timely medical atten- ers. When at the scene of a traffic accident, try tion from trained medical personnel. to note key location markers such as street Nearly always, the most appropriate names and intersections, highway numbers, first step in an emergency is to call 911 exit ramp numbers, or milepost markers. to summon medical assistance. • What happened and is it still happening? Though most emergency dispatch includes law Three basic rules govern emergency and first enforcement, fire, and medical personnel, aid response for the average person in nearly knowing what has happened helps the 911 dis- every type of situation. patcher send an appropriate balance and num- Rule One: First Summon Emergency Personnel ber of personnel. A motor vehicle accident, a fire, and a shooting situation require different In the United States, cellular telephones and the blends of emphasis, personnel, and equipment. 911 network have revolutionized emergency response. The first action for the first person on • How many people are involved and what kinds the scene of a medical emergency should be to of injuries or medical crises do they appear to call 911 to summon emergency medical person- have? Just the basics—bleeding, BURNS, HEART nel. If the responder does not have a cell phone ATTACK, not BREATHING, not conscious—help the odds are high that the person in need of assistance 911 dispatcher determine an appropriate level does; cell phones have become ubiquitous in of medical response (evacuation helicopter or American society. Except for the most remote ambulance, for example).

355 356 Emergency and First Aid

Rule Two: Self-Protection in most locations, often the most appropriate The natural tendency is to rush to provide assis- actions for the first responder to take are only tance. But however strong the urge to leap into those necessary to safeguard the person’s life. the situation, the first responder must not become Often the full extent of a person’s injuries is not another victim. Self-protection has two compo- apparent. nents: situational safety and personal safety. For example, it is often better to leave a person Before moving to provide aid to the person in injured in an auto accident in the vehicle until need, the responder must determine whether the emergency personnel arrive, unless removing the situation continues to hold risk. If this is a fire, is it person is essential to save his or her life. The still burning? If a motor vehicle accident, is there tremendous forces of impact in MOTOR VEHICLE traffic, are there downed power poles or trees, or ACCIDENTS may cause head and SPINAL CORD trauma are any of the involved vehicles unstable or at risk such that improperly moving the person could for fire? If an apparent heart attack, are there any result in permanent PARALYSIS. As well, the pres- indications of ELECTROCUTION such as power tools, sure of being wedged in the vehicle may be con- electrical appliances, or downed power lines? Is taining an injury in ways that are temporarily there any evidence of toxic chemicals? beneficial, such as bracing a FRACTURE or slowing Next, the responder must protect his or her per- bleeding. Even an apparently obvious circum- sonal safety. This includes acting within the bound- stance, such as near-drowning or heart attack, aries of personal expertise as well as safeguarding may have hidden injuries. More appropriate oneself from exposure to bloodborne pathogens. actions on the part of the first responder might be For example, a person who does not have training to turn off the vehicle’s ignition and kick dirt or in water rescue should not enter the water to save gravel over any gasoline or oil that has leaked someone who is drowning; being a strong swimmer from the vehicle, for example, or to cover the per- is often not enough. Rushing into a burning build- son with blankets or coats to keep him or her ing or automobile is heroic and may save a life oth- warm and dry. erwise lost; however, the risk is far greater that such action will result instead in losing another life. The Learn More success of such rescues often requires expertise, All teens and adults should receive emergency experience, and specialized equipment. first aid and CPR training. Many high schools Exposure to pathogens through contact with include these classes as part of the health curricu- body fluids is an unfortunately common means of lum. Many employers also provide such classes, contracting serious infections such as HEPATITIS, often with content specific to health hazards HIV/AIDS, and TUBERCULOSIS. Two essential items of encountered on-the-job. Public agencies in such as personal protection that ideally all adults should fire departments, police departments, public safety have easily accessible are latex or latex-type gloves departments, health departments, community and CARDIOPULMONARY RESUSCITATION (CPR) shields. centers, and hospitals in most communities offer These items are widely available in disposable, such classes for nominal or no cost. key-chain-size packets. Medical response profes- Basic first aid and CPR are easy to learn; the sionals encourage everyone to carry these two investment of a few hours’ time for classes may personal protection items in their vehicles, first aid save countless lives. As well, many employers and kits, backpacks, purses, briefcases, or whatever public safety agencies conduct first responder they often have with them. training, typically a 40- to 60-hour curriculum that teaches advanced medical assistance and Rule Three: Do No Further Harm emergency response techniques. Companies and Because emergency medical personnel can reach communities may then call on certified first the scene of a medical emergency within minutes responders in emergency situations. First Response

The responses and actions of the first person who The situation and circumstances determine the arrives on the scene of an emergency, commonly first responder’s subsequent actions, which may called the first responder, are crucial. This person include administering first aid, removing the per- must rapidly assess the nature of the situation, the son from danger, directing traffic or the activities safety of the site, and the possible injuries and of others who arrive to help, or simply comforting treatment needs for those involved in the emer- the person until medical and rescue personnel gency. In many situations the most appropriate arrive. Because responding aid personnel may first response is to call 911 to summon medical have questions about what happened or the cir- assistance and provide comfort for those who are cumstances under which the first responder hap- injured. In other circumstances the first responder pened upon the scene, the first responder should may need to stop bleeding, perform CARDIOPUL- check with them before leaving the site. MONARY RESUSCITATION (CPR), or stabilize a possible FRACTURE. body substance isolation Procedures for safely The essential and most crucial first action for the handling and disposing of body fluids and tissues first person to arrive on the scene of an emergency such as BLOOD, SPUTUM, URINE, and feces. Body flu- is to safeguard his or her own safety and protection. ids can transmit bacterial and viral infections to This means conducting a rapid but thorough SITE others. Cuts and scrapes on the responder’s body AND SITUATION ASSESSMENT to determine: can allow pathogens to enter, risking INFECTION. Other possible points of entry are the responder’s • What happened? eyes, NOSE, and MOUTH. • Does the cause of the situation still exist as a Everyone who provides assistance to those risk for further harm? who are injured or ill should wear latex or latex- • How many people appear to be involved? type gloves and use barrier protection when per- • What is the nature of injuries or medical need? forming resuscitation BREATHING to protect against direct contact with body fluids. Commercial first The next action for the first responder is to aid kits such as many people carry in their cars summon aid. Though it is a natural tendency to typically contain gloves. When gloves or resuscita- rush to the aid of the person who needs care, the tion shields are not available, the responder must few seconds it will take to call 911 are more likely carefully consider his or her personal risk for to save lives by getting trained and equipped res- infection before proceeding with any contact. The cue personnel to the scene. This is especially criti- natural tendency when first arriving on the scene cal when the emergency is a HEART ATTACK; people of an emergency to arrive at the scene of an who receive advanced cardiac care in a hospital emergency is to perform the necessary first aid within one hour of the heart attack’s onset have a procedures without consideration for personal significantly higher chance of survival. As well, risk. Materials such as clothing, towels, and other taking a few moments to survey the scene and the substances provide some protection from direct situation helps the responder focus and become contact when the situation is life threatening. calm. When emergency aid personnel are on the way a

357 358 Emergency and First Aid minimal response may be both adequate and most so with good intent and due prudence. These laws appropriate. do not prevent legal action, however. Should direct contact with body fluids occur, See also CONFIDENTIALITY; FIRST RESPONSE; SITE AND the responder should wash the area of contact SITUATION ASSESSMENT; SYMPTOM ASSESSMENT AND CARE thoroughly (rinse extensively with water if the TRIAGE. eyes or mouth) and promptly seek a doctor’s advice and appropriate prophylaxis (preventive responder safety and personal protection Items measures). Prophylaxis is available to reduce the and methods responders should use when provid- risk for contracting infections such as HEPATITIS and ing emergency assistance and first aid. The per- TUBERCULOSIS. However, there are currently no sonal safety and protection of responders is methods to prevent infection with HIV (human essential. At a minimum, personal protection immunodeficiency virus), the virus that causes items should include AIDS (acquired immunodeficiency syndrome). • latex gloves (or medical-grade, latex-free gloves See also ACCIDENTAL INJURIES; BLEEDING CONTROL; for people who have latex allergies) CARDIOPULMONARY RESUSCITATION (CPR); HIV/AIDS; MULTIPLE TRAUMA; PATHOGEN; RESPONDER SAFETY AND • a resuscitation shield or mask when performing PERSONAL PROTECTION; SITE AND SITUATION ASSESSMENT; RESCUE BREATHING or CARDIOPULMONARY RESUSCITA- SYMPTOM ASSESSMENT AND CARE TRIAGE. TION (CPR) Most commercial first aid kits now contain confidentiality The requirement to maintain the these items. If the responder does not have them, personal privacy of individuals who require emer- the person in need of medical attention might gency assistance or first aid. Though laws regard- have them in a home or auto first aid kit. When ing confidentiality apply to people employed in these items are not available and the situation is a fields such as health care, law enforcement, and dire one in which the person is likely to die with- firefighting, any person who responds to provide out immediate aid that risks exposure to body flu- assistance should similarly respect the privacy of ids, the responder can reduce such exposure by those involved in the situation. Such respect using clothing to establish a barrier. includes not discussing details of the situation The other fundamental dimension of responder with anyone, including media or press, other than safety and personal protection is quick but thor- those involved in the subsequent care of the per- ough SITE AND SITUATION ASSESSMENT to determine son. A good rule of thumb is for the responder to what, if any, risks exist that pose hazards for the consider whether he or she would want the infor- responder. Key among these risks are the possibili- mation divulged were the responder the one who ties of received assistance. As well, it is possible for there to be legal repercussions should information made • fire, explosion, or ELECTROCUTION public turn out to be erroneous. • drowning, when the person needing assistance See also GOOD SAMARITAN LAWS. is in or near the water • direct harm, when the situation is one of VIO- Good Samaritan laws Legal protections in the LENCE such as a shooting United States that states enact to shelter people • hazardous conditions such as traffic or unstable who provide emergency assistance and first aid terrain from legal liability for outcomes that may result • toxic chemical exposure from their actions. Such laws primarily affect indi- viduals (other than those who work in public When these risks are present or uncertain, they safety or health care jobs) who stop to help at put the responder at great peril. MOTOR VEHICLE ACCIDENTS, when a person suffers a See also ACCIDENTAL INJURIES; HEPATITIS PREVEN- HEART ATTACK, or in other crisis situations. The TION; HIV/AIDS; INFECTION; PATHOGEN; SYMPTOM ASSESS- premise is that the person providing aid is doing MENT AND CARE TRIAGE; TUBERCULOSIS PREVENTION. First Response 359 site and situation assessment The first action a that have caused injury and remain plugged in, or responder should take when arriving at a situation gasoline leaking from a vehicle involved in an that requires emergency assistance or first aid. The accident. Often the most appropriate response for assessment must be brief but thorough enough to the person first on the site is to summon emer- determine potential hazards for the responder as gency personnel and follow their instructions after well as the condition of the person who needs they arrive for providing further assistance. assistance. Site and situation assessment should See also ACCIDENTAL INJURIES; MOTOR VEHICLE ACCI- consider, at minimum DENTS; RESPONDER SAFETY AND PERSONAL PROTECTION; SYMPTOM ASSESSMENT AND CARE TRIAGE. Nature of the emergency symptom assessment and care triage A • How many people are involved? methodic approach to quickly determining the • Is anyone bleeding? nature and severity of injuries so as to provide • Is anyone not BREATHING? appropriate FIRST RESPONSE. A responder’s ability to • Is the cause of the emergency still an active provide symptom assessment depends on the hazard? responder’s level of knowledge and training. Medical emergency personnel use various sys- • Are those who need aid safe from further tems to triage patients—that is, determine the harm? severity of injuries, type of care the injuries need, and likelihood for survival within the context of Risk of fire the medical resources immediately available. • Are flames visible? Emergency personnel will conduct such an assess- • Is there a smell of smoke? ment when they arrive at the site. In the mean- • Is there a smell of gasoline, diesel, oil, or natu- time, the person who is first on the scene of a ral gas? medical emergency that involves more than one person, or one person with multiple injuries, • Are the engines of any vehicles still running needs to determine how to provide the most after involvement in a collision or accident? appropriate attention to those who need care until • Are there downed power lines? medical emergency personnel arrive. The most important and fundamental assess- Risk of ELECTROCUTION ment is whether the person’s life is in imminent • Are or were there power tools in use? danger. These four basic steps help make a rapid determination; the findings direct the responder’s • Are there downed trees, power poles, or power subsequent actions. Because time is crucial when lines? the injuries or circumstances (such as HEART Risk of drowning ATTACK) are life threatening, the basic assessment should take no more than 30 seconds. • Is the person in water? • Does the responder have training in water res- 1. Is the person conscious? If so ask, “Where do cues? you hurt?” CONSCIOUSNESS, especially right after an injury or medical crisis such as heart attack, Multiple hazards are often present, such as traf- is not of itself an indication of whether the situ- fic attempting to pass through the scene of a ation is life threatening. motor vehicle accident or water on the surface 2. Is the person BREATHING? Look for bluish gray when power lines are down. Less obvious hazards discoloration of the lips, fingers, and SKIN over- may include dogs in the home or at the scene of a all. Watch to see if the person’s chest rises and motor vehicle accident whose behaviors to protect falls. Feel for air coming out of the NOSE or their owners threaten responders, power tools MOUTH. 360 Emergency and First Aid

3. Is the person’s HEART beating? Feel for a before initiating emergency care because the find- PULSE in the side of the neck, two finger-widths ings determine the most appropriate response. below the notch toward the back of the lower Multiple life-threatening injuries present a com- jaw. Listen, with the EAR against the chest, for a plicated situation, especially when there is only heart beat. one responder and he or she may have to make 4. Is the person bleeding severely? External rapid decisions about what to do. It may be neces- bleeding is generally obvious; look at the per- sary to stop severe bleeding before proceeding to son’s front and back. Indications of internal CARDIOPULMONARY RESUSCITATION (CPR), for example. bleeding include unusual or rapid swelling. The first action of the responder—call 911 to sum- mon emergency aid—is often the most crucial. It is essential to assess all four life-threatening See also BLEEDING CONTROL; RESPONDER SAFETY AND factors as well as the context of the situation PERSONAL PROTECTION; SITE AND SITUATION ASSESSMENT. Burns, Bleeding, Breaks

The most common types of injuries that require BLOOD vessels. Small abrasions are more nuisance emergency medical assistance are BURNS, LACERA- than health problem. Large, deep abrasions may TIONS (cuts) that result in external bleeding, BLUNT leave scars after they heal though most abrasions TRAUMA that results in internal bleeding, and frac- do not damage the dermis, the innermost layer of tures (broken bones). Many such injuries are mild skin. Most abrasions require only minor first aid to moderate in severity; mild burns and lacera- and heal uneventfully within two weeks. tions often require only self-care. Fractures and These are the recommended steps for treating moderate injuries may need medical attention to abrasions: assess their severity, especially burns and lacera- tions that may extend deep into the tissues. • Gently but thoroughly flush all dirt and debris Burns and bleeding have the highest risk for from the abrasion with normal saline or a being life threatening. Traumatic injury to the wound cleansing solution. Do not use soap and chest can result in the loss of 25 percent of the water or hydrogen peroxide; these formerly popular approaches delay scab formation and body’s BLOOD supply within minutes. A second- or third-degree burn that covers 36 percent of the HEALING. body’s surface results in extensive fluid and heat • Apply a topical antibiotic ointment and cover loss. Both circumstances cause rapid SHOCK. the abrasion completely with a bandage. Though fractures are not as likely to be life threat- • Change the bandage daily or when it gets wet, ening, an open FRACTURE exposes body tissues to applying fresh antibiotic ointment with each high risk for INFECTION. As well, the BONE ends may bandage change. sever blood vessels, resulting in hemorrhage. • Keep antibiotic ointment and a bandage on the These types of injuries present the highest risk abrasion until it heals, typically 7 to 10 days. of bloodborne infection, such as HEPATITIS and HIV/AIDS, for first responders. Latex or latex-type A health-care provider should assess and gloves are essential; the responder should be débride (clear away debris and damaged tissue) wearing them before touching the injured person. large abrasions to minimize the risk of scarring There is also the risk for injury to the responder, and INFECTION. such as in a fire or explosion or when injuries See also ANTIBIOTIC MEDICATIONS; LACERATIONS; result from VIOLENCE. SCAR. abrasions Scrape wounds that remove the outer avulsion An injury of force that tears away a layers of SKIN to expose the dermis and sometimes body structure such as a TOOTH, segment of finger or the subcutaneous layer beneath. Abrasions are toe, piece of tissue, or fragment of BONE. A major common sports- and activity-related injuries avulsion may involve a limb. Avulsion may be, resulting from falling or sliding on hard surfaces though is not always, a type of TRAUMATIC AMPUTA- such as sidewalks, pavement, artificial turf, and TION. Surgeons can replant some avulsed struc- hard-packed dirt. tures, such as teeth and bone fragments. The force Abrasions often look raw and may bleed; they that creates the separation often causes significant usually hurt because they expose nerves and and irreparable damage to the tissues, however. 361 362 Emergency and First Aid

Site and situation assessment The responder TAXIS) may also appear to produce a large amount of should identify what caused the avulsion and if bleeding. However, the amount of blood lost with necessary neutralize its ability to do further dam- these types of injuries is usually minor. age. This includes turning off the power to any machinery or equipment that caused an avulsion BLOOD that spurts or surges from the injury. wound comes from an ARTERY or major Responder personal protection measures Latex VEIN. Immediately apply pressure firmly gloves, which the responder should put on before enough to compress the blood vessel approaching the injured person, are essential for and maintain the pressure until emer- personal protection from bloodborne pathogens as gency medical personnel take over. nearly always there is moderate to heavy bleeding with avulsions. Injuries that damage major veins or arteries can First response actions Substantial bleeding is result in rapid loss of blood with risk for SHOCK and likely at the site of the avulsion. The first person possible death. Bleeding in such circumstances is to respond should take every practical effort to heavy and may spurt, gush, or surge from the stop the bleeding. When possible, salvage the injury. Life-threatening bleeding from the injury avulsed body part and protect it by wrapping it in may also occur internally or as the result of BLUNT sterile gauze moistened with sterile water or TRAUMA. Indications of INTERNAL BLEEDING include saline, if possible, and placing it in a plastic bag or rapid swelling in the area of the bleeding and signs container. Put the container in a portable cooler of shock in the injured person. with ice around it and transport it to the hospital Site and situation assessment Situations of with the wounded person. Time is of the essence, criminal VIOLENCE are often not safe for the first however; the longer the avulsed part remains sep- person who arrives to do any more than summon arated from the body the less likely the surgeon emergency aid. When injuries are due to animal will be able to successfully replant it. bites, the responder must determine that the ani- Follow-through An avulsion injury requires a mal is no longer present or a threat. MOTOR VEHI- physician’s prompt evaluation and treatment, usu- CLE ACCIDENTS may result in multiple injuries to the ally surgery either to replant the body part or sur- same person or to multiple people. Rapid SYMPTOM gically débride and repair the avulsion site. ASSESSMENT AND CARE TRIAGE is essential to deter- See also BLEEDING CONTROL; BLOOD; PATHOGEN. mine whether any injuries appear life threatening. Responder personal protection measures Latex bleeding control The measures necessary to stop gloves, which the responder should put on before bleeding. Bleeding occurs when an injury dam- approaching the injured person, are essential for ages the walls of the BLOOD vessels, allowing blood personal protection from bloodborne pathogens as to escape. well as to prevent BACTERIA on the responder’s Though profusely flowing blood may rapidly hands from causing INFECTION in the wound. become life threatening, the amount of blood pres- First response actions Bleeding frightens most ent or obvious is not always a good indication of the people, those who are injured and those who are injury’s severity. ABRASIONS (scrapes) and minor providing FIRST RESPONSE alike, especially when LACERATIONS (cuts) may appear to bleed extensively there appears to be a lot of blood. It is important when they damage large numbers of the tiny blood for the responder to act calmly and comfortingly vessels in the dermis (middle layer of the SKIN) and as well as quickly. the subcutaneous layer, as these tissues contain a Use these measures to stop bleeding from an rich supply of blood. Wounds to the face and head external injury such as an abrasion or laceration: tend to bleed especially profusely though often are not serious or life threatening. Injuries to the inside • Put on latex or latex-type gloves. of the MOUTH not only bleed extensively but the • Cover the injury with gauze bandages, a wash- blood also mixes with SALIVA, appearing as though cloth or towel, or even a wadded piece of cloth- there were even more blood. A nosebleed (EPIS- ing and apply firm, steady pressure. Burns, Bleeding, Breaks 363

• If the injury bleeds through the covering mate- sues (first degree, second degree, and third rial, add more but do not remove the original degree) and the amount of surface area the burn covering. covers (percentage). SHOCK is a significant risk • Maintain pressure until emergency medical with any burn. personnel arrive. Medical personnel often use a method called the “rule of nines” to assess the body surface area Use these measures to stop a nosebleed: a burn covers. This method assigns a percentage of 9 or 18 percent to regions of the body. For exam- • Put on latex or latex-type gloves. ple, each arm is 9 percent, as is the head; the legs, • Have the person sit upright, holding the head back, and chest are each 18 percent. The surface tipped slightly toward the chest. area a burn covers may have more significant health consequences than the burn’s depth. A • Firmly squeeze both nostrils with the thumb first-degree (superficial) burn that covers an and forefinger. extensive area is often more serious than a third- • Hold pressure in this way for at least 10 min- degree burn that covers a very small area. utes. Heat and explosion burns on the upper body, • If bleeding starts again after releasing the pres- face, and head may indicate the person also has sure, repeat the procedure. burns to the MOUTH, NOSE, or upper airway (INHALATION BURNS). Such burns are potentially life Follow-through A health-care provider should threatening because swelling may close the air- evaluate most bleeding injuries to cleanse them way, blocking the flow of oxygen to the LUNGS and and determine whether sutures (stitches) or other compromising the ability to breathe. treatments are necessary. Nosebleeds require med- Site and situation assessment Risk for injury to ical attention when they persist or frequently recur. the first person to respond is very high when the See also GASTROINTESTINAL BLEEDING; IMPALEMENT; source of the burn remains. In situations of active PUNCTURE WOUND; SYMPTOM ASSESSMENT AND CARE fire, risk for explosion, lightning, downed power TRIAGE. lines, or chemical or radioactive contamination, the only response that may be safe for the respon- burns Injuries resulting from exposure to fire, der is to provide as detailed information as possi- intense heat, extremely hot water, electricity ble when summoning emergency aid to help (including lightning), radiation (including ultravi- dispatchers send the appropriate equipment and olet radiation from sunlight or tanning systems), trained personnel. or caustic chemicals. The severity of a burn Responder personal protection measures Latex depends on the depth of penetration into the tis- gloves, which the responder should put on before

BURN SEVERITY Burn Classification Extent of Burn Symptoms first degree or superficial burn penetrates only into the epidermis redness, PAIN, slight swelling thickness (outer layer of SKIN) second degree or partial burn penetrates into the dermis (middle blisters, pain, moderate swelling thickness layer of skin) third degree or full thickness burn penetrates into the subcutaneous open wound or charring, may be no pain layer (innermost layer of skin) and possibly into underlying tissues 364 Emergency and First Aid approaching a person who has burns, are essential Do not move a person who may have a for personal protection from bloodborne FRACTURE of the back or neck. Brace the pathogens as well as to prevent BACTERIA on the person with rolled towels and blankets responder’s hands from causing INFECTION in the or other objects and keep him or her burn wounds. still until emergency medical personnel First response actions If the person’s clothing is arrive. on fire, get the person on the ground and smother the flames by rolling or covering with a blanket, rug, jacket, or other object that can block the flow The most appropriate action for the responder is of air. Burns require specialized care from medical to immobilize the limb, as well as the joints above personnel trained in burn care. The most appro- and below the point of the fracture when possible, priate actions for an untrained responder first on and obtain immediate medical attention. Splints the scene are to keep the person warm and com- are effective for fractures of the fingers, arms, and fort the person until medical personnel arrive. legs. Commercial first aid kits may include soft or Most important: inflatable splints. As well, the responder can use many common objects to fashion an improvised • Do not put anything on the burns. splint: towels, pillows, cardboard, and folded news- • Do not pull clothing or debris from the burns. papers or magazines. A sling to support the arm on the side of the injury helps immobilize a fractured • Do not pop BLISTERS or pull the SKIN off blisters clavicle (collarbone) or shoulder blade (scapula). that spontaneously rupture. Scarves, belts, towels, and even a long-sleeve jacket Cool water, such as from a water faucet, is or shirt with the sleeve pinned to the upper part of appropriate first aid to soothe small, minor burns. the garment are among the items the responder can Promptly cooling a small first- or second-degree use to make a sling. burn relieves PAIN and reduces swelling. However, See also ACCIDENTAL INJURIES; ATHLETIC INJURIES; the burn may still require medical attention. OPEN FRACTURE; SYMPTOM ASSESSMENT AND CARE TRIAGE Follow-through A health-care provider should evaluate and treat most second- and third-degree dislocations Injury to the ligaments at a JOINT burns as well as first-degree burns that cover 36 that allows the ends of the bones to separate. percent or more of the body. Infection is a signifi- Often the responder cannot determine whether an cant risk with second- and third-degree burns; any injury is a dislocation or a CLOSED FRACTURE; FIRST indications (FEVER, increased pain or swelling) RESPONSE treats them the same. require prompt medical assessment. See also SITE AND SITUATION ASSESSMENT; SUNBURN; Do not attempt to “pop” a dislocated SYMPTOM ASSESSMENT AND CARE TRIAGE. JOINT back into place. closed fracture A broken BONE that does not The primary first response action is to immobi- protrude through the surface of the SKIN. A closed lize the joint using a splint, or, in the case of a dis- FRACTURE most commonly results from a blow that located shoulder, a sling. A health-care provider delivers intense energy to small or limited area, should evaluate a dislocation to determine if there causing the bone beneath to break. The bone ends is a FRACTURE (which requires an X-RAY) and may remain relatively aligned or may cause signif- whether surgery is necessary to repair the liga- icant soft tissue damage even though the ends do ments. not penetrate through the skin. Although the ends See also ACCIDENTAL INJURIES; ATHLETIC INJURIES; of the bones with a closed fracture do not break BONE; LIGAMENT; SPRAINS AND STRAINS; SURGERY BENE- the skin, they may still do considerable damage to FIT AND RISK ASSESSMENT. tissues and structures around the area of the break. Fractures require prompt evaluation and impalement A wound in which an object pene- treatment from a health-care provider. trates a part of the body and remains embedded Burns, Bleeding, Breaks 365 there. Impalement injuries may occur when a per- tracheotomy (invasive methods to bypass the son falls into a stationary object such as a fence upper airway to get air to the LUNGS) may be the rail or tree branch. Nail guns are responsible for only measures to save the person’s life, the need numerous impalement injuries. Such injuries may for care from appropriate medical personnel is penetrate a hand or foot in such a way as to nail it urgent. to a surface. Because nail guns expel nails under Site and situation assessment The risk for tremendous force, a nail may penetrate the skull injury to rescuers and others is high if there is still or sternum to cause potentially life threatening a burning or smoldering fire or a chemical expo- injury. Impalement injuries may also occur when sure remains uncontained. A situation that falling on an object such as a pencil. requires personal protective equipment is one the first person to arrive should not enter. Do not attempt to remove an impaled Responder personal protection measures The object from any part of the body. responder should use a resuscitation shield if CAR- Immobilize the part as quickly as possi- DIOPULMONARY RESUSCITATION (CPR) or RESCUE BREATH- ble and summon emergency medical ING is necessary. personnel. First response actions Most inhalation burns are critical injuries that require advanced life sup- Site and situation assessment Generally there port care well beyond the scope of untrained med- are no risks to others at the site of an impalement ical response. The most effective action on the part injury. An exception might be in the circumstance of the first person at the site is to rapidly summon of a nail gun, in which the responder must deter- emergency personnel. mine the nail gun is inactive. Follow-through Inhalation burns require Responder personal protection measures Latex urgent medical treatment from physicians and gloves, which the responder should put on before other personnel trained and experienced in treat- approaching the injured person, are essential for ing such injuries. Emergency transportation to a personal protection from bloodborne pathogens as hospital or trauma center is often crucial. there is often bleeding from an impalement injury. See also ACUTE RESPIRATORY DISTRESS SYNDROME First response actions It is crucial to avoid (ARDS); INHALED TOXINS; SHOCK. moving a person who is impaled on an immobile object and to provide as much information as pos- lacerations Cuts or tears of the skin and tissues. sible about the object to the 911 dispatcher. The Lacerations may be fairly superficial or extend responder should stabilize the person to support deep into the body. The risk for damage to nerves the body or impaled body part and attempt to and BLOOD vessels is high. A large or deep lacera- comfort and calm the person until emergency per- tion may bleed profusely, requiring immediate sonnel arrive. BLEEDING CONTROL efforts. A responder providing Follow-through Impalement injuries require a first aid for a laceration should put on latex or physician’s assessment and medical treatment. latex-type gloves approaching the injured person, See also INFECTION; PUNCTURE WOUND; SITE AND SIT- are essential for personal protection from blood- UATION ASSESSMENT; SYMPTOM ASSESSMENT AND CARE borne pathogens as well as to prevent BACTERIA TRIAGE; TRAUMA TO THE EYE. from the responder’s hands from causing INFECTION in the wound. 1 inhalation burns Thermal or chemical BURNS of To treat a mild laceration (less than ⁄2 inch in the upper airway (TRACHEA) that result from length): BREATHING extreme heat (as in a fire) or toxic fumes. There may also be burns to the lips, • Apply a bandage or gauze pad and hold it in tongue, and inside of the MOUTH and NOSE. Inhala- place to stop any bleeding. tion burns may cause rapid swelling of the airway, • When the bleeding stops, remove the bandage blocking the flow of air and presenting a life and apply an antibiotic ointment and a clean threatening situation. As emergency intubation or bandage. 366 Emergency and First Aid

• Change the bandage daily or when it gets wet, which a heavy object falls on the person, falls, or applying free antibiotic ointment with each collisions (such as when bicycling, skiing, or skate- bandage change. boarding). A person who has an open fracture • Continue to treat the laceration until its edges may have multiple injuries or there may be multi- completely heal together (typically 7 to 10 ple people involved in the accident who have vari- days). ous injuries. Possible site hazards that present risk of injury for responders, particularly the respon- 1 A laceration that is jagged or longer than ⁄2 der first to arrive, include downed power lines, inch, or whose edges do not stay together, unstable terrain or structures, and traffic. requires medical treatment. These are the recom- Responder personal protection measures Latex mended steps for the first responder to take to gloves, which the responder should put on before help protect the wound until the person can approaching the injured person, are essential for receive such treatment: personal protection from bloodborne pathogens as nearly always there is moderate to heavy bleeding • Stop the bleeding; apply a bandage or other from open fractures. covering and hold it firmly enough to exert First response actions Necessary actions from pressure. the first responder may include BLEEDING CONTROL, • When the bleeding stops place gauze or tape to fracture stabilization, and comforting the injured hold the bandage in place. Do not remove the person. Open fractures are serious injuries and bandage. If bleeding persists, add more ban- moving the person is likely to require technical dage. expertise as well as multiple rescuers. Often the • Immobilize the area of the laceration to mini- most important role for the first responder is to mize and further damage. keep the injured person calm, warm, and dry until rescue and emergency medical personnel arrive. Minor lacerations often heal well with self- Follow-through Open fractures require urgent treatment. When the edges of a laceration will not medical treatment and surgery to clean the injury stay together on their own, the wound needs and repair the fracture and damage to the sur- sutures (stitches). A jagged or deep laceration may rounding tissues. require debridement, a procedure in which a doc- See also BODY SUBSTANCE ISOLATION; LACERATION; tor or physician’s assistant numbs the area with a SHOCK; SYMPTOM ASSESSMENT AND CARE TRIAGE. local anesthetic and trims away all loose tissue and cleans out any debris that contaminates the puncture wound An injury in which an object wound. The provider may suture the wound if it is penetrates through the SKIN and into the underly- clean enough or allow it to heal on its own, a ing structures, sometimes deeply, with the wound process called granulation in which new tissue closing with the object’s withdrawal. There may grows from the inside to the outside of the be little or no external bleeding with a puncture wound. wound. However, the risk for INFECTION is See also ABRASIONS; ANTIBIOTIC MEDICATIONS; AVUL- extremely high. First aid measures include rinsing SION; SCAR. debris and BLOOD from the wound and applying a bandage to protect it from exposure to further open fracture A FRACTURE in which the broken pathogens. A health-care provider should evaluate BONE protrudes through the surface of the SKIN, the wound promptly as it might be necessary to creating an open wound that may bleed profusely. incise it (cut it open under sterile conditions) to There is high risk for the bone ends to significantly clean it and irrigate it with antibiotic solution. The damage nerves, BLOOD vessels, and other tissues in health-care provider is also likely to prescribe the area around the fracture. ANTIBIOTIC MEDICATIONS to treat bacterial INFECTION. Site and situation assessment Open fractures The injured person should receive a tetanus tox- result from significant trauma as may occur in oid booster if the last one was more than 10 years MOTOR VEHICLE ACCIDENTS, industrial accidents in ago. Burns, Bleeding, Breaks 367

See also BODY SUBSTANCE ISOLATION; GUNSHOT TION ASSESSMENT; SYMPTOM ASSESSMENT AND CARE WOUNDS; IMPALEMENT; NECROTIZING FASCIITIS; TRIAGE. PATHOGEN; SITE AND SITUATION ASSESSMENT; SYMPTOM ASSESSMENT AND CARE TRIAGE; TRAUMA TO THE EYE. soft tissue injuries Injuries to muscles, tendons, and ligaments that occur as a result of sudden shock Life-threatening cardiovascular collapse. excessive tension, causing the tissue to tear or Shock occurs when BLOOD PRESSURE drops below stretch. Soft tissue injuries are common and may the level necessary to pump BLOOD to the tissues occur during everyday activities as well as during (peripheral perfusion), depriving them of oxygen athletic activities. Soft tissue injuries tend to hurt (HYPOXIA). The symptoms of shock may include and swell fairly immediately. Ice to the injured area is the most effective FIRST RESPONSE to reduce • clammy or bluish SKIN (CYANOSIS) both PAIN and swelling. Immobilization, such as • confusion, anxiety, or disorientation with elastic bandage wraps, splints, or slings, helps prevent further damage. • diminished or loss of CONSCIOUSNESS In general, a soft tissue injury requires evalua- • rapid BREATHING (TACHYPNEA) and HEART RATE tion and treatment from a doctor or other health- (tachycardia) care provider when: • difficulty BREATHING (DYSPNEA) • the person cannot bear weight on a lower Urgent medical treatment is essential. While extremity or use an upper extremity waiting for emergency medical personnel to • swelling significantly distorts the appearance of arrive, the responder first on the scene should the injured part perform whatever emergency aid measures are • over-the-counter (OTC) ANALGESIC MEDICATIONS appropriate for the person’s circumstances. It is such as acetaminophen or NONSTEROIDAL ANTI- also important to keep the person warm and calm INFLAMMATORY DRUGS (NSAIDS) fail to relieve pain and to have the injured person lie as horizontally as is possible with the feet and legs elevated about Though most soft tissue injuries are minor and 12 inches to help blood flow back to the HEART. heal with self-care measures in two to six weeks, severe injuries may require surgical repair, espe- CIRCUMSTANCES THAT CAN RESULT IN SHOCK cially tears. ANAPHYLAXIS BURNS ELECTROCUTION GUNSHOT WOUNDS COMMON SOFT TISSUE INJURIES HEART ATTACK HEAT STROKE ACHILLES TENDON INJURY ANKLE INJURIES hemorrhage MULTIPLE TRAUMA groin pull KNEE INJURIES OPEN FRACTURE poisoning MUSCLE tears and pulls SPRAINS AND STRAINS severe DEHYDRATION SPINAL CORD INJURY TRAUMATIC AMPUTATION TRAUMATIC BRAIN INJURY (TBI) See also ATHLETIC INJURIES; CLOSED FRACTURE; DIS- LOCATIONS; FRACTURE; HERNIA; INFLAMMATION; OPEN See also CARDIOPULMONARY RESUSCITATION (CPR); FRACTURE; SPRAINS AND STRAINS; SYMPTOM ASSESSMENT MULTIPLE TRAUMA; RESCUE BREATHING; SITE AND SITUA- AND CARE TRIAGE. Drowning

More than 4,000 Americans die from drowning nonetheless there is great risk for the rescuer who each year. About 15,000 are revived and survive. does not know water rescue techniques. Being a The most common causes of drowning are swim- strong swimmer is not enough. Public pools, ming, boating, and scuba diving accidents. water parks, and swimming beaches typically Though a person may struggle in the water for an have lifeguards and rescue equipment. Poles, res- extended time, the threshold for remaining sub- cue flotation rings, and other devices can allow a merged is only about three minutes, after which first responder to begin helping a drowning victim the BRAIN can no longer function and the person while waiting for trained rescue personnel to loses CONSCIOUSNESS. reach the scene. When the head goes under the water a sequence of physiologic changes are activated, cold water drowning Drowning that occurs sometimes called the diving REFLEX, that alter the when the water temperature is below 50ºF. Sur- body’s cardiovascular system to reserve BLOOD and vival is somewhat higher with cold water drown- the oxygen it carries to maintain the body’s vital ing because the cold temperature of the water functions. The HEART RATE slows, BLOOD PRESSURE seems to further depress METABOLISM, dramatically decreases, peripheral blood vessels constrict, blood lowering the body’s oxygen needs. Though in supply to vital organs increases, and body temper- general a person who has been submerged in cold ature drops. These changes rapidly slow METABO- water for longer than 10 minutes has a poor LISM (the rate at which the body uses energy), chance for revival, some people have survived significantly cutting the body’s need for oxygen, being under frigid water for 40 minutes. Rescue which is one of the two fuel sources for cells (the experts recommend initiating resuscitation efforts other being GLUCOSE) throughout the body and the for all cold water drownings. only fuel source for brain cells. When water Site and situation assessment Important aspects enters the airway, the larynx severely spasms, of the situation include the type of water (pool, closing off the TRACHEA. This laryngeal SPASM reflex lake, river), how long the person has been under is so intense that most people who die of drown- water, and whether other injuries are possible. ing die from asphyxiation (lack of oxygen). In SPINAL CORD INJURY or head injury is likely when only about 10 percent of drownings does water diving into the water, for example. enter the LUNGS. Responder personal protection measures Essen- The urge to save someone who is drowning is tial responder personal protection items include so strong that many would-be rescuers rush to latex or latex-style gloves and a resuscitation jump into the water. However, water rescues are shield. difficult. A person who is still struggling will often First response actions When the person is still in fight with the rescuer as a survival reaction, even the water and is conscious, the responder should to the extent of pushing the rescuer under the use items such as ropes, poles, and flotation devices water. All too often the outcome is two drownings to attempt to help the person rather than jumping rather than a rescue. An unconscious drowning into the water, unless the responder has training in victim is easier to pull from the water, though water rescues. RESCUE BREATHING or CARDIOPUL-

368 Drowning 369

MONARY RESUSCITATION (CPR) may be necessary when could block air from entering the airway (such the person is brought to shore or the pool’s edge. as dentures, food, vomitus, or blood). Follow-through Emergency medical personnel 2. Place a resuscitation shield over the person’s typically transport cold water drowning victims to mouth, pinch the nostrils closed, and breathe a hospital emergency department or trauma cen- with normal intensity into the shield (or the ter even when resuscitative efforts appear unsuc- person’s mouth) until the chest rises. cessful because there is the possibility for revival when body temperature returns to normal. A doc- 3. Give one breath about every five seconds. Pull tor should thoroughly assess a person who sur- away from the shield to allow air to leave the vives, as secondary complications may occur. LUNGS. See also RESPONDER SAFETY AND PERSONAL PROTEC- 4. Continue rescue breathing until the person TION; SITE AND SITUATION ASSESSMENT; SYMPTOM ASSESS- resumes breathing independently or emergency MENT AND CARE TRIAGE; WARM WATER DROWNING. medical personnel arrive and take over. rescue breathing A method to revive a person Follow-through A person who stops breathing who has stopped BREATHING (RESPIRATORY FAILURE) requires urgent evaluation and treatment from a but who still has a HEART beat (PULSE). Rescue physician at a hospital emergency department or breathing may be necessary in drowning, poison- trauma center. ing, ELECTROCUTION, and other circumstances in See also ANAPHYLAXIS; COLD WATER DROWNING; POI- which the respiratory failure occurs suddenly and SON PREVENTION; RESPONDER SAFETY AND PERSONAL the first response is rapid. The BRAIN begins to PROTECTION; SITE AND SITUATION ASSESSMENT; SYMPTOM experience irreversible damage after about 6 min- ASSESSMENT AND CARE TRIAGE; WARM WATER DROWN- utes of oxygen deprivation, so urgent response is ING. essential. Site and situation assessment Risks for the first warm water drowning Drowning that occurs responder may include the continued presence of when the water temperature is higher than 60ºF. the cause of the person’s respiratory failure, such Most warm water drownings take place in swim- as live electricity. ming pools and shallow lakes. The risk for death is Responder personal protection measures Essen- very high when the person has been underwater tial responder personal protection items include longer than three minutes, thus rapid response is latex or latex-style gloves and a resuscitation essential. However, there is great risk for the shield. responder in an attempted rescue when the First response actions Position the person to lie responder does not have training in water rescues. flat on his or her back and tilt the head back. Site and situation assessment Important aspects Sometimes this action is sufficient to clear the air- of the situation include the type of water (pool, way and the person begins to breathe. Check for a lake, river), how long the person has been under PULSE (press two fingers against the side of the water, and whether injuries in addition to drown- neck just beneath the notch at the back of the ing are possible. SPINAL CORD INJURY or head injury is lower jaw) and watch and feel for signs of air likely when diving into the water, for example. movement. When there is also no heart beat, Responder personal protection measures Essen- CARDIOPULMONARY RESUSCITATION (CPR) is neces- tial responder personal protection items include sary. CPR adds chest compressions to pump the latex or latex-style gloves and a resuscitation heart to push BLOOD through the body. If there is a shield. pulse but no evidence of air movement, begin res- First response actions When the person is still cue breathing: in the water and is conscious, the responder should use items such as ropes, poles, and flota- 1. Quickly look (and feel, if wearing latex gloves) tion devices to attempt to help the person rather inside the person’s MOUTH for any objects that than jumping into the water, unless the responder 370 Emergency and First Aid has training in water rescues. RESCUE BREATHING or A physician should thoroughly assess a person CARDIOPULMONARY RESUSCITATION (CPR) may be nec- who revives, as secondary complications may essary when the person is brought to shore or the occur. pool’s edge. See also CARDIAC ARREST; COLD WATER DROWNING; Follow-through Emergency medical personnel RESPONDER SAFETY AND PERSONAL PROTECTION; SITE AND may decide whether to continue resuscitative SITUATION ASSESSMENT; SYMPTOM ASSESSMENT AND CARE efforts after they arrive and evaluate the situation. TRIAGE. Cardiac Arrest

Cardiac arrest—any circumstance in which the and circulation of BLOOD through the body. CPR HEART stops beating—is immediately life-threaten- combines RESCUE BREATHING with cardiac compres- ing. The BRAIN can survive only four to six min- sions. The first person to respond to a situation utes without oxygen, after which brain cells begin that requires CPR must first call 911 to summon to die. Their loss is permanent. After 10 minutes emergency medical aid. Do not stop CPR once without oxygen brain death occurs. The American under way, unless the person begins to COUGH or Heart Association (AHA) identifies four actions, breath independently or until trained medical per- called the cardiac chain of survival, as crucial: sonnel arrive to take over. Essential responder personal protection items 1. Call 911 to summon emergency medical aid. include latex or latex-style gloves and a resuscita- 2. Start CARDIOPULMONARY RESUSCITATION (CPR) to tion shield. To perform CPR: restore circulation. 1. Listen or feel for BREATHING and check for PULSE. 3. Defibrillate (shock) the heart to restore func- If absent, continue with CPR. tional electrical activity. 2. Place the person on his or her back with the 4. Get the person to a hospital for advanced car- head tilted back. diac life support care. 3. Pinch closed the nostrils and open the MOUTH. The first person to come upon a person who is Place the resuscitation shield and breathe into in cardiac arrest sets this chain in motion and may the shield (or the person’s mouth) until the perform the first two or three actions, depending person’s chest rises. on whether there is an AUTOMATED EXTERNAL DEFIB- 4. Place the palm of one hand on the back of the RILLATOR (AED) at the scene. The speed with which other hand and interlace the fingers. the first responder acts establishes the likelihood 5. Place the hands in the center of the person’s of survival. For optimal outcome, CPR must begin chest. (For an infant under 12 months, use the within four minutes of when the heart stops. A flat of the fingers on the center of the chest person who reaches step 4 within 30 minutes has between the nipples.) the highest chance for survival. 6. Sharply push downward to compress the chest about 2 inches. Pump the person’s chest in this COMMON CAUSES OF CARDIAC ARREST way at the rate of 100 compressions per ANAPHYLAXIS ASPHYXIATION minute. diabetic SHOCK drowning ELECTROCUTION HEART ATTACK 7. Give 2 normal breaths every 30 compressions. hemorrhage MULTIPLE TRAUMA When an AUTOMATED EXTERNAL DEFIBRILLATOR poisoning STROKE (AED) is available, a second responder may add DEFIBRILLATION to the resuscitation efforts, which is cardiopulmonary resuscitation (CPR) Emer- the next step. The AED unit determines whether gency efforts to restore the function of the HEART defibrillation is appropriate.

371 372 Emergency and First Aid

See also COLD WATER DROWNING; RESCUE BREATH- this include downed power lines and plugged in ING; RESPONDER SAFETY AND PERSONAL PROTECTION; SITE power tools or appliances. Water, including wet AND SITUATION ASSESSMENT; SYMPTOM ASSESSMENT AND surfaces, increases the risk to the responder as CARE TRIAGE; WARM WATER DROWNING. water conducts electricity. There may also be risk for explosion or fire. defibrillation Delivery of a controlled electrical Responder personal protection measures Latex shock, using an AUTOMATED EXTERNAL DEFIBRILLATOR gloves, which the responder should put on before (AED), to restore a functional HEART BEAT of a per- approaching the injured person, are essential for son who has suffered CARDIAC ARREST and whose personal protection from bloodborne pathogens. A HEART is in a state of fibrillation (rapid, disorgan- resuscitation shield is necessary for personal pro- ized, and useless contractions). Numerous public tection when performing RESCUE BREATHING or full locations and businesses have AEDs. CARDIOPULMONARY RESUSCITATION (CPR). The AED provides voice instruction for defibril- First response actions When certain there is no lation. The AED pads, when placed on the per- live electricity at the scene, determine whether son’s chest as directed, first detect and send to the the person is breathing and has a heart beat. AED’s computer the heart’s electrical signals. If the When necessary, begin rescue breathing or CPR. rhythm is one that could respond to defibrillation, When these measures are not necessary, provide the AED prepares to deliver a preset electrical basic FIRST RESPONSE for burns and any other appar- shock. If the heart is not beating or has a rhythm ent injuries. for which defibrillation is inappropriate the AED Follow-through The person requires urgent advises the responder what to do, which may be transportation to a trauma center or hospital to perform CARDIOPULMONARY RESUSCITATION (CPR). emergency department. Burns are usually more As with any life-threatening situation, the severe than they appear and other injuries are responder should first call 911 to summon emer- likely. gency medical personnel. See also PATHOGEN; RESPONDER SAFETY AND PER- See also HEART ATTACK; RESPONDER SAFETY AND SONAL PROTECTION; SHOCK. PERSONAL PROTECTION; SITE AND SITUATION ASSESSMENT; SUDDEN CARDIAC DEATH; SYMPTOM ASSESSMENT AND Heimlich maneuver A method to dislodge a for- CARE TRIAGE. eign object from the upper airway that blocks the flow of air. The most common substances that electrocution Injury resulting from electrical become stuck and block BREATHING are incom- shock. Typically a person who experienced elec- pletely chewed foods, especially meats, and small trocution is not BREATHING and may not have a foods such as grapes, nuts, and hard candies. HEART beat, which is a life-threatening circum- Young children may choke on nearly any food as stance. The person is also likely to have electrical well as small toys and other objects they pick up BURNS. and put in their mouths. To perform the Heimlich maneuver: Do not approach a person who has suf- fered electrocution until certain the 1. Confirm that the person is choking by asking source of electricity is no longer active. him or her to speak. If the person cannot speak, Do not try to move a person who the airway is blocked. remains in contact with a high-voltage 2. Stand behind the person, with the person power line. standing. Site and situation assessment The scene of an 3. Reach around the person and place one hand electrocution is extremely hazardous. The first formed into a fist just above the person’s belly person to respond must determine whether the button, thumb-side of the fist toward the per- source of electricity remains “live.” Indications of son’s body. Cardiac Arrest 373

4. Grab the fist with the other hand and give a Rapid response is essential. Most people are sharp pull inward and upward. fine once the object dislodges and they can breathe again. An object that does not come out 5. For an infant or small child, hold the infant in a with the Heimlich maneuver, or a person who sitting position. Use two or three fingers placed loses CONSCIOUSNESS, requires further emergency just above the belly button and jab sharply. care from trained medical personnel. 6. Repeat until the force of air pressure in the air- See also CARDIOPULMONARY RESUSCITATION (CPR); way expels the object. COUGH; RESCUE BREATHING; SWALLOWING DISORDERS. Heat and Cold Injuries

Heat and cold injuries most often occur in wet clothing a person loses body heat at a rate up response to environmental exposure to extremes to 20 times that which occurs in cold air. Wind in temperature. Environmental temperatures that also influences the effects of cold; a calculation are above or below the body’s normal tempera- called the wind-chill factor represents the effect. ture require the body to implement actions to Moisture similarly affects the consequences of compensate. When the external temperature is heat. High humidity in combination with high higher than body temperature, these actions temperature intensifies the risk for heat injury; a include peripheral vasodilation (BLOOD vessels in calculation called the heat index represents the the extremities relax to increase the flow of effect. HEAT EXHAUSTION and HEAT STROKE, the two blood), which moves greater quantities of blood types of heat-related injuries, most often occur in closer to the body’s surface where the tempera- people who are engaged in intense physical activ- ture is somewhat cooler, and sweating, which ity in circumstances of combined high tempera- cools the SKIN through evaporation. ture and high humidity. DEHYDRATION can occur When the external temperature is lower than rapidly with heat injuries, further complicating body temperature, the body’s compensatory health concerns. mechanisms include peripheral vasoconstriction Untreated, progressive heat or cold injury has (blood vessels in the extremities narrow to high risk for permanent tissue and organ damage decrease the flow of blood), which pulls more or death. blood within the body core where temperature is somewhat warmer, and shivering, which dehydration Insufficient water intake or exces- increases energy output that in turn raises body sive water loss resulting in electrolyte imbalance temperature. When either set of mechanisms fails within the body. Though there are numerous pos- to achieve an acceptable body temperature, body sible causes for dehydration, the most common chemistry and METABOLISM begin to change, alter- first aid scenario for dehydration occurs with ath- ing vital body activities such as neurologic (BRAIN), letic activities, sporting events, intense physical cardiovascular (HEART rhythm and BLOOD PRES- labor (especially in hot conditions), and extremely SURE), and renal (kidney) functions. hot weather. A person’s body size and composition and Early symptoms of dehydration include thirst, activity level also influence the rate at which the light-headedness, and dry SKIN. Drinking cool body retains or loses heat. A person who has fairly water, to 6 ounces every 15 minutes, is often ade- high body fat loses body heat more slowly; he or quate treatment for mild dehydration. Symptoms she may have better tolerance for exposure to of moderate dehydration may include mild MUSCLE cold and less tolerance for exposure to heat. For a cramps, mental confusion, and disorientation. person who has low body fat, the reverse is the Though drinking water may improve moderate case: He or she often has better tolerance for dehydration as a first aid response, intravenous exposure to heat and less for exposure to cold. fluids are often necessary to restore electrolyte Moisture further influences the extent to balance. Severe dehydration may result in loss of which such exposure is tolerable or becomes a CONSCIOUSNESS, rapid or irregular HEART RATE health concern. In cold water or when wearing (tachycardia or ARRHYTHMIA), rapid BREATHING, 374 Heat and Cold Injuries 375 severe muscle cramps, and SHOCK. Severe dehydra- • rapid HEART RATE (tachycardia) tion requires urgent treatment from a hospital • HALLUCINATION emergency department or trauma center. • disorientation, agitation, or loss of CONSCIOUS- COMMON CAUSES OF DEHYDRATION NESS acute GASTROENTERITIS DIABETES • seizures excessive diuretic use excessive laxative use heavy sweating inadequate drinking Body temperature is usually above 102ºF. persistent DIARRHEA persistent VOMITING Urgent treatment is necessary to avert permanent strenuous exercise sustained FEVER BRAIN and other neurologic damage. Call 911 to summon emergency medical aid, then get the per- See also HEAT EXHAUSTION; HEAT STROKE. son into an air-conditioned location, if possible, and remove outer layers of clothing. Spray a mist of heat exhaustion Overheating of the body in water or apply cool, wet washcloths to the skin. If conditions of extreme heat or heavy physical possible, place ice packs or extremely cold objects activity. Symptoms of heat exhaustion come on under the armpits and at the groin; at these loca- suddenly and may include blanched SKIN, heavy tions large volumes of BLOOD circulate near the sweating, NAUSEA, and lightheadedness. Get the skin’s surface. Position the person lying on his or person into a cool environment, such as a shaded her back with feet and legs elevated about 12 area or an air-conditioned location, as quickly as inches (SHOCK position). Emergency medical per- possible. Loosen clothing, offer cool water or cool sonnel may have cooling blankets and will begin sports drinks (nothing iced), and spray or moisten intravenous fluids, then transport the person to a the skin with cool water. When these measures hospital or trauma center for further care. are effective, the person improves dramatically See also DEHYDRATION; FEVER. and does not need further medical care. Though heat exhaustion is mild and nearly hypothermia The sustained loss of body heat always improves with appropriate interventions resulting in low body temperature. Hypothermia such as these, untreated heat exhaustion may occurs with extended exposure to cold external progress to HEAT STROKE, a potentially life-threaten- temperatures. Cool, wet conditions may also result ing disturbance of body temperature. Call 911 to in hypothermia. The key symptom of mild summon emergency medical aid if the person’s hypothermia, in which body temperature is no temperature is higher than 102ºF or the person lower than 95ºF, is intense shivering. Attempt to has seizures. warm the person getting him or her into a warm See also DEHYDRATION; FEVER; SPORTS DRINKS AND location, removing wet clothing and wrapping in FOODS. warm blankets, and offering warm fluids to drink. When body temperature drops below 95ºF in heat stroke A life-threatening emergency in moderate hypothermia, the body loses the ability which the body is unable to lower body tempera- to shiver and the rate of heat loss increases. HEART ture. Heat stroke most commonly develops when RATE slows, BLOOD PRESSURE drops, and METABOLISM there is a combination of intense physical activity slows. The person is often confused or agitated, and high environmental temperature. Though may paradoxically feel warm, and feels increas- most people who develop heat stroke first experi- ingly sleepy. Emergency response includes warm- ence HEAT EXHAUSTION, symptoms of heat stroke ing efforts as well as calling 911 to summon may appear suddenly. Such symptoms include emergency aid personnel. Moderate hypothermia often requires further medical care to stabilize • hot, flushed SKIN body temperature. The lower body temperature drops, the less • absence of sweating likely recovery becomes. Body temperature below • HEADACHE 90ºF, severe hypothermia, is very precarious. 376 Emergency and First Aid

Organ systems, especially the cardiovascular and UNCONSCIOUSNESS. The pupils are often fixed (non- neurologic, become exceedingly fragile. The risk responsive to light). CARDIOPULMONARY RESUSCITA- for life-threatening ARRHYTHMIA (irregular heart TION (CPR) is necessary if the person is not beat) and especially VENTRICULAR FIBRILLATION is BREATHING and has no PULSE. As with COLD WATER already high because of the body’s altered meta- DROWNING, aggressive resuscitation efforts may bolic and biochemical state; jostling the person revive someone who has had very low body tem- during movement can rapidly destabilize the HEART perature for an extended time. and cardiovascular function. Severe hypothermia See also FROSTBITE; HEAT EXHAUSTION; HEAT STROKE; significantly slows neurologic function, causing RAYNAUD’S SYNDROME; SITE AND SITUATION ASSESSMENT. Major Trauma

Major trauma is a circumstance of a single cata- cause rapid death. Surgery is the only means to strophic injury, such as GUNSHOT WOUNDS or BURNS, treat internal bleeding. or multiple injuries that affect multiple body sys- Follow-through A health-care provider should tems in such a fashion that without urgent med- evaluate blunt trauma to determine the need for ical intervention death is likely. Major trauma further treatment. most often results from events such as MOTOR VEHI- See also CLOSED FRACTURE; SYMPTOM ASSESSMENT CLE ACCIDENTS, fires, serious falls, occupational AND CARE TRIAGE; SITE AND SITUATION ASSESSMENT; accidents, and other situations in which the body SYMPTOM ASSESSMENT AND CARE TRIAGE. encounters multiple hazards. Situations of major trauma are often more than an individual first gunshot wounds Injuries that result from bul- responder can adequately assess. The top priority lets. Gunshot wounds are often more serious than of FIRST RESPONSE is to get emergency personnel they appear, particularly when the bullet remains and equipment to the scene and prevent further lodged in the body. A bullet enters the body with injuries to the person or to others who are high velocity and follows a trajectory of least involved in the situation or arrive at the scene. resistance. That trajectory may carry the bullet on a direct path through soft tissue or along the path blunt trauma Injury that results from a strong of a BONE. Gunshot wounds may be accidental or blow or force. The injury may not be initially intentional, self-inflicted or inflicted by another obvious because there may be no outward signs person. such as LACERATIONS or bruises. However, blunt trauma may cause internal bleeding or rupture of Do not approach a person who has a upper abdominal organs such as the SPLEEN or PAN- gunshot wound or the site of a shooting CREAS. Blunt trauma to the head may cause TRAU- if there is still gunfire or the where- MATIC BRAIN INJURY (TBI). abouts and status of the shooter are Site and situation assessment MOTOR VEHICLE uncertain. Use extreme caution until ACCIDENTS, industrial accidents, and collisions with the situation is clear. stationary objects (such as a skier running into a tree) are among the situations that may result in Site and situation assessment The most essen- multiple trauma. tial determination is whether gunfire presents an Responder personal protection measures Latex ongoing risk for the injured person, other people, gloves, which the responder should put on before and responders. approaching the injured person, are essential for Responder personal protection measures Latex personal protection from the possibility of acquir- gloves, which the responder should put on before ing INFECTION through contact with body fluids. approaching the injured person, are essential for First response actions There are few FIRST personal protection from bloodborne pathogens as RESPONSE measures for blunt trauma beyond keep- nearly always there is moderate to heavy bleeding ing the injured person still and calm. SHOCK may from gunshot injuries. be the only indication of internal bleeding from First response actions After calling 911 to sum- blunt trauma, which can be serious enough to mon emergency aid and then determining that 377 378 Emergency and First Aid the situation is safe, try to locate the entrance and Follow-through Head injuries require urgent exit wounds. The entrance wound is often small medical evaluation and treatment at a hospital and is easy to overlook, especially when the exit emergency department or trauma center. wound is large. BLEEDING CONTROL is critical; apply See also ACCIDENTAL INJURIES; CONCUSSION; TRAU- direct pressure to stop or slow bleeding. Do not MATIC BRAIN INJURY (TBI); SITE AND SITUATION ASSESS- move the injured person unless necessary for MENT; SYMPTOM ASSESSMENT AND CARE TRIAGE. safety, as movement may cause further damage from a lodged bullet. SHOCK is likely; help the motor vehicle accidents Collisions between injured person to remain calm, warm, and as motor vehicles or between motor vehicles and comfortable as possible. objects. Accidental injuries are the fifth leading Follow-through Gunshot wounds require cause of death in the United States; motor vehicle urgent treatment at a hospital emergency depart- accidents account for nearly half of those deaths. ment or trauma center. Nearly three million people receive injuries in See also MULTIPLE TRAUMA; RESPONDER SAFETY AND motor vehicle accidents that require medical care. PERSONAL PROTECTION; SITE AND SITUATION ASSESSMENT; Motor vehicle accidents often result in multiple SYMPTOM ASSESSMENT AND CARE TRIAGE. serious injuries affecting two or more people. Site and situation assessment The situation the head and spinal cord injuries Trauma that may first person on the scene of an accident often cause BRAIN or neurologic damage. Common encounters is chaotic and panicked. The responder causes of head and SPINAL CORD injuries include must remain calm and clear headed to appropri- collisions and accidents involving motor vehicles, ately assess the circumstances and extent of motorcycles, bicycles, skiing, skateboarding, and injuries. Factors to consider include diving into water. Indications of such injuries may • number of vehicles and people involved include UNCONSCIOUSNESS, bleeding from the ears or NOSE, bruises around the eyes or behind the ears, • severity of injuries HEADACHE, NAUSEA, and PARALYSIS. • risks such as traffic, downed power lines, dan- Site and situation assessment Determine gerous terrain (woods, cliffs, water), fire, leak- whether the injured person is at risk for further ing gasoline injury, such as from traffic or drowning. MOTOR Responder personal protection measures Latex VEHICLE ACCIDENTS may involve injuries to multiple people. gloves, which the responder should put on before Responder personal protection measures Latex approaching the scene, are essential for personal gloves, which the responder should put on before protection from bloodborne pathogens as nearly approaching the injured person, are essential for always there is moderate to heavy bleeding from personal protection from bloodborne pathogens as injuries. often there is moderate to heavy bleeding from First response actions The responder often traumatic injuries of the head and spinal cord. must act to concurrently provide a safer site and First response actions Do not move a person aid to those who have injuries. Sometimes the responder must help the injured out of the vehi- who may have a head or SPINAL CORD INJURY. Use cles. The first actions of the responder include: appropriate BLEEDING CONTROL when there are bleeding injuries. Head wounds especially can • Call 911 to summon rescue personnel. bleed profusely. To the best extent possible, brace • Turn off the ignitions of any vehicles that are or splint the person to immobilize the head and still running. back. Discourage the person from attempting to move, including the arms and legs. Do not remove • Kick dirt or gravel over any spilled gasoline to a helmet (bicycle, ski, motorcycle, football, horse- reduce risk for fire or explosion. back riding, or other type) unless the helmet • Check for BREATHING; perform RESCUE BREATHING interferes with aid attempts or the injured person’s or CARDIOPULMONARY RESUSCITATION (CPR) when ability to breathe. necessary. Major Trauma 379

• Stop bleeding. pathogens as nearly always there is heavy bleed- • Speak calmingly and comfortingly to those ing with multiple trauma. involved in the accident. First response actions Multiple trauma is a dif- ficult circumstance for an individual first respon- Unless there is risk for fire or further injury, or der to handle. After calling 911 to summon it is necessary to remove the person from the emergency personnel, priorities include checking vehicle to provide lifesaving first aid, it is usually the injured person’s BREATHING and HEART beat, best to wait for emergency personnel to safely looking for bleeding, and providing basic first aid evacuate or extricate people from their vehicles. for SHOCK. CARDIOPULMONARY RESUSCITATION (CPR) Even injuries that appear mild may involve more and BLEEDING CONTROL may be necessary. serious damage that incorrectly moving the person Follow-through A person who has multiple could exacerbate. trauma is often gravely wounded and requires Follow-through People who have moderate to urgent medical care at a hospital emergency severe injuries need further medical assessment department or trauma center. and care. Medical aid personnel typically perform See also ACCIDENTAL INJURIES; BLEEDING CONTROL; minimal treatment at the accident scene to stabi- BODY SUBSTANCE ISOLATION; BLUNT TRAUMA; GUNSHOT lize the injured person’s condition, with the goal WOUNDS; RESPONDER SAFETY AND PERSONAL PROTECTION; of transporting the person to a hospital or trauma SITE AND SITUATION ASSESSMENT; SYMPTOM ASSESSMENT center within one hour of the accident. People AND CARE TRIAGE. who have mild injuries may desire to follow-up with their regular health-care providers. trauma to the eye Penetrating or blunt force See also BLEEDING CONTROL; BODY SUBSTANCE ISO- injuries to the EYE or the structures around the LATION; CLOSED FRACTURE; MULTIPLE TRAUMA; OPEN eye, flash BURNS, and chemical burns. Such FRACTURE; RESPONDER SAFETY AND PERSONAL PROTEC- injuries can cause partial or complete loss of vision TION; SITE AND SITUATION ASSESSMENT; SYMPTOM ASSESS- as well as loss of the eye itself. Do only what is MENT AND CARE TRIAGE. necessary to minimize movement and prevent further injury. multiple trauma Numerous significant injuries such as may occur in MOTOR VEHICLE ACCIDENTS, Do not remove an object that penetrates shooting incidents, falls from high places, and into the EYE, the eyelid, or the tissues fires. Multiple trauma is often life threatening around the eye. and beyond the ability of the first responder to take much action beyond comforting the injured person until emergency medical personnel For FIRST RESPONSE for eye trauma, cover the arrive. injured eye with a small paper cup or similar item Site and situation assessment Multiple trauma to prevent contact with the eye or any object that situations require rapid assessment of the nature might be penetrating the eye. Cover the uninjured and extent of the injuries, especially when numer- eye with a bandage or cloth; covering both eyes ous people are injured. The first person to respond prevents movement that could further damage the to the scene of multiple trauma should also deter- injured eye. Talk reassuringly and steadily to the mine what risks are present that threaten respon- person; being unable to see is disorienting and ders and emergency personnel, such as unstable often frightening. Conversation helps the injured terrain, traffic, and crime scenes. Other important person maintain contact with his or her surround- details include the number of people involved and ings and know what is going on. the nature and seriousness of injuries. An ophthalmologist (physician who specializes Responder personal protection measures Latex in care of the eyes) should evaluate most eye gloves, which the responder should put on before injuries, even those that appear minor. Bacterial approaching the scene or the injured person, are INFECTION in ABRASIONS and small LACERATIONS on essential for personal protection from bloodborne the surface of the eye can threaten vision. Signifi- 380 Emergency and First Aid cant injuries to the eye require urgent ophthalmo- have MULTIPLE TRAUMA, depending on the cause of logic care. the traumatic amputation. See also ACCIDENTAL INJURIES; BLACK EYE; CONJUNC- Responder personal protection measures Latex TIVITIS; ENUCLEATION; IMPALEMENT; SYMPTOM ASSESS- or latex-type gloves, which the responder should MENT AND CARE TRIAGE; VISION IMPAIRMENT. put on before approaching the injured person, are essential for personal protection from bloodborne traumatic amputation The accidental or unin- pathogens as nearly always traumatic amputation tended severance of a body part. Fingers are the results in heavy bleeding. body parts most often lost to traumatic First response actions A major traumatic AMPUTATION. When the amputation is clean, such amputation is a difficult circumstance for an indi- as may occur with a sharp object, surgeons may be vidual responder to handle. Call 911 to summon able to reattach the amputated part. Avulsions emergency medical aid, then attempt to control (tearing of the structures) are often jagged and do the bleeding. As with other bleeding injuries, considerable damage to the tissues, and the ampu- direct pressure to the injury is the most effective tated part may not be intact enough to recover. method. Continue adding bandages, cloths, or Traumatic amputations typically bleed heavily and other materials to establish bulk with the pressure. cause extreme PAIN. SHOCK is a significant risk. BLOOD loss may rapidly be substantial Try to keep Site and situation assessment It is important to the person warm and calm. salvage the amputated part and take it to the hos- Follow-through Traumatic amputation typi- pital with the injured person. A person who cally requires emergency surgery to stop the remains entangled in machinery remains at high bleeding, repair tissue damage, and reattach the risk for further injury unless properly extricated amputated part when possible. by emergency personnel trained in such situa- See also ACCIDENTAL INJURIES; AVULSION; BLEEDING tions. Power tools and appliances that remain CONTROL; BODY SUBSTANCE ISOLATION; MOTOR VEHICLE plugged in create a hazard for further injury to the ACCIDENTS; RESPONDER SAFETY AND PERSONAL PROTEC- person or injury to the responder as well as the TION; SITE AND SITUATION ASSESSMENT; SYMPTOM ASSESS- risk for ELECTROCUTION. The injured person may MENT AND CARE TRIAGE. Poisoning

Many substances are toxic when used inappropri- bees, and fire ants, collectively known as the ately or through accidental exposure. Personal Hymenoptera order. For the two million Ameri- protection and safety are crucial for the first cans who are allergic to the venom of these responder, who must first determine that there is insects, the sting is far more significant than irrita- no risk for becoming another victim of the same tion or discomfort. Severe hypersensitivity exposure. This is especially of concern with poi- response can cause swelling of the THROAT that sonous BITES AND STINGS, CONTACT TOXINS, and blocks the airway; anaphylactic SHOCK is a life- INHALED TOXINS. Though the FIRST RESPONSE should threatening circumstance. always be to call 911 to summon emergency med- First response for Hymenoptera stings: ical aid, contact with a poison control telephone hotline can provide specific advice for the first 1. Gently scrape the stinger out of the wound responder until emergency medical personnel with the edge of an object such as a credit card. arrive. In the United States, there is a nationwide Do not grasp the stinger with tweezers or fin- toll-free telephone hotline available 24 hours a gernails as this squeezes the venom sack and day, 7 days a week. forces more venom into the wound. 2. Apply ice until the area is numb. US national poison control hotline: 3. Make a paste of baking soda and water and lib- 1-800-222-1222 erally spread it over the area of the sting. Available 24 hours a day, 7 days a week, (Alternately, apply a small amount of hydro- from anywhere in the United States. cortisone cream or diphenhydramine cream.) The number is toll-free. 4. Seek further evaluation and treatment from a health-care provider when PAIN persists or bites and stings Poisoning or HYPERSENSITIVITY worsens, or when the person stung has a RESPONSE (allergic reaction) to insect and reptile hypersensitivity response (allergic reaction). venoms. Though numerous insects sting and spi- ders and snakes bite, most are not poisonous Poisonous spider bites and scorpion stings (harmful beyond local discomfort at the site of the There are only two types of poisonous spiders in sting or bite). Rapid FIRST RESPONSE efforts can North America, the widows (of which the black often reduce the severity of the resulting injury widow is the most notorious species) and the from poisonous stings and bites. brown recluse. There is one species of poisonous scorpion, Centruroides sculpturatus, found in the Remove rings, watches, and other jew- southwestern United States (particularly Arizona) elry in the area of a bite or sting to and northern Mexico. The venom of a widow spi- prevent further injury if swelling der is a neurotoxin that produces pain and occurs. Significant swelling is especially swelling at the site of the bite and systemic effects common with poisonous snake bites. that may include generalized discomfort or pain, MUSCLE CRAMP, and muscle SPASM. It may also ele- Hymenoptera stings The most common stings vate BLOOD PRESSURE (HYPERTENSION). Many people come from wasps, hornets, yellow jackets, honey do not notice the bite of the brown recluse spider 381 382 Emergency and First Aid for up to a week, when the toxin begins to cause 1. Soak the area of the sting in water as hot as the tissue necrosis (death) at the site of the bite. The person stung can tolerate for at least 30 min- sting of the C. sculpturatus scorpion is also a neuro- utes. toxin; pain is immediate and later systemic 2. After the hot water soak, place gauze pads response is common. Though unpleasant, these soaked in vinegar over the sting area. bites and stings are seldom fatal. 3. Repeat these measures until symptoms improve First response for poisonous scorpion stings and or the stung person reaches a hospital for fur- spider bites: ther treatment. 1. Apply ice to the bite. Jellyfish and related creatures such as sea 2. Minimize movement of the bitten area; splint if anemones and Portuguese man-o-war have clus- possible. ters of long tentacles covered with stinging cells. 3. Seek immediate medical care at a hospital First response for these stings: emergency department. ANTIVENIN is available for widow spider and C. sculpturatus scorpion 1. Flush the area of the sting with seawater. bites. 2. Place gauze pads soaked in vinegar over the sting area for at least 30 minutes. Poisonous snake bites There are four types of poisonous snakes in North America (see table), 3. Use gloved hands or tweezers to remove tenta- the bites of which are all capable of causing death. cles. Antivenin is available for each type. Bites from 4. Repeat steps 2 and 3 until all tentacles are gone poisonous snakes require urgent medical treat- and pain subsides. ment at a hospital emergency department. 5. Seek treatment at a hospital emergency depart- First response for snake bite: ment.

1. Loosely splint or otherwise immobilize the area See also ALLERGY; POISON PREVENTION. of the bite, and keep it lower than the HEART. 2. Keep the bitten person calm and still. contact toxins Substances, such as chemicals, 3. If it will be longer than 30 minutes before the that cause symptoms upon coming in contact with bitten person can get to a hospital, wrap a the SKIN. Many contact toxins cause mild symp- bandage (or improvise with a scarf or other toms such as contact DERMATITIS; some can cause item of clothing) firmly but not tightly three to chemical BURNS that require urgent or prompt four inches above the bite, between the bite medical care, depending on their severity. Rapid and the heart. The tightness of the wrap should FIRST RESPONSE minimizes the severity of injury and be such that the responder’s finger can fit prevents further absorption of the toxin through under it. After placing such a bandage, do not the skin and into the BLOOD circulation, if the remove it for any reason. Doing so will release toxin is one that absorbs in such of a way. a surge of venom into the person’s BLOOD circu- Site and situation assessment Determine the lation. severity of symptoms and the toxin. When a chemical, take the container (with due caution to Stings from stingrays, jellyfish, and sea urchins avoid contact with the ingredients) or label. Numerous species common in the oceans in the Responder personal protection measures Latex coastal United States can deliver a significant sting. or latex-style gloves are essential to prevent Stingrays and sea urchins sting with spines coated responder contact with the toxin. in venom. The spines may break off under the SKIN, First response actions Call 911 to summon continuing to release venom. They also present emergency medical personnel when situation very high risk for bacterial INFECTION. Heat inacti- appears significant or call the poison control hot- vates the venom and vinegar dissolves the spines. line (in the United States: 1-800-222-1222) for First response for stingray and sea urchin stings: guidance. Further first response actions: Poisoning 383

POISONOUS SNAKES IN THE UNITED STATES Type of Snake Geographic Range Characteristics of Bite copperhead much of United States from Texas to Rhode Island PAIN, swelling, and discoloration at the site of the and the southern coast to the Ohio River valley bite that expand progressively systemic effects can cause significant illness bites of some species more toxic with risk of death treatment may require ANTIVENIN coral snake 2 species in the US southeast, 1 species in the venom is a powerful neurotoxin US southwest rapid systemic symptoms that may include NAUSEA, sleepiness, excessive drooling, difficulty BREATHING, and sometimes PARALYSIS high risk for death without prompt treatment antivenin need is urgent cottonmouth, also southern United States from eastern Texas to pain, swelling, and discoloration at the site of the called water the northeast Maryland shore and inland to bite that expand progressively moccasin southern Missouri and western Tennessee systemic effects can cause significant illness bites of some species more toxic with risk of death treatment may require antivenin rattlesnake 20 species diversely throughout United States pain, swelling, and discoloration at the site of the and Mexico bite that expand progressively systemic effects can cause significant illness bites of some species more toxic with risk of death treatment may require antivenin

1. Remove any clothing contaminated by the COMMON CONTACT TOXINS toxin. ammonia bleach 2. If the toxin is a dry powder, use gauze or a drain cleaners gardening and yard products piece of fabric or a small brush to brush the household cleaning products industrial solvents powder off the skin. lye pesticides 3. After the powder is completely gone and for all poison ivy, oak, and sumac stinging nettles other contact toxins, flush the area of contact See also ACCIDENTAL INJURIES; POISON PREVENTION; (including the eyes if the toxin is in the eyes) RESPONDER SAFETY AND PERSONAL PROTECTION; SITE AND with large amounts of water for at least 20 SITUATION ASSESSMENT; SYMPTOM ASSESSMENT AND CARE minutes. Hold or position the injured area such TRIAGE; WORK AND OCCUPATIONAL SAFETY. that the runoff water does not spread the toxin to other body parts or to the responder. ingested toxins Substances, that when swal- Follow-through Most poisonings resulting from lowed, can cause systemic poisoning. Ingestion contact poisons require further medical care to may be intentional or accidental. Accidental inges- provide relief from symptoms such as itching, tion of medications is the most common form of swelling, or PAIN. Chemical burns that form blisters poisoning in children. Children may also eat or (second-degree BURNS) or cover 10 percent or drink other substances not intended for consump- more of body surface require evaluation and treat- tion such as cleaning products, nail polish ment at a hospital emergency department or remover, and plants. Injury may range from gas- urgent care facility. trointestinal upset to life-threatening cardiovascu- 384 Emergency and First Aid lar, kidney, LIVER, or neurologic damage. Appropri- down in case of VOMITING. If vomiting occurs, ate FIRST RESPONSE is often crucial. clear vomitus from the MOUTH to maintain an Site and situation assessment Determine, to open airway. the best extent possible, what and how much of it 4. If the person is not BREATHING, begin rescue the person has swallowed, as well as when. Take breathing. the container or label when it is present. 5. If the person is not breathing and does not Responder personal protection measures Latex have a PULSE, begin CPR. or latex-style gloves are essential to prevent responder contact with the toxin as well as body Follow-through People who have ingested fluids from the injured person. A resuscitation toxic substances or overdoses of medications shield is necessary for RESCUE BREATHING or CAR- require urgent treatment at a hospital emergency DIOPULMONARY RESUSCITATION (CPR). department or trauma center. First response actions Call 911 to summon See also BODY SUBSTANCE ISOLATION; OVERDOSE; emergency medical personnel when the situation POISON PREVENTION; RESPONDER SAFETY AND PERSONAL appears significant or call the poison control hot- PROTECTION; SITE AND SITUATION ASSESSMENT; SUICIDE line (in the United States: 1-800-222-1222) for IDEATION AND SUICIDE; SYMPTOM ASSESSMENT AND CARE guidance. Further first response actions: TRIAGE. 1. If the person is conscious, give small, frequent inhaled toxins Substances that, when breathed, drinks of water. can injure the airways and LUNGS as well as cause 2. Do not give anything else and do not induce systemic poisoning. Inhaled toxins require urgent vomiting unless emergency medical or poison medical care. control personnel so instruct. Site and situation assessment Attempt to 3. If the person is unconscious, position the per- determine the toxin and whether it remains pres- son to lie on a side with the head somewhat ent in the environment. There may be multiple

COMMON INHALED TOXINS Toxin Common Sources Characteristics carbon monoxide poorly ventilated furnaces or stoves odorless automobiles or gas power tools running symptoms include intense sleepiness progressing in enclosed area such as garages to loss of consciousness, bright redness to face propane gas; natural gas heating and cooking appliances sulfuric odor (“rotten egg” smell) added to help detect leaks symptoms include disorientation and confusion progressing to loss of consciousness ammonia gas fertilizer products for commercial strong, pungent odor agricultural use small exposure is highly toxic industrial exposures symptoms include severe respiratory irritation, intense coughing, and chemical BURNS to the nasal passages and airways chlorine gas pool cleaning products strong, bleachlike odor industrial exposures symptoms include intense irritation to eyes, nose, and respiratory tract Poisoning 385 people injured with environmental toxins such as Site and situation assessment Attempt to chemical leaks. determine the drug or substance injected. Collect any vials, syringes, and other apparatus that may Do not approach or enter an area where help identify the substance (handle these items the possibility of environmental pres- only if wearing latex or latex-style gloves). ence of the toxin exists. Responder personal protection measures Latex or latex-style gloves are essential to prevent Responder personal protection measures Latex responder contact with the toxin as well as body or latex-style gloves are essential to prevent fluids from the injured person. A resuscitation responder contact with the toxin as well as body shield or mask is necessary for RESCUE BREATHING or fluids from the injured person. A resuscitation CARDIOPULMONARY RESUSCITATION (CPR). The risk for shield or mask is necessary for RESCUE BREATHING or exposure to HEPATITIS, HIV/AIDS, and TUBERCULOSIS is CARDIOPULMONARY RESUSCITATION (CPR). very high when illicit drug abuse is the cause of First response actions Call 911 to summon the injected toxin poisoning. emergency medical personnel or call the poison First response actions Call 911 to summon control hotline (in the United States: 1-800-222- emergency medical personnel and call the poison 1222) for guidance. Many situations of inhaled control hotline (in the United States: 1-800-222- toxins require self-contained BREATHING apparatus, 1222) for guidance. Further first response actions: protective clothing, and specialized training to safely rescue injured people. In such situations the 1. If the person is conscious, try to keep him or first responder can only summon help. Do not per- her awake and moving. form rescue breathing or CPR without a resuscita- 2. If the person is unconscious, position the per- tion shield or mask, as doing so exposes the son to lie on a side with the head somewhat responder to the toxin. down in case of VOMITING. If vomiting occurs, Follow-through People exposed to inhaled tox- clear vomitus from the MOUTH to maintain an ins require urgent medical evaluation and treat- open airway. ment at a hospital emergency department or trauma center. 3. If the person is not BREATHING, begin rescue breathing using a resuscitation shield or mask. See also INHALATION BURNS; ORGANIC SOLVENTS; RESPONDER SAFETY AND PERSONAL PROTECTION; SITE AND 4. If the person is not breathing and does not SITUATION ASSESSMENT; SYMPTOM ASSESSMENT AND CARE have a PULSE, begin CPR using a resuscitation TRIAGE. shield or mask. injected toxins Poisons that enter a person’s Follow-through Overdose or poisoning due to body through injection with a needle subcuta- injected toxins requires urgent medical assessment neously (beneath the SKIN), intramuscularly (into and treatment at a hospital emergency depart- a MUSCLE), or intravenously (into a VEIN). Most cir- ment. cumstances of injected toxins are inadvertent DRUG See also INJECTING DRUGS, RISKS OF; POISON PREVEN- OVERDOSE resulting from ILLICIT DRUG USE. Illicit TION; RESPONDER SAFETY AND PERSONAL PROTECTION; drugs may also contain poisons used as fillers or to SITE AND SITUATION ASSESSMENT; SYMPTOM ASSESSMENT dilute the drug. AND CARE TRIAGE. Radiation and Biochemical Injuries

Acts of terrorism using radiation, biologic Biologic injuries Biologic injuries that occur pathogens, and chemical toxins became a height- when there is exposure to pathogens (BACTERIA ened worldwide concern in the latter decades of and viruses) for which immunity is low are often the 20th century. Such acts have the potential to serious or life-threatening illnesses. Among the affect large numbers of people. Because the toxic- pathogens of concern for intentional harm ity of these methods is very high, even FIRST through biologic injury are those that cause RESPONSE requires a sophisticated public health ANTHRAX, BOTULISM, plague, and SMALLPOX. approach. Injuries resulting from radiation, bio- Chemical injuries Chemical injuries that occur logic, or chemical exposure may also occur through intentional exposure to highly toxic through industrial accidents. RESPONDER SAFETY AND chemicals, typically through inhalation or contact, PERSONAL PROTECTION are crucial. often cause serious or fatal neurologic and pul- Radiation injuries Radiation injuries occur monary injury. Among the chemicals of concern when there is exposure to radiation that exceeds are ammonia, arsenic, benzine, chlorine, cyanide, the recommended safe limits. The exposure may mercury, mustard gas, nitrogen mustard, osmium be chronic (small exposure over time) or acute tetroxide, phosphine, ricin, sarin, tabun, thallium, (sudden, massive exposure). Exposure to massive and VX. radiation doses results in acute radiation syn- See also BODY SUBSTANCE ISOLATION; CHEMOTHER- drome, which is often fatal. Radioactive sub- APY; CONTACT TOXINS; ENVIRONMENTAL HAZARD EXPO- stances that pose the greatest risk for radiation SURE; HEAVY-METAL POISONING; INFECTION; INHALED injuries include radionuclides, diethylenetri- TOXINS; PATHOGEN; POISON PREVENTION; RADIATION aminepentaacetate (DTPA), Neupogen, potassium THERAPY; SITE AND SITUATION ASSESSMENT; SYMPTOM iodide, and Prussian blue. ASSESSMENT AND CARE TRIAGE.

386 APPENDIXES

I. Vital Signs II. Advance Directives III. Glossary of Medical Terms IV. Abbreviations and Symbols V. Medical Specialties and Allied Health Fields VI. Resources VII. Biographies of Notable Personalities VIII. Diagnostic Imaging Procedures IX. Family Medical Tree X. Immunization and Routine Examination Schedules XI. Modern Medicine Timeline XII. Nobel Laureates in Physiology or Medicine

387 388 Appendix I APPENDIX I VITAL SIGNS

Vital signs are the observable, objective measures according to age, gender, aerobic condition, and of a person’s basic health status. The four standard level of physical activity. Health conditions further vital signs are PULSE (HEART RATE), BLOOD PRESSURE, affect vital signs. A person may have vital signs RESPIRATION RATE (BREATHING rate), and body tem- that are outside the parameters of “normal” in a perature. Within a range of normal measure- general context though are consistent for him or ments, these signs vary among individuals and her.

VITAL SIGNS Heart Rate (Pulse) Blood Pressure Breathing Rate Body Temperature adult 60 to 89 beats per systolic < 120 millimeters 12 to 18 breaths per 97.8º to 99.1ºF minute at rest of mercury (mm Hg) minute diastolic < 80 mm Hg child, 1 to 8 years 80 to 100 beats per systolic <110 mm Hg 15 to 30 breaths per 97.8º to 99.1ºF minute at rest minute infant, 1 to 12 100 to 120 beats per systolic 70 to 100 mm Hg 25 to 50 breaths per 97.8º to 99.1ºF months minute at rest minute infant, birth to 30 120 to 160 beats per systolic > 60 mm Hg 40 to 60 breaths per 97.8º to 99.1ºF days minute at rest minute

389 APPENDIX II ADVANCE DIRECTIVES

Advance directives are instructions a person pre- Advance directives are valid in all states in the pares that state his or her desires and preferences United States, though each state has unique laws, for end-of-life care. Typically advance directives regulations, and procedures for implementing consist of two legal documents advance directives. Documents should be updated, renewed, and resigned every few years • a living will, which specifies the person’s inten- to ensure currency. Information for obtaining and tions in regard to medical treatment and resus- completing advance directive forms for each state citative efforts is available through • a durable power of attorney for health care, also called durable medical power of attorney, National Hospice and Palliative which authorizes another individual (called a Care Organization (NHPCO) health-care agent or proxy) to make medical 1700 Diagonal Road, Suite 625 decisions on behalf of a person in the circum- Alexandria, VA 22314 stance of a medical crisis when the person is 703-837-1500 unable to make such decisions www.nhpco.org

390 APPENDIX III GLOSSARY OF MEDICAL TERMS afferent Moving inward or toward the body’s diagnostic imaging Procedures that allow visu- center. alization of internal organs, structures, or anastomosis A natural or surgically created con- processes to diagnose health conditions or moni- nection between two structures. tor the progress of treatment. Common diagnostic arterial blood gases Measurement of the levels imaging procedures include X-ray, ultrasound, of oxygen (partial pressure of oxygen, PO2) and computed tomography (CT) scan, and magnetic carbon dioxide (partial pressure of carbon dioxide, resonance imaging (MRI).

PCO2) in a sample of blood drawn from an artery. disease A health condition for which there are Tests may also measure the level of carbon signs (objective and observable evidence) though monoxide and the blood’s acidity (pH). the person may experience no symptoms (subjec- benign Harmless. tive perceptions). biopsy Removal of a tissue or fluid sample from donor A person who gives a structure or sub- the body to conduct pathologic examination for stance (blood, tissue, organ) to another person, diagnostic purposes. the recipient. cabbage Pronunciation of the acronym “CABG,” dorsal The back, or spinal, surface. which stands for coronary artery bypass graft. efferent Moving outward or away from the carcinogenic Capable of causing cancer. body’s center. complete blood count (CBC) Measure of the electrocautery The use of electrical current to numbers and types (differentiation) of blood cells generate heat capable of fusing bleeding blood present in a sample drawn from a vein. vessels or eliminating tissue. computed tomography (CT) scan A diagnostic electromyography (EMG) A diagnostic proce- imaging procedure that uses a computer to gener- dure that uses electrodes attached to tiny needles ate three-dimensional images from multiple, seg- inserted into selected muscles or placed on the mental X-rays. A CT scan may include ingestion surface of the skin, to measure the electrical activ- or injection of a contrast medium to increase the ity in muscles to assess their function. density of structures, making them more visible electronystagmography A diagnostic procedure via X-ray. that measures the electrical activity of the muscles cyst An enclosed, saclike structure that may con- that move the eyes. tain liquid or solid material. fatigue Extended, persistent loss of physical, dark adaptation test A test that assesses the mental, and emotional energies and abilities. ability to see in a dimly lighted environment. fissure A natural division or channel in an organ deformity An abnormality of structure. Deformi- or an abnormal split in a tissue. ties, also called defects, may be congenital (pres- fistula An abnormal opening between two struc- ent at birth) or acquired (result from injury or tures. disease). fluoroscopy An imaging procedure that uses a diagnosis The identification of a health condi- steady stream of X-rays viewed on a monitor (tel- tion, disorder, or disease. evision screen) to provide real-time, moving

391 392 Appendix III images during diagnostic or therapeutic proce- of radiofrequency energy that causes the hydro- dures such as cardiac catheterization. gen atoms in the body to align in a uniform pat- fundus The base or body of a hollow organ. tern. When the hydrogen atoms return to their graft Tissue, including whole organs, that a sur- normal alignment they send out electromagnetic geon places within a person’s body to treat a dis- signals that the MRI machine’s magnets detect. A ease, defect, or deformity. computer translates the signals into visual images. hematocrit A blood test to determine the per- malignant Capable of causing harm. centage of red blood cells (erythrocytes) in a blood medically necessary A product, device, sub- sample drawn from a vein. stance, or treatment that a person needs to hemorrhage Rapid and significant loss of blood. recover from, accommodate to, or prevent injury home health care Medical providers such as or disease. nurses and physical therapists who provide treat- membrane A thin layer of tissue that covers or ment and care at the person’s home. lines a structure or organ. hospice Care and support for a person who is ter- mucus A somewhat thick (viscous) fluid that minally ill. Hospice providers may care for the glands or membranes produce. person at home or in a hospice center. occlusion Blockage. humor Fluid within the body (from Latin, mean- organ A distinctive structure of tissues that per- ing “wet”). forms a complex function within the body. illness The perception of being unwell; the expe- positron emission tomography (PET) scan A rience of symptoms. diagnostic imaging procedure that uses radionu- in situ In the natural position or surroundings (in clides, also called radioisotopes, to “see” cellular the body as opposed to in a test tube, for example). metabolism. The radionuclides (radioactive parti- in utero Contained within the uterus during cles that rapidly disintegrate) enter cells attached pregnancy. to glucose molecules, which the cells use for inferior Below or beneath. energy. The rate at which the cells use the glucose, integumentary A covering or cloak; refers to the measured by tracking the rate of radionuclide dis- skin. integration, indicates whether the cells’ function is ischemia Deprived of oxygen, usually as a conse- normal; abnormal function may indicate disease quence of restricted blood flow. such as cancer. lap choly Medical shorthand for “laparoscopic post After (in the context of time, as in postoper- cholecystectomy” (surgical removal of the gall- ative). bladder). primary Occurring without underlying cause. latent Delayed. prognosis The anticipated course of a health con- lateral Side. dition, disorder, or disease. lavage To rinse, wash, or flush with fluid. prone The position of lying with the chest and lesion An abnormal growth of cells that are simi- belly on the surface, with arms at the sides and lar to, though altered from, the tissue from which legs outstretched. they arise. Some injuries are also called lesions. recipient A person who receives a structure or lifestyle Habits and practices in which a person substance (blood, tissue, organ) from another per- chooses to engage that influence health and dis- son, the donor. ease. resection The surgical removal of part of an lobe A distinctive, defined section of an organ or organ or structure. gland. risk factor A circumstance that contributes to the localized Confined to a distinct area. likelihood for developing a disease. magnetic resonance imaging (MRI) A diagnos- Schirmer’s test A procedure to assess the tic imaging procedure that uses very powerful amount of tears the tear glands produce. The test magnets to provide images of internal structures involves placing tiny pieces of special paper at the and organs. The MRI machine first emits a pulse edges of the eyelids, with the eyes closed, for five Glossary of Medical Terms 393 minutes and then measuring the amount of fluid supine The position of lying on the back with the paper absorbs. arms at the sides and legs outstretched. scope of practice The legal, professional, and suture A thread or wire used to hold closed the conventional responsibilities and duties of a edges of a wound. Also called a stitch. health-care provider. symptom A subjective perception of a body func- secondary Occurring as a consequence of tion or dysfunction. another health condition, injury, disorder, disease, syndrome A collection of symptoms, signs, and or treatment. diagnostic findings that occurs in a particular pat- sensory perception Information the brain tern. receives through the five senses: vision, hearing, system Organs and structures of the body that smell, taste, and touch. work together to perform related, coordinated sign An objective observation of a body function functions and activities. or dysfunction. teratogenic Capable of causing birth defects in a single photon emission computed tomogra- developing fetus. phy (SPECT) scan A diagnostic imaging proce- tissue An organized group of cells that work col- dure that uses radionuclides to generate lectively to perform a specific function. three-dimensional images of internal organs, transposition Body structures that are present structures, and functions. A special camera detects but switched or exchanged in location or position; the presence of the radionuclides (rapidly disinte- also called transposed. grating radioactive particles) in cells and tissues. tumor An abnormal growth of cells that are Normal cells and tissues take up the radionuclides unique from the tissue from which they arise; also at known rates; unusual cell activity results in called a neoplasm. variations from these rates that may indicate ultrasound A diagnostic imaging procedure that health conditions such as infection or cancer. uses focused sound waves to generate images of speculum An instrument to hold apart the walls internal organs, structures, or functions. The of an opening or hollow organ within the body to sound waves reflect, or echo, from objects they allow its examination. encounter. A computer translates the echoes into spirometry A measure of the amount of air a electrical signals, which are displayed on a moni- person is capable of breathing in and breathing tor screen as visual images. out, performed to assess basic pulmonary (lung) vag hyst Medical short hand for “vaginal hys- function. terectomy“ (surgical removal of the uterus). standard of care The customary practices in ventral The front, or belly, surface. diagnosis, treatment, and follow-up care as deter- watchful waiting A planned treatment approach mined by professional health organizations. of observation and regular physician visits to mon- superior Above. itor the status of a health condition. APPENDIX IV ABBREVIATIONS AND SYMBOLS

AA Alcoholics Anonymous CAD coronary artery disease ac before eating (ante cibum; Latin) CBC complete blood count ACTH adrenocorticotropic hormone cc cubic centimeter ADH antidiuretic hormone CDA certified dental assistant ADHD attention-deficit hyperactivity CDC US Centers for Disease Control and disorder Prevention AED automated external defibrillator CEA carcinoembryonic antigen AFP alpha-fetoprotein CICU cardiac intensive care unit AHA alphahydroxy acid; American Heart CIN cervical intraepithelial neoplasia Association CIS carcinoma in situ (cancer in the cell) AIDS acquired immunodeficiency syndrome CJD Creutzfeldt-Jakob disease ALS amyotrophic lateral sclerosis CLS/MT clinical laboratory scientist/medical AMC arthrogryposis multiplex congenita technologist ANCA antineutrophil cytoplasmic antibody CMA certified medical assistant APLS antiphospholipid syndrome CMV cytomegalovirus ARDS adult respiratory distress syndrome CNM certified nurse midwife ARMD age-related macular degeneration CNS central nervous system ART assisted reproductive technology COPD chronic obstructive pulmonary disease ASA aspirin (acetylsalicylic acid) CP cerebral palsy ATC certified athletic trainer CPAP continuous positive airway pressure AuD doctor of audiology CPhT certified pharmacy technician AV atrioventricular CPR cardiopulmonary resuscitation AVM arteriovenous malformation CRC certified rehabilitation counselor BALT bronchus-associated lymphoid tissue CRH corticotropin-releasing hormone BCP birth control pill CRNA certified registered nurse anesthetist BID/bid twice a day (bis in die; Latin) CRNP certified registered nurse practitioner BiPAP bilevel positive airway pressure CRT certified respiratory therapist BM bowel movement CSA certified surgical assistant BMI body mass index CSF cerebrospinal fluid; colony- BP blood pressure stimulating factor BPH benign prostatic hyperplasia; benign CST certified surgical technologist prostatic hypertrophy CST/CFA certified surgical technologist/certified BPPV benign paroxysmal positional vertigo first assistant BSE breast self-examination CT computed tomography BUN blood urea nitrogen CTCL cutaneous T-cell lymphoma c with (cum; Latin) CTRS certified therapeutic recreational Ca cancer specialist CABG coronary artery bypass graft CVD cardiovascular disease 394 Abbreviations and Symbols 395

CVID common variable immunodeficiency GH growth hormone CVS chorionic villi sampling GHB gamma hydroxybutyrate D&C dilation and curettage (also dilatation GHRH growth hormone–releasing hormone and curettage) GIFT gamete intrafallopian transfer DASH dietary approaches to stop GnRH gonadotropin-releasing hormone hypertension GPI gastric inhibitive polypeptide DC doctor of chiropractic HAART highly active antiretroviral therapy DDS doctor of dental surgery Hg mercury DEA US Drug Enforcement Agency HGE human granulocytic ehrlichiosis DES diethylstilbestrol HHV human herpesvirus DHEA dehydroepiandrosterone HIV human immunodeficiency virus DIC disseminated intravascular HLA human leukocyte antigen coagulation HME human monocytic ehrlichiosis dL (dl) deciliter HNPCC hereditary nonpolyposis colorectal DLE discoid lupus erythematosus cancer DMARD disease-modifying antirheumatic drug HPV human papillomavirus DMD doctor of dental medicine HRT hormone replacement therapy DNA deoxyribonucleic acid IABP intra-aortic balloon pump DO doctor of osteopathy IBD inflammatory bowel disease DRE digital rectal examination IBS irritable bowel syndrome DrPH doctor of public health ICD implantable cardioverter defibrillator DTH delayed-type hypersensitivity ICSI intracytoplasmic sperm injection DUB dysfunctional uterine bleeding IgA immunoglobulin A DVT deep vein thrombosis IgD immunoglobulin D EBCT electron beam computed tomography IgE immunoglobulin E ECC emergency cardiovascular care IgG immunoglobulin G ECG electrocardiogram IgM immunoglobulin M ECT electroconvulsive therapy IM intramuscular EECP enhanced external counterpulsation IND investigational new drug EEG electroencephalogram ITP immune thrombocytopenic purpura EENT eyes, ears, nose, throat IUI intrauterine artificial insemination EKG electrocardiogram IV intravenous EMG electromyogram IVF in vitro fertilization EMT emergency medical technician IVP intravenous pyelogram EPO erythropoietin L (l) liter EPS electrophysiology study LAAM levo-alpha acetylmethadol ERCP endoscopic retrograde LAc licensed acupuncturist cholangiopancreatography LAVH laparoscopically assisted vaginal ESRD end-stage renal disease hysterectomy ESRF end-stage renal failure LH luteinizing hormone ESWL extracorporeal shock wave lithotripsy LP lumbar puncture FAP familial adenomatous polyposis LPN licensed practical nurse FDA US Food and Drug Administration LPT licensed physical therapist FOBT fecal occult blood test LQTS long QT syndrome FSH follicle-stimulating hormone LSD lysergic acid diethylamide GABA gamma-aminobutyric acid LSW licensed social worker GAD generalized anxiety disorder LVEF left ventricular ejection fraction GALT gut-associated lymphoid tissue LVN licensed vocational nurse GERD gastroesophageal reflux disorder m meter 396 Appendix IV

MAb (Mab)monoclonal antibody PharmD doctor of pharmacy MAF macrophage-activating factor PID pelvic inflammatory disease MALT mucosa-associated lymphoid tissue PKU phenylketonuria MD doctor of medicine PMS premenstrual syndrome MDMA methylenedioxymethamphetamine PNS peripheral nervous system MEN multiple endocrine neoplasia PO by mouth (per os; Latin) MET metabolic equivalent POF premature ovarian failure MHC major histocompatibility complex PPI proton pump inhibitor MI myocardial infarction PRN as is needed (pro re nata; Latin) mL (ml) milliliter PSA prostate-specific antigen mm millimeter PT-PTT prothrombin time and partial mm Hg millimeters of mercury thromboplastin time MMR measles/mumps/rubella (vaccine) PTA physical therapy assistant MRA magnetic resonance angiography PTK phototherapeutic keratectomy MRI magnetic resonance imaging PTSD post-traumatic stress disorder MS multiple sclerosis PUVA psoralen and ultraviolet A mtDNA mitochondrial deoxyribonucleic acid PVC premature ventricular contraction mtRNA mitochondrial ribonucleic acid PVD peripheral vascular disease NCCAM National Center for Complementary QD once a day (quaque die; Latin) and Alternative Medicine QID four times a day (quartar in die; Latin) ND doctor of naturopathy QN once a night (quaque noc; Latin) NDV Newcastle disease virus QOD every other day (quaque altera die; NIH US National Institutes of Health Latin) NK natural killer RA rheumatoid arthritis NPO nothing by mouth (non per os; Latin) RBC red blood count NSAID nonsteroidal anti-inflammatory drug RD registered dietitian NTI narrow therapeutic index RDH registered dental hygienist OC oral contraceptives Rh Rhesus (factor blood type) OCD obsessive–compulsive disorder RICE rest, ice, compression, elevation OCT optical coherence tomography RN registered nurse OD doctor of optometry RNA ribonucleic acid OMT osteopathic manipulative treatment RPh registered pharmacist OR operating room RRA registered radiology assistant OTC over the counter RT radiology technologist OTR registered occupational therapist s without (sans; Latin) PA-C certified physician assistant SA sinoatrial; surface area; surgeon’s PAT paroxysmal atrial tachycardia assistant Pb lead SAD seasonal affective disorder pc after eating (post cibum; Latin) SALT skin-associated lymphoid tissue PCA patient-controlled analgesia SAMe S-adenosylmethionine PCID partial combined immunodeficiency SARS severe acute respiratory syndrome PCOS polycystic ovary syndrome SC subcutaneous PCP phencyclidine SCI spinal cord injury PCTA percutaneous transluminal coronary SCID severe combined immunodeficiency angioplasty SIDS sudden infant death syndrome PDD pervasive developmental disorder sig as instructed (signa; Latin) PE pulmonary embolism SLE systemic lupus erythematosus PERP positive end-respiratory pressure SNP single nucleotide polymorphism PET positron emission tomography SOB shortness of breath Abbreviations and Symbols 397

SPECT single photon emission computed TPMT thiopurine methyltransferase tomography TRH thyrotropin-releasing hormone SPF sun protection factor TSE testicular self-examination SQ subcutaneous TSH thyroid-stimulating hormone SSRI selective serotonin reuptake inhibitor TTP thrombotic thrombocytopenic STAT immediately (statim; Latin) purpura STD sexually transmitted disease UA urinalysis

T3 triiodothyronine URI upper respiratory infection T4 thyroxine URR urea reduction ratio TBI traumatic brain injury USP United States Pharmacopeia TCA trichloroacetic acid UTI urinary tract infection TCM traditional Chinese medicine UVA ultraviolet A TENS transcutaneous electrical nerve UVB ultraviolet B stimulation VAD ventricular assist device TGF transforming growth factor VALT vascular-associated lymphoid tissue TIA transient ischemic attack VBAC vaginal birth after cesarean TID/tid three times a day (ter in die; Latin) vCJD variant Creutzfeldt-Jakob disease TMLR transmyocardial laser VIP vasoactive intestinal peptide revascularization WBC white blood count TNF tumor necrosis factor ZIFT zygote intrafallopian transfer APPENDIX V MEDICAL SPECIALTIES AND ALLIED HEALTH FIELDS

MEDICAL PRACTITIONERS AND SPECIALTIES Practitioner Specialty Practitioner Specialty anesthesiologist anesthesiology; anesthesia during neonatologist neonatology; newborns surgery, pain management nephrologist nephrology; kidney conditions bariatrician bariatrics; obesity neurologist neurology; nervous system cardiologist cardiology; heart and blood vessels obstetrician obstetrics; pregnancy and childbirth chiropractor chiropractic; spine and back oncologist oncology; cancer dermatologist dermatology; integumentary system ophthalmologist ophthalmology; eyes (skin, hair, nails) optometrist optometry; vision correction endocrinologist endocrinology; endocrine glands orthopedist orthopedics; musculoskeletal system epidemiologist epidemiology; trends in health and otolaryngologist otolaryngology; ear, nose and throat disease pathologist pathology; tissue examination family practitioner family practice; medical and pediatrician pediatrics; children (birth through surgical care, children and adults adolescence) gastroenterologist gastroenterology; gastrointestinal physiatrist physiatry; physical and rehabilitative system medicine geneticist genetics; inherited and metabolic podiatrist podiatry; feet diseases psychiatrist psychiatry; mental disorders geriatrician geriatrics; elderly psychologist mental health counseling gynecologist gynecology; women’s reproductive pulmonologist pulmonology; lungs system radiologist radiology; diagnostic and therapeutic hematologist hematology; blood and circulation radiologic and nuclear medicine hospitalist care for hospitalized patients procedures immunologist immunology; immune system rheumatologist rheumatology; rheumatic diseases conditions and allergies surgeon surgery; surgical operations internist internal medicine; adult health care urologist urology; urologic system, male (except surgery) reproductive system

398 APPENDIX VI RESOURCES

The resources cited in this section offer up-to-date American Academy of Family Physicians treatment and research information. Most have (AAFP) access through written communication, tele- PO Box 11210 phone, and Web sites. As Internet access becomes Shawnee Mission, KS 66207-1210 more available, many organizations find the 913-906-6000 / 800-274-2237 World Wide Web to be the most efficient means www.aafp.org for providing current and varied information. Consequently, some organizations are shifting American Academy of Pediatrics (AAP) their point of contact entirely to their Web sites. 141 Northwest Point Boulevard Though the contact information for these Elk Grove Village, IL 60007-1098 resources is current at the time of The Facts On File 847-434-4000 Encyclopedia of Health and Medicine’s publication, it www.aap.org is subject to change. For additional resource mate- rial, please see the section “Bibliography and Fur- American Board of Medical Specialties (ABMS) ther Reading.” 1007 Church Street, Suite 404 Evanston, IL 60201-5913 GENERAL 847-491-9091 www.abms.org Administration for Children and Families (ACF) US Department of Health and Human Services (HHS) American Medical Association 370 L’Enfant Promenade SW 515 North State Street Washington, DC 20447 Chicago, IL 60610 www.acf.hhs.gov 800-621-8335 www.ama-assn.org Administration on Aging (AoA) US Department of Health and Human Services (HHS) Centers for Medicare & Medicaid Services Washington, DC 20201 (CMS) 202-619-0724 US Department of Health and Human Services (HHS) www.aoa.gov 7500 Security Boulevard Baltimore, MD 21244 Agency for Healthcare Research and Quality 800-MEDICARE (800-633-4227) (AHRQ) TTY: 877-486-2048 US Department of Health and Human Services (HHS) www.cms.hhs.gov Office of Communications and Knowledge Transfer 540 Gaither Road, Suite 2000 ClinicalTrials.gov Rockville, MD 20850 US National Institutes of Health (NIH) www.ahcpr.gov www.clinicaltrials.gov

399 400 Appendix VI

Health Resources and Services Administration National Organization for Rare Disorders (HRSA) (NORD) US Department of Health and Human Services (HHS) 55 Kenosia Avenue, PO Box 1968 Parklawn Building Danbury, CT 06813-1968 5600 Fishers Lane 203-744-0100 Rockville, MD 20857 TDD: 203-797-9590 www.hrsa.gov www.rarediseases.org

Indian Health Service (IHS) Office of the Surgeon General US Department of Health and Human Services US Department of Health and Human Services (HHS) The Reyes Building 5600 Fishers Lane, Room 18066 801 Thompson Avenue, Suite 400 Rockville, MD 20857 Rockville, MD 20852 301-443-4000 www.ihs.gov www.surgeongeneral.gov

National Center for Health Statistics (NCHS) Office on Women’s Health US Centers for Disease Control and Prevention US Department of Health and Human Services (HHS) (CDC) 200 Independence Avenue SW, Room 712E 3311 Toledo Road Washington, DC 20201 Hyattsville, MD 20882 202-690-7650 301-458-4000 / 866-441-NCHS (866-441-6247) www.womenshealth.gov www.cdc.gov/nchs/ US Department of Health and Human Services National Center on Minority Health and Health 200 Independence Avenue SW Disparities (NCMHD) Washington, DC 20201 US National Institutes of Health (NIH) 202-619-0257 / 877-696-6775 6707 Democracy Boulevard, Suite 800, MSC 5465 www.hhs.gov Bethesda, MD 20892-5465 301-402-1366 US Food and Drug Administration (FDA) TTY: 301-451-9532 5600 Fishers Lane www.ncmhd.nih.gov Rockville, MD 20857-0001 888-INFO-FDA (888-463-6332) National Institute on Aging (NIA) www.fda.gov US National Institutes of Health (NIH) Building 31, Room 5C27 US National Institute of Environmental Health 31 Center Drive, MSC 2292 Sciences (NIEHS) Bethesda, MD 20892 PO Box 12233 301-496-1752 Research Triangle Park, NC 27709 TTY: 800-222-4225 919-541-3345 www.nia.nih.gov www.niehs.nih.gov

National Library of Medicine (NLM) US National Institutes of Health (NIH) US National Institutes of Health (NIH) 9000 Rockville Pike 8600 Rockville Pike Bethesda, MD 20892 Bethesda, MD 20894 301-496-4000 301-594-5983 / 888-346-3656 TTY: 301-402-9612 www.nlm.nih.gov www.nih.gov Resources 401

US Social Security Administration (SSA) The Eyes Office of Public Inquiries American Academy of Ophthalmology Windsor Park Building PO Box 7424 6401 Security Boulevard San Francisco, CA 94120 Baltimore, MD 21235 415-561-8500 800-772-1213 www.aao.org www.ssa.gov

VOLUME 1 American Optometric Association 243 North Lindbergh Boulevard The Ear, Nose, Mouth, and Throat St. Louis, MO 63141 314-991-4100 Alexander Graham Bell Association for the www.aoanet.org Deaf and Hard of Hearing (AG Bell) 3417 Volta Place NW Washington, DC 20007-2778 American Society of Ophthalmic Plastic and 202-337-5220 / 866-337-5220 Reconstructive Surgery TTY: 202-337-5221 1133 West Morse Boulevard, #201 www.agbell.org Winter Park, FL 32789 407-647-8839 American Society for Deaf Children (ASDC) www.asoprs.org PO Box 3355 Gettysburg, PA 17325 Lighthouse International 717-334-7922 / 800-942-ASDC (800-942-2732) 111 East 59th Street www.deafchildren.org New York, NY 10022-1202 800-829-0500 American Speech-Language-Hearing www.lighthouse.org Association (ASHA) 10801 Rockville Pike National Eye Institute (NEI) Rockville, MD 20852 US Institutes of Health (NIH) 301-897-5700 / 800-638-8255 2020 Vision Place TTY: 301-897-0157 Bethesda, MD 20892-3655 www.asha.org 301-496-5248 www.nei.nih.gov National Association of the Deaf (NAD) 814 Thayer Avenue, Suite 250 Silver Spring, MD 20910-4500 Prevent Blindness America 301-587-1788 500 East Remington Road TTY: 301-587-1789 Schaumburg, IL 60173 www.nad.org 847-843-2020 / 800-331-2020 www.preventblindness.org National Institute on Deafness and Other Communication Disorders (NIDCD) US National Institutes of Health (NIH) The Integumentary System 31 Center Drive, MSC 2320 American Society for Dermatologic Surgery Bethesda, MD 20892-2320 5550 Meadowbrook Drive, Suite 120 800-241-1044 Rolling Meadows, IL 60008 TTY: 800-241-1055 847-956-0900 www.nidcd.nih.gov asds-net.org 402 Appendix VI

International Pemphigus Foundation International Dyslexia Association The Atrium Plaza, Suite 210 8600 LaSalle Road 828 San Pablo Avenue Chester Building, Suite 382 Albany, CA 94706 Baltimore, MD 21286-2044 510-527-4970 410-296-0232 / 800-ABCD123 (800-222-3123) www.pemphigus.org www.interdys.org

National Organization for Albinism and Learning Disabilities Association of America Hypopigmentation (NOAH) 4156 Library Road, Suite 1 PO Box 959 Pittsburgh, PA 15234-1349 East Hampstead, NH 03826-0959 412-341-1515 603-887-2310 / 800-473-2310 www.ldaamerica.org www.albinism.org

National Pediculosis Association, Inc. Michael J. Fox Foundation for Parkinson’s 50 Kearney Road Research Needham, MA 02494 Grand Central Station 781-449-NITS (781-449-6487) PO Box 4777 www.headlice.org New York, NY 10163 800-708-7644 National Psoriasis Foundation www.michaeljfox.org 6600 Southwest 92nd Avenue, Suite 300 Portland, OR 97223-7195 Multiple Sclerosis Association of America 503-244-7404 / 800-723-9166 (MSAA) www.psoriasis.org 706 Haddonfield Road Cherry Hill, NJ 08002 The Nervous System 856-488-4500 Alzheimer’s Disease Education & Referral www.msaa.com Center (ADEAR) PO Box 8250 National Center for Learning Disabilities Silver Spring, MD 20907-8250 381 Park Avenue South, Suite 1401 800-438-4380 New York, NY 10016 www.alzheimers.org 212-545-7510 / 888-575-7373 www.ld.org American Academy of Neurology 1080 Montreal Avenue National Institute of Neurological Disorders St. Paul, MN 55116 and Stroke (NINDS) 651-695-2717 / 800-879-1960 US Institutes of Health (NIH) American Parkinson Disease Association PO Box 5801 135 Parkinson Avenue Bethesda, MD 20824 Staten Island, NY 10305 301-496-5751 / 800-352-9425 718-981-8001 / 800-223-2732 TTY: 301-468-5981 www.apdaparkinson.org www.ninds.nih.gov

Huntington’s Disease Society of America National Multiple Sclerosis Society 505 Eighth Avenue, Suite 902 733 Third Avenue New York, NY 10018 New York, NY 10017 212-242-1968 / 800-345-HDSA (800-345-4372) 800-FIGHT-MS (800-344-4867) www.hdsa.org www.nationalmssociety.org Resources 403

National Parkinson Foundation TTY: 301-565-2966 1501 Northwest 9th Avenue/Bob Hope Road www.niams.nih.gov Miami, FL 33136-1494 00-327-4545 National Institute of Dental and Craniofacial www.parkinson.org Research (NIDCR) US National Institutes of Health (NIH) Parkinson’s Disease Foundation 45 Center Drive, Room 4AS19, MSC 6400 1359 Broadway, Suite 1509 Bethesda, MD 20892-6400 New York, NY 10018 301-496-4261 212-923-4700 / 800-457-6676 www.nidcr.nih.gov www.pdf.org National Osteoporosis Foundation 1232 Twenty-second Street NW United Cerebral Palsy Washington, DC 20037-1292 1660 L Street NW, Suite 700 202-223-2226 Washington, DC 20036 www.nof.org 202-776-0406 / 800-872-5827 TTY: 202-973-7197 Pain and Pain Management www.ucp.org American Chronic Pain Association (ACPA) PO Box 850 The Musculoskeletal System Rocklin, CA 95677-0850 American Association of Orthopaedic Surgeons 916-632-0922 / 800-533-3231 (AAOS) www.theacpa.org 6300 North River Road Rosemont, IL 60018-4262 American Council for Headache Education 847-823-7186 / 800-346-AAOS (800-346-2267) 19 Mantua Road www.aaos.org Mt. Royal, NJ 08061 856-423-0258 / 800-255-ACHE (800-255-2243) www.achenet.org Arthritis Foundation 1330 West Peachtree Street, Suite 100 American Pain Foundation Atlanta, GA 30309 201 North Charles Street 404-872-7100 Suite 710 800-568-4045 Baltimore, MD 21201 www.arthritis.org 888-615-PAIN (888-615-7246) www.painfoundation.org Muscular Dystrophy Association (MDA) 3300 East Sunrise Drive National Chronic Pain Outreach Association Tucson, AZ 85718 (NCPOA) 800-FIGHT-MD (800-344-4863) PO Box 274 www.mdausa.org Millboro, VA 24460 540-862-9437 National Institute of Arthritis and www.chronicpain.org Musculoskeletal and Skin Diseases (NIAMS) Information Clearinghouse National Foundation for the Treatment of Pain US National Institutes of Health (NIH) PO Box 70045 1 AMS Circle Houston, TX 77270 Bethesda, MD 20892-3675 713-862-9332 301-495-4484 / 877-226-4267 www.paincare.org 404 Appendix VI

National Headache Foundation The Pulmonary System 820 North Orleans, Suite 217 American Lung Association/American Thoracic Chicago, IL 60610-3132 Society 773-388-6399 / 888-NHF-5552 (888-643-5552) 1740 Broadway www.headaches.org New York, NY 10019-4374 800-LUNG-USA VOLUME 2 www.lungusa.org

The Cardiovascular System The Immune System and Allergies American College of Cardiology Allergy and Asthma Network/Mothers of Heart House Asthmatics, Inc. 9111 Old Georgetown Road 3554 Chain Bridge Road, Suite 2000 Bethesda, MD 20814-1699 Fairfax, VA 22030 301-897-5400 / 800-253-4636, ext. 694 800-878-4403 www.acc.org www.podi.com/health/aanma

American Heart Association American Academy of Allergy, Asthma and 7272 Greenville Center Immunology Dallas, TX 75231 611 East Wells Street 800-AHA-USA1 (800-242-8721) Milwaukee, WI 53202 www.americanheart.org 800-822-ASMA www.aaaai.org American Stroke Association 7272 Greenville Avenue Dallas, TX 75231 American College of Allergy, Asthma and 888-4STROKE (888-478-7653) Immunology www.strokeassociation.org 85 West Algonquin Road, Suite 550 Arlington Heights, IL 60005 The Mended Hearts, Inc. 800-842-7777 7272 Greenville Avenue www.allergy.mcg.edu Dallas TX 75321 214-706-1442 / 888-HEART99 (888-432-7899) American College of Rheumatology www.mendedhearts.org 1800 Century Place, Suite 250 Atlanta, GA 30345 The Blood and Lymph 404-633-3777 American Association of Blood Banks (AABB ) www.rheumatology.org 8101 Glenbrook Road Bethesda, MD 20814-2749 Asthma and Allergy Foundation of America 301-907-6977 1125 Fifteenth Street NW, Suite 502 www.aabb.org Washington, DC 20036 202-466-7643 / 800-7ASTHMA National Heart, Lung, and Blood Institute www.aafa.org (NHLBI) Health Information Center National Institutes of Health Food Allergy and Anaphylaxis Network PO Box 30105 10400 Eaton Place, Suite 107 Bethesda, MD 20824-0105 Fairfax, VA 22030 301-592-8573 800-929-4040 www.nhlbi.nih.gov www.foodallergy.org Resources 405

JAMA Asthma Information Center 800-4-CANCER (800-422-6237) American Medical Association www.cancer.gov 515 North State Street Chicago, IL 60610 National Comprehensive Cancer Network www.ama-assn.org/asthma (NCCN) 500 Old York Road, Suite 250 Lupus Foundation of America, Inc. Jenkintown, PA 19046 2000 L Street NW, Suite 710 215-690-0300 / 888-909-NCCN (888-909-6226) Washington, DC 20036 www.nccn.org 202-349-1155 / 800-558-0121 www.lupus.org VOLUME 3

Parents of Asthmatic/Allergic Children The Gastrointestinal System 1412 Marathon Drive Ft. Collins, CO 80524 American College of Gastroenterology (ACG) 303-842-7395 PO Box 342260 Bethesda, MD 20827-2260 Scleroderma Foundation 301-263-9000 12 Kent Way, Suite 101 www.acg.gi.org Byfield, MA 01922 800-722-4673 American Gastroenterological Association www.scleroderma.org (AGA) 4930 Del Ray Avenue Sjögren’s Syndrome Foundation Bethesda, MD 20814 366 North Broadway 301-654-2055 Jericho, NY 11753 www.gastro.org 516-933-6365 / 800-475-6473 www.sjogrens.org National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) US National Institutes of Health (NIH) Infectious Diseases Office of Communications and Public Liaison National Institute of Allergy and Infectious Building 31, Room 9A04 Diseases (NIAID) 31 Center Drive, MSC 2560 US National Institutes of Health Bethesda, MD 20892-2560 Bethesda, MD 20892 www.niddk.nih.gov www.niaid.nih.gov The Endocrine System Cancer American Diabetes Association American Cancer Society (ACS) National Call Center 1599 Clifton Road NE 1701 North Beauregard Street Atlanta, GA 30329 Alexandria, VA 22311 800-ACS.2345 (800-227-2345) 800-DIABETES (800-342-2383) www.cancer.org www.diabetes.org

National Cancer Institute (NCI) American Thyroid Association US National Institutes of Health (NIH) 6066 Leesburg Pike, Suite 500 NCI Public Inquiries Office Falls Church, VA 22041 6116 Executive Boulevard, Room 3036A 703-998-8890 / 800-THYROID (800-849-7643) Bethesda, MD 20892-8322 www.thyroid.org 406 Appendix VI

National Diabetes Education Program Rockville, MD 20847 One Diabetes Way 800-370-2843 Bethesda, MD 20814-9692 TTY: 888-320-6942 301-496-3583 www.nichd.nih.gov www.ndep.nih.gov National Women’s Health Information Center The Urinary System US Department of Health and Human Services (HHS) National Kidney Foundation Office on Women’s Health 30 East 33rd Street 800-994-9662 New York NY 10016 TTD: 888-220-5446 800-622-9010 www.4women.gov www.kidney.org North American Menopause Society The Reproductive System 5900 Landerbrook Drive, Suite 195 Alan Guttmacher Institute (AGI) Mayfield Heights, OH 44124 120 Wall Street, 21st Floor 440-442-7550 New York, NY 10005 www.menopause.org 212-248-1111 800-355-0244 Planned Parenthood Federation of America www.agi-usa.org 434 West 33rd Street New York, NY 10001 American College of Obstetricians and 212-541-7800 Gynecologists (ACOG) www.plannedparenthood.org 409 Twelfth Street SW, PO Box 96920 Washington, DC 20090-6920 Psychiatric Disorders and Psychologic Conditions www.acog.org American Academy of Child and Adolescent Psychiatry (AACAP) Kinsey Institute for Research in Sex, Gender, 3615 Wisconsin Avenue NW and Reproduction Washington, DC 20016-3007 Morrison 313, Indiana University 202-966-7300 Bloomington, IN 47405 www.aacap.org 812-855-7686 www.kinseyinstitute.org American Psychiatric Association (APA) 1000 Wilson Boulevard, Suite 1825 La Leche League International Arlington, VA 22209 1400 North Meacham Road 703-907-7300 Schaumburg, IL www.healthyminds.org 847-519-7730 www.lalecheleague.org Depression and Bipolar Support Alliance (DBSA) March of Dimes 730 North Franklin Street, Suite 501 1275 Mamaroneck Avenue Chicago, IL 60610-7224 White Plains, NY 10605 800-826-3632 www.marchofdimes.com www.dbsalliance.org

National Institute of Child Health and Human National Alliance for the Mentally Ill (NAMI) Development (NICHD) Colonial Place Three US National Institutes of Health (NIH) 2107 Wilson Boulevard, Suite 300 PO Box 3006 Arlington, VA 22201-3042 Resources 407

800-950-NAMI (6264) Cincinnati, OH 45226 www.nami.org 800-356-4674 www.cdc.gov/niosh National Institute of Mental Health (NIMH) US National Institutes of Health (NIH) National Safety Council Public Information and Communications 1121 Spring Lake Drive 6001 Executive Boulevard, Room 8184, MSC 9663 Itasca, IL 60143-3201 Bethesda, MD 20892-9663 630-285-1121 301-443-4513 / 866-615-6464 www.nsc.org TTY: 301-443-8431 / 866-415-8051 www.nimh.nih.gov Occupational Safety & Health Administration (OSHA) National Mental Health Association (NMHA) US Department of Labor 2001 North Beauregard Street, 12th Floor 200 Constitution Avenue Alexandria, VA 22311 Washington DC 20210 800-969-NMHA (6642) 202-693-1999 / 800-321-OSHA (6742) www.nmha.org www.osha.gov

VOLUME 4 US Centers for Disease Control and Prevention (CDC) Preventive Medicine 1600 Clifton Road Agency for Toxic Substances and Disease Atlanta, GA 30333 Registry (ATSDR) 404-639-3534 / 800-311-3435 Division of Toxicology www.cdc.gov US Centers for Disease Control and Prevention (CDC) US Environmental Protection Agency (EPA) 1600 Clifton Road NE, Mailstop F-32 Ariel Rios Building Atlanta, GA 30333 1200 Pennsylvania Avenue NW 888-42-ATSDR (888-422-8737) Washington, DC 20460 www.atsdr.cdc.gov 202-272-0167 www.epa.gov Healthy People 2010 www.healthypeople.gov Alternative and Complementary Approaches National Center for Injury Prevention and American Association of Naturopathic Control Physicians (AANP) US Centers for Disease Control and Prevention 3201 New Mexico Avenue NW #350 (CDC) Washington, DC 20016 4770 Buford Highway NE, Mailstop K65 202-895-1392 / 866-538-2267 Atlanta, GA 30341-3724 www.naturopathic.org 770-488-1506 www.cdc.gov/ncipc National Center for Complementary and Alternative Medicine (NCCAM) National Institute for Occupational Safety and NCCAM Clearinghouse Health (NIOSH) PO Box 7923 US Centers for Disease Control and Prevention Gaithersburg, MD 20898 (CDC) 888-644-6226 4676 Columbia Parkway TTY: 866-464-3615 Mail Stop C-18 www.nccam.nih.gov 408 Appendix VI

Genetics and Molecular Medicine Indianapolis, IN 46202-3233 National Human Genome Research Institute 317-637-9200 (NHGRI) www.acsm.org US National Institutes of Health (NIH) Building 31, Room 4B09 President’s Council on Physical Fitness and 31 Center Drive, MSC 2152 Sports 9000 Rockville Pike US Department of Health and Human Services (HHS) Bethesda, MD 20892-2152 Department W 301-402-0911 200 Independence Avenue SW, Room 738-H www.genome.gov Washington, DC 20201-0004 202-690-9000 National Institute of General Medical Sciences www.fitness.gov (NIGMS) Human Relations US National Institutes of Health (NIH) 45 Center Drive, MSC 6200 APA Lesbian, Gay, and Bisexual Concerns Bethesda, MD 20892-6200 Program 301-496-7301 American Psychiatric Association www.nigms.nih.gov 750 First Street NE Washington, DC 20002 United Mitochondrial Disease Foundation 202-336-6050 8085 Saltsburg Road, Suite 201 www.apa.org/pi/lgbc/ Pittsburgh, PA 15239 412-793-8077 National Gay and Lesbian Task Force www.umdf.org 2320 Seventeenth Street Washington, DC 20009 Drugs 202-332-6483 National Council on Patient Information and www.thetaskforce.org Education (NCPIE) 4915 Saint Elmo Avenue, Suite 505 Parents, Families and Friends of Lesbians and Bethesda, MD 20814-6082 Gays (PFLAG) 301-656-8565 1726 M Street NW, Suite 400 www.talkaboutrx.org Washington, DC 20036 202-467-8180 Nutrition and Diet www.pflag.org American Dietetic Association 216 West Jackson Boulevard Sexuality Information and Education Council Chicago, IL 60606-6995 of the United States (SIECUS) 800-877-1600 130 West 42nd Street, Suite 350 www.eatright.org New York, NY 10036 212-819-9770 US Department of Agriculture (USDA) www.siecus.org 1400 Independence Avenue SW Washington DC 20250 Surgery www.usda.gov American Academy of Cosmetic Surgery 737 North Michigan Avenue, Suite 2100 Fitness: Exercise and Health Chicago, IL 60611-5405 American College of Sports Medicine (ACSM) 312-981-6760 401 West Michigan Street www.cosmeticsurgery.org Resources 409

American Academy of Facial Plastic and Substance Abuse Reconstructive Surgery (AAFPRS) National Council on Alcoholism and Drug 310 South Henry Street Dependence, Inc. Alexandria, VA 22314 22 Cortlandt Street, Suite 801 703-299-9291 / 800-332-FACE (800-332-3223) New York, NY 10007-3128 www.aafprs.org 212-269-7797 www.ncadd.org Lifestyle Variables: Smoking and Obesity American Obesity Association National Institute on Alcohol Abuse and 1250 Twenty-fourth Street NW, Suite 300 Alcoholism (NIAAA) Washington, DC 20037 US National Institutes of Health (NIH) 202-776-7711 5635 Fishers Lane, MSC 9304 www.obesity.org Bethesda, MD 20892-9304 www.niaaa.nih.gov SmokeFree.gov A Web-based partnership of the American Cancer Society National Institute on Drug Abuse (NIDA) (ACS), CDC Office on Smoking and Health, and the US National Institutes of Health (NIH) National Cancer Institute (NCI). 6001 Executive Boulevard, Room 5213 800-QUITNOW (800-784-8669) Bethesda, MD 20892-9561 TTY: 800-332-8615 301-443-1124 www.smokefree.gov www.nida.nih.gov

Tobacco Control Research Branch Substance Abuse and Mental Health Services NCI Division of Cancer Control and Population Administration Sciences National Cancer Institute US Department of Health and Human Services (HHS) US National Institutes of Health (NIH) 1 Choke Cherry Road 6130 Executive Boulevard, Room 6134 Room 8-1036 Executive Plaza North Rockville, MD 20857 Rockville, MD 20852 crisis hotline: 800-273-8255 301-594-6776 TTY crisis hotline: 800-799-4889 www.tobaccocontrol.cancer.gov www.samhsa.gov

Tobacco Information and Prevention Source (TIPS) Emergency and First Aid Office on Smoking and Health (OSH) American Red Cross National Center for Chronic Disease Prevention and 2025 East Street NW Health Promotion Washington, DC 20006 US Centers for Disease Control and Prevention (CDC) 202-303-4498 www.cdc.gov/tobacco/index.htm www.redcross.org APPENDIX VII BIOGRAPHIES OF NOTABLE PERSONALITIES

Auenbrugger, [Josef] Leopold (1722–1809) heart transplant operation in 1967. Barnard trans- Austrian physician, also known as Leopold von planted the heart of a young woman who Auenbrugg, who developed chest percussion as a received fatal injuries in an auto accident, Denise diagnostic method. Auenbrugger recognized that Darvall, into the chest of Louis Washkansky, a 55- fluid accumulations in the tissues changed the year-old dentist in the end stages of heart failure. densities of the structures and consequently their Washkansky lived only 18 days with his new tonal qualities. The method became a mainstay of heart before dying of pneumonia; however, by the diagnosis for cardiomyopathy (enlargement of the 1990s heart transplantation became the standard heart characteristic of heart failure) and lung con- of care for end-stage heart failure. During his ditions such as pulmonary edema, pneumonia, career Barnard pioneered numerous surgical tech- and tuberculosis. niques and devices for heart surgery. Avicenna (980–1037) Persian physician and Beaumont, William (1785–1853) US Army philosopher, also known as Ibn Sina, who earned surgeon who studied the workings of the stomach recognition and fame before he turned 20 for his through a healed gunshot wound that left an gifts as a healer. Among Avicenna’s numerous opening into the stomach of his patient Alexis St. writings was The Canon of Medicine (Canticum de Martin. Beaumont used the opening to observe medicina), 14 volumes that covered health, dis- the processes of the stomach’s stages of digestion. ease, treatment, and prevention. The Canon of Med- Beaumont collected samples of “gastric juices” icine was a primary medical text throughout and analyzed them, discovering the chemical Europe from the 11th to the 17th century. composition of stomach acid to be primarily Axelrod, Julius (1912–2004) American hydrochloric acid. Beaumont detailed his experi- research scientist who discovered the reuptake ments and findings in his book Experiments and process of the brain neurotransmitters epineph- Observations on the Gastric Juice and the Physiology of rine and norepinephrine, work for which he Digestion published in 1833. received a share of the Nobel Prize for Physiology Bernard, Claude (1813–1878) French physi- or Medicine in 1970. Axelrod also conducted key ologist who studied and documented numerous research of the pineal gland, contributing to dimensions of human physiology, key among understanding of the hormone melatonin, and of them the functions of the pancreas in digestion analgesic medications (pain relievers), contribut- and the discovery of vasomotor nerves (nerves ing to the discovery of acetaminophen. that cause blood vessels to dilate or constrict). Banting, Frederick (1891–1941) Canadian Bernard’s most significant postulation was that physician and researcher who, with medical stu- the interior environment of the human body dent Charles Best and physician John Macleod, remained stable relative to the external environ- discovered insulin and its connection to diabetes. ment. This postulation became the foundation for Banting and Macleod shared the Nobel Prize in the contemporary concept of homeostasis. Physiology or Medicine in 1923 for this discovery. Best, Charles (1899–1978) Canadian medical Barnard, Christiaan (1922–2001) South student whose work with physician Frederick African surgeon who performed the first human Banting resulted in the discovery of insulin. 410 Biographies of Notable Personalities 411

Though Best did not receive a share of the Nobel Chain, Ernst (1906–1979) German-born bio- Prize in Physiology or Medicine in 1923 awarded chemist who shared the Nobel Prize in Physiology to Banting and another collaborator, John or Medicine in 1945 with Alexander Fleming and Macleod, Banting protested and shared his portion Howard Florey. The award honored the work of of the award money with Best. Best pursued a the three in the discovery and uses of penicillin. career in medical research that resulted in numer- Chain developed methods to analyze natural anti- ous other honors including induction into the bacterial substances and discovered the process by Canadian Medical Hall of Fame. which penicillin killed bacteria. Blackwell, Elizabeth (1821–1910) First Charcot, Jean Martin (1825–1893) French woman to earn a medical degree from an Ameri- physician who identified multiple sclerosis. can medical school. Blackwell was born in Eng- Cooley, Denton (b. 1920) American cardio- land and came with her family to the United vascular surgeon renowned for his skill and inno- States in 1832. She graduated with a doctor of vation in operations on the heart. As an intern medicine degree from Geneva Medical College in Cooley assisted pediatric heart surgeon Alfred New York in 1849. Though she wanted to become Blalock in the first operation to correct a congeni- a surgeon, an infection that cost her the vision in tal heart malformation (“blue baby” syndrome). one eye forced her to change direction to special- Cooley spent much of his surgical career perfect- ize in obstetrics and gynecology. Blackwell ing techniques that would extend the ability to founded the New York Infirmary for Women and surgically repair such defects. He was one of the Children in 1857 and 10 years later opened an first American cardiovascular surgeons to perform affiliated medical school for women. During her a human heart transplantation (in 1968) and to career Blackwell wrote several influential medical implant an artificial heart as a bridge to transplan- texts about women’s health and diseases. tation (in 1969). Cooley also pioneered and per- Blalock, Alfred (1899–1964) American heart fected coronary artery bypass graft (CABG). surgeon who pioneered numerous techniques, Crick, Francis (1916–2004) British scientist devices, and instruments to repair congenital who co-discovered, with American zoologist heart defects. Blalock’s interest in the heart came James Watson, the structure of DNA in 1953. about as a result of his research to investigate and Crick and Watson, along with biophysicist Mau- find treatments for cardiovascular shock. Blalock rice Wilkins, received the Nobel Prize in Physiol- and his assistant, Vivien Thomas, subsequently ogy or Medicine in 1962 for the discovery. Crick turned their interest and methods to create surgi- devoted the remainder of his research career to cal repairs for otherwise fatal “blue baby” heart studies of protein synthesis and genetic code. defects, notably tetralogy of Fallot. Blalock per- de Graaf, Regnier (1641–1673) Dutch formed the first successful such operation in 1944 anatomist who published the first detailed studies on a patient of pediatrician Helen Taussig. of the male and female reproductive systems. The Blalock’s collaborations with other researchers egg-bearing follicles on the ovaries, which de resulted in operations for coarctation of the aorta Graaf identified and described, are called Graafian and transposition of the great arteries, two other follicles. severe congenital heart defects. de Luzzi, Mondinus (1275–1326) Italian Broca, Pierre Paul (1824–1880) French surgi- anatomist whose book Anathomia, published in cal pathologist and medical researcher best known 1316, was the first detailed textbook of anatomy for his study of brain anatomy and physiology. of what medical historians consider modern West- Broca identified the region of the brain’s frontal ern medicine. Though heavily framed within the lobe that controls speech, now known as Broca’s teachings of Galen, Anathomia presented de Luzzi’s area. Broca also studied correlations between observations from the numerous autopsies he per- brain structure and intelligence, developing formed as a professor at Bologna. numerous methods for measuring the convolu- DeVries, William (b. 1943) American heart tions and size of human and other primate brains, surgeon best known for implanting the first artifi- and was a prolific writer. cial heart into retired dentist Barney Clark in 412 Appendix VII

1982, an experimental procedure that unfolded in Florey, Howard Walter (1898–1968) Aus- full public scrutiny via television. People around tralian research pathologist whose work to investi- the world were simultaneously captivated and gate the actions of penicillin earned him a share of repulsed during the four months Clark survived the Nobel Prize in Physiology or Medicine in 1945, with the device in his chest attached by six feet of with Alexander Fleming and Ernest Chain. Florey tubing to an external and noisy pump the size of a worked to produce large quantities of penicillin for washing machine. DeVries worked closely with use as an antibiotic at the end of World War II. He Robert Jarvik, the pump’s designer, and physician- co-authored numerous books during his career. inventor Willem Kolff, on the mechanical heart’s Freud, Sigmund (1856–1939) Austrian psy- design. After Clark, DeVries implanted mechanical chiatrist who developed the method of psycho- hearts into four other people. DeVries retired from analysis. As a physician Freud specialized in cardiovascular surgery in 1999. emotional disorders, such as neurosis, and became Ehrlich, Paul (1854–1915) German bacteriolo- intrigued with the nature of the unconscious gist and physician whose extensive research on mind. He studied dreams, forgetfulness, and inad- immunity resulted in developing salvarsan, the vertent comments (“Freudian slips”)—all of which first successful treatment for syphilis, and earned he perceived as insights into the workings of the him the Nobel Prize for Physiology or Medicine in mind. Freud also correlated much of the mind’s 1908. Ehrlich’s studies of cell structure and func- functions with sexuality. Freud wrote extensively tion later became the foundation of chemotherapy of his findings and theories, some of which remain as a treatment for cancer. controversial and highly debated even today. Einthoven, Willem (1860–1927) Dutch physi- However, Freud remains the founder of psychia- cian and scientist whose penultimate achievement try, and his work continues to provide insights for was the development of the electrocardiogram medical researchers interested in understanding (ECG) in 1903. The importance of this device for the link between body and mind. measuring and visually representing the electrical Galen, Claudius (129–199) A physician and activity of the heart became apparent over the philosopher, also called Galen of Pergamum, next two decades. Einthoven received the Nobel whose observations and study of the human body Prize in Physiology or Medicine in 1924 to honor framed the practice of medicine until the Middle the discovery. Ages. Galen drew much of his information from Elion, Gertrude (1918–1999) American dissections of animals such as pigs and apes, how- chemist who developed the first chemotherapy ever, which resulted in some fundamental errors agents successful in treating childhood leukemia, in understanding of human anatomy and physiol- an achievement for which she received the Nobel ogy. Galen also embraced the premise of the four Prize in Physiology or Medicine in 1988 (shared humors (blood, phlegm, yellow bile, and black with her collaborator, chemist George H. Hitch- bile), in which illness and disease resulted from ings, and chemist James W. Black who won for his imbalances among these vital substances. work to develop beta blockers and histamine H2 Gibbon, John H. Jr. (1904–1973) American blockers). Elion developed other drugs that, physician and thoracic surgeon who developed although ineffective as treatments for leukemia, the cardiopulmonary bypass machine, the first became therapies for immunosuppression (aza- successful use of which took place in 1953. Gib- thioprine) and gout (allopurinol). bon continued to perfect the design and methods Fleming, Alexander (1881–1955) Scottish for using cardiopulmonary bypass, making possi- bacteriologist credited with the discovery of peni- ble the many advances in surgical operations on cillin and its actions to kill pathogenic microbes. the heart that occurred through the latter half of Fleming shared, with Ernest Chain and Howard the 20th century. Florey, the Nobel Prize in Physiology or Medicine Gray, Henry (1825–1861) English physician, in 1945 for his work with penicillin. Fleming anatomist, and physiologist best known for his devoted his career to the study of antisepsis and landmark work Gray’s Anatomy. This extraordinary wrote prodigiously of his work. detailed description of the human body’s structure Biographies of Notable Personalities 413 and function was first published in 1864 and though his writings did not emerge into the main- remains the standard text today for medical stu- stream of Western medicine for several centuries dents and other students of the medical arts. Gray because there was little contact between East and taught at St. George’s Hospital Medical School in West during his lifetime. London and originally produced his anatomy book Ingrassias, Giovanni (1510–1580) Italian to serve as a textbook for his students. physician and anatomist who identified the small- Hales, Stephen (1677–1761) English physiol- est bone in the body, the inner ear’s stapes, and a ogist who developed a method for measuring arte- pair of small bones at the back of the eye socket rial blood pressure. Hales’s method required that bear his name, the processes of Ingrassias. inserting a glass tube into an artery and measuring Jarvik, Robert (b. 1946) American physician the level to which blood rose within it. Though and researcher who developed a series of mechani- this method was not practical from a clinical per- cal hearts in the 1970s and 1980s. In the first oper- spective, doctors soon realized the value of blood ation of its kind cardiac surgeon William DeVries pressure as a diagnostic marker and researchers implanted a Jarvik-7 mechanical heart (which developed less intrusive methods for its measure- Jarvik developed in collaboration with heart sur- ment. Hales also conducted the first measure of a geon Willem Kolff) into retired dentist Barney heart’s capacity by filling the chambers of a freshly Clark in 1982. Though heart surgeons eventually slaughtered sheep’s heart with molten wax. implanted Jarvik-7 mechanical hearts into about Hall, Marshall (1790–1857) English physician six dozen people, complications were extensive and who discovered capillaries and their role in blood quality of life was poor. In 1990 the US Food and circulation. Hall also developed the first method of Drug Administration (FDA) withdrew approval for resuscitation for drowning victims. human use of the mechanical heart. Harvey, William (1578–1657) English physi- Jenner, Edward (1749–1823) British physi- cian who determined the flow of blood through the cian who developed the smallpox vaccine and the body’s circulation to be a closed system, with the process of vaccination in 1796. A country doctor heart and lungs at its core. Harvey broke with the in rural England, Jenner observed that dairymaids Galenic understanding that defined medical knowl- who recovered from cowpox infection did not edge at the time, testing his theories extensively again get the disease and furthermore did not get before releasing them in the 1628 manuscript that smallpox, a deadly or disfiguring infection that profoundly changed understanding of the human researchers later identified as being caused by a body: Exercitatio Anatomica de Motu Cordis et Sanguinis related virus. At the time the process for inducing in Animalibus (An Anatomical Exercise on the Motion of immunity to smallpox, called variolation, was the Heart and Blood in Animals). nearly as hazardous as the disease itself. Jenner Havers, Clopton (1650–1701) English physi- instead variolated people with cowpox, a milder cian and physiologist who was the first to docu- disease. This form of vaccination rapidly replaced ment detailed microscopic descriptions of the variolation and became mandatory in England, tubular structure of compact bone, now known as significantly reducing smallpox infection and lead- the Haversian system. ing to improved vaccination methods that would Hippocrates (460–400 B.C.E.) Greek physician eventually eradicate smallpox worldwide. widely credited with establishing the tenets of Jerne, Niels (1911–1994) Danish immunolo- modern medicine. A keen observer, Hippocrates gist who proposed the theories that led to the developed numerous diagnostic and therapeutic development of methods to produce monoclonal methods and the philosophy that the physician antibodies (MAbs), specifically targeted immune “first and foremost, do no further harm” when substances now used as treatment for certain can- treating patients. Hippocrates advanced the prem- cers and other diseases. Jerne received a share of ise of treating the body as a whole rather than iso- the Nobel Prize in Physiology or Medicine in 1984 lating and treating its symptoms. for his work. Ibn Al-Nafis (1213–1288) Islamic physician Julian, Percy (1899–1975) African American who discovered the circulation of the blood, research chemist who developed a method to syn- 414 Appendix VII thesize (create in the laboratory) cortisone, a nat- types. The discovery earned Landsteiner the 1930 ural hormone of the adrenal glands. Julian’s Nobel Prize for Physiology or Medicine. methods also made possible the synthesis of other Lister, Joseph (1827–1912) British surgeon hormones for therapeutic applications, such as responsible for implementing methods of antisep- oral contraceptives (birth control pills) and sis to prevent infection during and after surgical immunosuppressive drugs. operations. Lister built on the foundations that Jung, Carl (1875–1961) Swiss psychiatrist, Louis Pasteur’s work established, implementing a once a protégé of Austrian psychiatrist Sigmund routine of cleaning surgical and traumatic wounds Freud, who developed a theory of personality with carbolic acid to kill any bacteria present. He based on the premise of a collective unconscious, also applied antiseptic methods to cleaning surgi- a pool of inborn recognitions and experiences. The cal instruments and maintaining a clean operating collective unconscious, in Jung’s view, explained field, turning surgery from an approach of last commonalities across human populations in resort to a successful therapeutic method. dreams, mythology, and religion. Jung identified Macleod, John James Richard (1876–1935) these commonalities as archetypes, which he Co-discoverer, with Frederick Banting and Charles defined as unlearned experiences. Best, of insulin. Macleod and Banting won the Koch, [Heinrich Herman] Robert Nobel Prize in Physiology or Medicine in 1923 for (1843–1910) German bacteriologist who discov- their research. While Banting shared his Nobel ered the pathogenic nature of bacteria and the Prize money with Charles Best, whom he felt was bacterium responsible for causing tuberculosis. slighted in being not similarly honored, Macleod Koch received the Nobel Prize in Physiology or shared his with the young chemist James Bertram Medicine in 1905 for his work in understanding (J.B.) Collip, who had acquired a steady supply of the infectious mechanisms of tuberculosis. Koch insulin for the team’s research. made further numerous contributions to the dis- Maimonides, Moses (1135–1204) Jewish covery of the role of pathogenic microbes and dis- physician and rabbi, also known as Moshe ben ease. Maimon, who was the first of four generations of Kolff, Willem J. (b. 1911) Physician and med- his family to serve as court physician for the sul- ical inventor who founded the first European tans of Egypt. Maimonides established a practice blood bank during World War II and developed of medicine that integrated body, mind, and spirit, the first artificial kidney a few years later. A pio- blending the most advanced scientific knowledge neer in devices for the heart, Kolff devised an of his time with meditation and prayer. implantable mechanical heart in 1955 and an Paré, Ambroise (1510–1590) French battle- intra-aortic balloon pump in 1957. In the 1970s field surgeon considered the father of trauma sur- and 1980s Kolff collaborated with Robert Jarvik to gery. Paré developed numerous techniques for develop a series of mechanical hearts. Heart sur- rapid and humane treatment with an orientation geon William DeVries implanted one model, the toward eventual recovery and return to productiv- Jarvik-7, into the chest of retired dentist Barney ity through the use of prosthetic limbs and other Clark in 1982. Clark lived for four months on the devices. Paré served as court surgeon to four artificial heart. Kolff also developed a portable kid- French kings. ney dialysis unit. Pasteur, Louis (1822–1895) French bio- Laënnec, René (1781–1826) French physician chemist who recognized that pathogenic microbes, who invented the stethoscope to listen to the notably bacteria, caused infection. Pasteur devel- heart and lungs. Laënnec’s early stethoscopes oped what became known as the germ theory of were straight tubes carved of wood. Later models disease, establishing an understanding of the incorporated brass fittings to better hear certain causes of infection fundamental to developing ranges of sounds. methods for treating and preventing infection. Landsteiner, Karl (1868–1943) Austrian sci- Pasteur’s work became the foundation for antisep- entist who discovered the antigens on the surfaces sis, vaccination, and pasteurization, all methods of blood cells that led to the identification of blood for preventing infection. Pasteur further discov- Biographies of Notable Personalities 415 ered the bacterial cause of rabies and developed culosis infection. In the latter years of her medical the first vaccine to prevent the fatal infection in career Sabin turned her efforts to public health in dogs, the primary source of rabies in his time, as her home state of Colorado. well as in people bitten by rabid dogs. Salk, Jonas (1914–1995) American physician Pavlov, Ivan (1849–1936) Russian scientist who developed the first polio vaccine, released in best known for his research on conditioned 1955 after eight years of research. Polio vaccina- reflexes, in which he trained dogs to expect food tion has eradicated poliomyelitis, once one of the when he rang a bell. Pavlov observed that after a most debilitating and often fatal infections, from time the dogs began to salivate when they heard much of the world. the bell ring, altering the body’s normal physio- Semmelweis, Ignaz Philipp (1818–1861) logic response to salivate at the sight and smell of Hungarian physician who recognized the connec- food. Pavlov also used surgical gastric fistulas in tion between puerperal fever (childbirth fever) dogs (operations to create openings into the stom- and the then-common practice physicians fol- ach) to study the physiology of digestion, research lowed of moving between autopsies on women for which he won the 1904 Nobel Prize in Physiol- who died and women who had just given birth. ogy or Medicine. Semmelweis implemented stringent antisepsis Piaget, Jean (1896–1980) Swiss psychologist procedures at the hospital where he worked, who developed numerous theories about human requiring physicians to wash their hands with intelligence, the foundation of which centered chlorinated lime before examining patients. As a around his belief of intelligence as a process of result the death rate dropped to nearly zero. adaptation within genetically defined frameworks. Though the established medical community was Piaget defined this process through four stages slow to embrace this revolutionary change, anti- beginning at birth and culminating in adolescence, septic hand washing eventually became standard with completion of one stage crucial to entering practice. the next. Soper, Fred (1893–1977) American epidemi- Prusiner, Stanley (b. 1942) American neurol- ologist who organized vector-eradication programs ogist and biochemist who discovered prions, infec- worldwide to eliminate diseases such as malaria, tious protein fragments that cause progressive, yellow fever, and hookworm infestation. degenerative brain diseases such as kuru disease, Taussig, Helen (1898–1986) American pedia- Creutzfeldt-Jakob disease (CJD), and variant CJD trician and cardiologist who worked with heart (vCJD) arising from infection with bovine spongi- surgeon Alfred Blalock and surgical researcher form encephalopathy (BSE; commonly called mad Vivien Thomas to develop an operation to correct cow disease). Prusiner received the Nobel Prize in severe congenital defects of the heart. The first Physiology or Medicine in 1997 for his discovery such operation, the Blalock-Taussig procedure, and work in understanding the infectious mecha- was a shunt that restored the flow of blood nisms of prions. through the lungs in defects such as tetralogy of Roëntgen, Wilhelm (1845–1923) German Fallot. Taussig overcame a severe hearing loss suf- physicist who discovered X-rays and the process fered in childhood as well as bias that prevented for using them to create images, called women from obtaining medical degrees at most roentgenograms, which revealed internal struc- medical schools in the United States. tures of density such as the bones. Roëntgen Thomas, Vivien (1910–1985) African Ameri- received the Nobel Prize in Physiology or Medi- can researcher who collaborated with heart sur- cine in 1901 for his discoveries. geon Alfred Blalock and pediatrician Helen Taussig Sabin, Florence (1871–1953) American physi- to develop the operative procedures and instru- cian who was the first woman to become a full ments to correct congenital heart defects. Intend- professor at Johns Hopkins Medical School. Sabin ing himself to become a physician, Thomas lost his conducted research that resulted in significant savings in the stock market crash of 1929 that findings about the structure of the brain, fetal ushered in the American Great Depression. By the development of the lymphatic system, and tuber- time he recovered financially, changing educa- 416 Appendix VII tional standards and racial discrimination in com- toxins led to the development of tetanus and bination proved too formidable for Thomas to fol- diphtheria vaccines, established the foundation for low his dream. Blalock nonetheless insisted that serum therapy, and earned the first Nobel Prize for Thomas assist him in the operating room, and Physiology or Medicine awarded in 1901. often Thomas guided Blalock through difficult Waksman, Selman (1888–1973) Biochemist aspects of the operations Thomas devised. who discovered the antibiotic medications strepto- van Leeuwenhoek, Antonie (1632–1723) mycin, the first antibiotic effective for treating Dutch amateur scientist who built his own micro- tuberculosis, and neomycin. Waksman received scopes. His studies were among the earliest to the 1952 Nobel Prize in Physiology or Medicine in detail the structures and functions of blood cells, recognition of his work. bacteria, and sperm. The work of van Leeuwen- Watson, James (b. 1928) American scientist hoek also established the role of bacteria in caus- who co-discovered, in collaboration with British ing illness, providing the foundation for the researcher Francis Crick, the double helix struc- research more than a century later of Robert Koch ture of DNA in 1953. Watson and Crick shared the and Joseph Lister. 1962 Nobel Prize in Physiology or Medicine for Vesalius, Andreas (1514–1564) Flemish their work. Watson conducted much research on anatomist whose book De Humanis Corporis Fabrica the role of RNA in viruses and served as director (On the Workings of the Human Body) was the founda- of the Human Genome Project from 1989 to 1992. tion of human anatomy for centuries. Through a He wrote several books, among them the 1968 friendship with a judge, Vesalius gained access to best-seller Double Helix, which chronicled the dis- the bodies of executed criminals for dissection. covery of DNA. Many of Vesalius’s discoveries contradicted the Yalow, Rosalyn (b. 1921) American physicist teachings of Galen, still popular at the time. Key who developed techniques to use radioisotopes to among them were that the heart had four cham- measure the amount of peptide hormones such as bers, not two as Galen asserted, and that the major insulin in the blood, which are present in very blood vessels arose from the heart, not the liver. small quantities. These techniques became known Vesalius also provided correct and detailed draw- as radioimmunoassays (RIAs) and are today the ings of the gastrointestinal structures. basis for such measurements. Yalow received a von Behring, Emil Adolf (1854–1917) Pruss- share of the Nobel Prize in Physiology or Medicine ian physician whose research on toxins and anti- in 1977 for her work. APPENDIX VIII DIAGNOSTIC IMAGING PROCEDURES

Diagnostic imaging procedures offer noninvasive sense of being closed in. Most often it is necessary approaches for visualizing the structure and func- to change out of regular clothing into a hospital tion of internal organs. Though each procedure gown for the scan, to prevent interference from has specific applications and diagnostic value, doc- objects such as zippers and buttons. A CT scan tors often use procedures in combination with generally takes between 15 minutes and an hour, one another to give detailed information to help depending on the type of images the doctor diagnose health conditions as well as monitor the desires. No recovery is necessary; when the radi- effectiveness of treatment. Some procedures ologist is satisfied with the quality of images, the involve the injection or consumption of radio- person may get dressed and leave. opaque contrast media (special dyes) or radioiso- There is a slight risk of an adverse or allergic topes to create dimensional images. reaction to contrast dye, which is iodine-based. CT The entries in this appendix discuss procedures scan does expose a person to ionizing radiation, that have broad application across body systems though for most procedures the level of exposure and health conditions. Entries for diagnostic imag- is within the established safety boundaries. Fre- ing procedures specific to a particular body system quent CT scans or complex CT scans, such as car- are in the section of The Facts On File Encyclopedia of diac multislice CT (CMCT), result in significantly Health and Medicine that covers that body system. higher exposure, however. It is important to dis- For example, MAMMOGRAM—X-RAY of the breast— cuss the potential risks of such exposure before appears in the section “The Reproductive System” undergoing the procedure. and INTRAVENOUS PYELOGRAM (IVP)—imaging of the Doctors may order CT scans to evaluate STROKE KIDNEYS—appears in the section “The Urinary Sys- and TRAUMATIC BRAIN INJURY (TBI), complex or ques- tem.” tionable BONE fractures, internal masses that could computed tomography (CT) scan A radio- be tumors, and damage to the HEART after HEART logic procedure that uses multiple X-RAY images to ATTACK. Certain surgeries that require extraordi- create multi-dimensional pictures of the structure nary precision, such as operations on the BRAIN of internal organs. The CT scanner takes numer- (for example, THALAMOTOMY and PALLIDOTOMY), ous X-ray “slices” that a computer then assembles may use CT scan to guide the placement of surgi- into an image of the organ or structure. The X-ray cal instruments. tube rotates within the scanner, moving around magnetic resonance imaging (MRI) An area of the body being scanned. A CT scan may be imaging procedure that uses powerful magnetic done with or without contrast media, depending energy to visualize internal organs and structures. on the reason for the procedure. CT scan of the MRI does not involve exposure to radiation. The abdomen may require a bowel prep (laxative or nuclei of hydrogen atoms (a component molecule enema). Most other CT scans do not require any of water) align themselves in a known pattern advance preparation. within the body’s natural magnetic field. The MRI The scan itself is painless, though some people machine emits a strong pulse of electromagnetic may feel claustrophobic when inside the scanner. energy, also called radiofrequency (RF) energy, Some CT scanners are open, which reduces the causing the hydrogen nuclei to temporarily 417 418 Appendix VIII realign themselves. The MRI machine then detects over the area of the body being evaluated. The pro- the rate at which the nuclei return to their natural cedure may take 15 to 90 minutes. There is usually alignment. A computer constructs multidimen- no need to change out of regular clothes. The risks sional images based on this data. of radionuclide scans are minimal. The radioiso- MRI is particularly effective for detecting abnor- topes dissipate rapidly, so the radiation does not mal tissue within the body, such as tumors, tears to remain in the body very long. Specialized types of muscles, and neurologic injury or deterioration. radionuclide scans include positron emission Because of the electromagnetic disruption the MRI tomography (PET) scan and single photon emission machine temporarily causes, people who have computed tomography (SPECT). implanted pacemakers and other devices, metal ultrasound Also called ultrasonography, a hardware (such as to repair fractures), permanent diagnostic procedure that uses high-frequency prostheses (such as an artificial eye or COCHLEAR sound waves (beyond the frequency human hear- IMPLANT), and certain other circumstances cannot ing can detect) to create images of internal organs undergo MRI. It is essential to remove all clothing and structures. Ultrasound does not involve expo- and items that may contain metal; the person wears sure to radiation. Ultrasound is painless and is a hospital gown during the procedure. especially effective for evaluating hollow struc- MRI is painless and takes 15 minutes to an hour tures within the body such as the GALLBLADDER, depending on the area of the body being scanned. urinary BLADDER, and arteries and veins. Doppler Sometimes the doctor may choose to administer an ultrasound is a technique that presents moving intravenous injection of a contrast medium to images, such as the flow of BLOOD or the move- enhance the images the MRI produces. The MRI ment of a FETUS within a pregnant woman’s machine is very loud and surrounds the person uterus. Ultrasound is also useful for detecting cysts during the procedure. Some people find the experi- and tumors in structures such as the OVARIES, TESTI- ence of the procedure disconcerting because of CLES, BREASTS, and PROSTATE GLAND. Doctors some- these factors. The technologist performing the MRI times use ultrasound to guide the placement of can provide methods to minimize this. MRI does biopsy instruments. not have any adverse side effects. Ultrasound typically requires no advance radionuclide scan A nuclear medicine proce- preparation, though pelvic ultrasound may dure that measures the rate of deterioration of require a full urinary bladder. The procedure is low-level radioactive isotopes to present images of painless. During the procedure, the sonographer the cellular function of organs such as the BRAIN, applies a warm gel to the surface of the skin over BONE, LIVER, THYROID GLAND, and GALLBLADDER. the area being scanned. The gel improves the con- Radionuclide scans involve exposure to radiation. ductivity of sound signals. The sonographer gently Before the scan, the person receives an intra- presses a transducer against the skin and moves it venous injection of a small amount of fluid, typi- in a particular pattern. The transducer emits ultra- cally a glucose (sugar) solution, “tagged” with the sound waves, which “echo” from the structures appropriate radioisotope (the radionuclide). Cells within the body. The transducer then picks up the throughout the body uptake, or take in, the echoes and transmits them back to the ultrasound tagged glucose molecules. The attached radioiso- machine, which creates representational images tope molecules deteriorate as the body uses the from them. glucose. Some ultrasound procedures involve placing Cells in various organs and structures use glu- the transducer within a natural body opening cose at known rates; measuring the rate helps such as the VAGINA, RECTUM, or ESOPHAGUS to pro- doctors to determine whether there is abnormal vide focused examination of key structures that function such as tumors or healing (increased glu- are deeper within the body. Transesophageal cose use). Slowed uptake may indicate degenera- ultrasound, for example, can provide close exami- tive disorders or problems with healing. nation of the heart. ECHOCARDIOGRAM is another During the scan the person lies on a procedure type of ultrasound that specifically examines the table and the gamma camera or other device passes HEART. Diagnostic Imaging Procedures 419

X-ray A radiologic procedure to evaluate the Most X-ray procedures require removing cloth- structure of dense organs within the body such as ing that could interfere with the X-ray image, bone. X-ray involves exposure to ionizing radia- such as items that have buttons and zippers. Some tion. An X-ray machine emits a beam of ionizing X-ray procedures, such as BARIUM ENEMA, require radiation that tissues within the body absorb. The advance preparation and the use of contrast more dense the tissue, the more radiation it media. Some X-ray procedures require awkward absorbs. Solid structures such as bone absorb high positions or holding the breath, which may be amounts of radiation; thus X-ray is particularly temporarily uncomfortable. Most X-ray proce- effective for detecting injuries and other abnor- dures are painless, though people may feel pain malities of the bones. X-ray can also detect the from the injuries being evaluated during the pro- presence of many types of tumors because their cedure. Infrequent X-rays pose very little risk to tissues have different density than normal struc- health. People who need frequent X-rays should tures, as well as the presence of abnormal air or discuss the risk of radiation exposure with their fluid (such as in the lungs or abdomen). doctors. APPENDIX IX FAMILY MEDICAL TREE

A family medical tree can help your doctor deter- • neurologic disorders such as ALZHEIMER’S DIS- mine inherited and genetic health risks. Optimally EASE, HUNTINGTON’S DISEASE, and PARKINSON’S DIS- a family medical tree includes information about EASE the causes of death and significant medical condi- • known GENETIC DISORDERS or CHROMOSOMAL DIS- tions for as many family generations as possible. ORDERS such as HEMOPHILIA, DOWN SYNDROME, The most significant health information is that for TURNER’S SYNDROME, KLINEFELTER’S SYNDROME, or first-degree relatives (siblings, parents, and chil- generalized BIRTH DEFECTS dren) and second-degree relatives (nephews, nieces, cousins, aunts, uncles, and grandparents). • SEASONAL ALLERGIES, allergies to medications or Some health information may be vague or use foods, ASTHMA, or MIGRAINE HEADACHE antiquated terminology (for example, consump- • INFLAMMATORY BOWEL DISEASE (IBD), SYTEMIC LUPUS tion to identify tuberculosis or dropsy to identify ERYTHEMATOSUS (SLE), HYPOTHYROIDISM, type 1 congestive heart failure). DIABETES, RHEUMATOID ARTHRITIS, or other AUTOIM- It is especially important to know the cause of MUNE DISORDERS death whenever possible, as this provides clues to • INFERTILITY, PREMATURE OVARIAN FAILURE (POF), MIS- underlying health conditions. For deaths occur- CARRIAGE (spontaneous ABORTION), STILLBIRTH, ring within the past few decades, this information breech presentation, or other difficulties with appears on the death certificate. Other useful PREGNANCY and CHILDBIRTH information includes any history of • type 2 DIABETES, OBESITY, or INSULIN RESISTANCE • DEPRESSION, GENERALIZED ANXIETY DISORDER (GAD), • HEART disease, such as STROKE, HEART ATTACK BIPOLAR DISORDER, SCHIZOPHRENIA, SEASONAL AFFEC- (MYOCARDIAL INFARCTION), sudden (or unex- TIVE DISORDER (SAD), LEARNING DISORDERS, or plained) cardiac death, ATHEROSCLEROSIS, ARTE- intellectual deficiency (mental retardation) RIOSCLEROSIS, CARDIOMYOPATHY (enlarged heart), congestive HEART FAILURE, PERIPHERAL VASCULAR • ALCOHOLISM, SUBSTANCE ABUSE, or CIGARETTE DISEASE (PVD), DEEP VEIN THROMBOSIS (DVT), INTER- SMOKING MITTENT CLAUDICATION, LONG QT SYNDROME (LQTS), • HEMOCHROMATOSIS, WILSON’S DISEASE, PHENYLKE- and ARRHYTHMIA TONURIA (PKU), and other disorders of METABO- LISM • congenital heart defects or disorders, including treatments (such as surgery) to repair or treat • MUSCULAR DYSTROPHY or CYSTIC FIBROSIS them A family history of health conditions does not • CANCER, especially BREAST CANCER, COLORECTAL necessarily point to a personal history with the CANCER, OVARIAN CANCER, PROSTATE CANCER, and same conditions. However, it provides important childhood cancers such as LEUKEMIA or WILMS’S clues about a person’s possible predilection for TUMOR such conditions. The most accurate method to

420 Family Medical Tree 421 compile a family medical tree is to ask key family lar health condition affects more than one first members, such as parents and grandparents, about degree relative or multiple second degree relatives. health conditions. However, some people are Record family health information, and give a reluctant to discuss health problems. Sometimes it copy of the document to the family or regular is helpful to mention to the doctor that a particu- physician as well as other family members. APPENDIX X IMMUNIZATION AND ROUTINE EXAMINATION SCHEDULES

Preventive health examinations and immuniza- WELL CHILD EXAMINATION tions are crucial for optimal health and disease SCHEDULE RECOMMENDATIONS BY AGE resistance across the spectrum of life. Recom- Infancy mended schedules, examination procedures, and 2 to 4 days after birth 10 days after birth immunizations change as knowledge grows and new developments become available. The infor- Early Childhood mation in this appendix represents a composite of 2 months 4 months common recommendations current at the time of 6 months 9 months publication. Recommendations may differ accord- 12 months 15 months ing to age and between men and women. 18 months 24 months

Preventive Health Care for Infants and Children Middle Childhood Most health experts recommend well child exami- 3 years 4 years nations for basic preventive health care on a 5 years 6 years schedule frequent enough for early detection of 8 years 10 years physical or mental developmental delays and concerns. Well child exams should include age- Adolescence appropriate general health measures such as 12 years 14 years 16 years 18 years • length/height Immunizations and immunization schedules • weight change as new vaccines become available. The • head circumference (infants) American Academy of Pediatrics (AAP) establishes and updates recommendations. The most current • reflexes immunizations and their schedules are available • vital signs (heart rate, breathing rate, blood on the AAP’s Web site (www.aap.org) as well as pressure, body temperature) through public health departments and public and private health organizations. • basic vision and hearing screening Immunization schedules for children vary according to the age at which the child receives • scoliosis detection the first dose of a multidose vaccination series. For • coordination, balance, and gait some immunizations there is a window of oppor- tune timing. The pediatrician adjusts each child’s • nutritional status schedule for appropriate timing of doses, includ- • appropriate immunizations ing “catch-up” scheduling for children who begin

422 Immunization and Routine Examination Schedules 423 immunizations later than recommended. Timing Preventive Health Care for Adults and doses for each vaccine are crucial for the Preventive health-care examinations for adults body’s process of developing immunity. Nearly all vary according to gender and age. Adults also children should receive all recommended immu- require certain immunizations. Most adults should nizations; public schools throughout the United receive a tetanus-diphtheria booster every 10 States require certain immunizations for school years, hepatitis B vaccine if not immunized in registration unless there are extenuating circum- childhood, and influenza vaccination (flu shot) stances. Such factors vary among states. and every year.

PREVENTIVE HEALTH EXAMINATION RECOMMENDATIONS: ADULTS Age Well Exam Frequency Exam Includes 19 to 39 men: every 5 years health risk screening: cholesterol, blood pressure, diabetes, sexually transmitted women: every 3 years diseases (STDs) height/weight vital signs men: testicular exam women: breast exam, pelvic exam, Pap test

40 to 49 men: every 5 years health risk screening: cholesterol, blood pressure, diabetes, STDs, heart disease, women: every 3 years cancer height/weight vital signs fecal occult blood test (FOBT) men: testicular exam, baseline prostate exam women: breast exam, pelvic exam, Pap test, baseline mammogram

50 to 64 men: every 3 to 5 years health risk screening: cholesterol, blood pressure, diabetes, STDs, heart disease, women: every 2 to 3 years cancer, thyroid height/weight vital signs FOBT baseline colonoscopy, repeat every 10 years men: testicular exam, prostate exam women: breast exam, pelvic exam, Pap test annual mammogram

65 and older men and women: health risk screening: cholesterol, blood pressure, diabetes, STDs, heart disease, every year cancer, thyroid height/weight vital signs FOBT colonoscopy every 10 years men: prostate exam women: breast exam, pelvic exam, mammogram APPENDIX XI MODERN MEDICINE TIMELINE

TIMELINE OF MODERN MEDICINE Date Discovery Date Discovery 1950 penicillin, the first broad-spectrum antibiotic, 1976 single photon emission computed tomography became available (SPECT) scan; coronary artery bypass graft 1952 polio vaccine; isoniazid developed to treat (CABG) tuberculosis; first published link between cigarette 1978 first in vitro fertilization infant born; radionuclides smoking and lung cancer for diagnostic imaging 1953 first open heart surgery using a heart–lung bypass 1980 magnetic resonance imaging (MRI); smallpox machine; DNA decoded; medical ultrasound declared eradicated worldwide; first laparoscopic 1954 first living donor kidney transplantation appendectomy 1959 first drug to treat leukemia 1981 first heart–lung combined transplantation; 1960 first oral contraceptive (birth control pill) hepatitis B vaccine becomes available in the United States 1982 acquired immunodeficiency syndrome (AIDS) 1962 oral polio vaccine identified; first permanent artificial heart 1963 first cadaveric donor kidney transplantation implanted; first use of monoclonal antibodies 1964 measles vaccine; first US Surgeon General’s report (MAbs) to treat cancer on smoking and health 1983 human immunodeficiency virus (HIV) identified as 1965 US Congress passes laws to establish Medicare and cause of AIDS Medicaid programs, require warning labels on 1984 first cochlear implant cigarette packages 1985 positron emission tomography (PET) scan 1966 first pancreas–kidney combined transplantation; 1986 first double-lung transplantation first mammography machine 1987 first small bowel transplantation 1967 first human heart transplantation; first liver 1988 first split-liver transplantation transplantation; mumps vaccine; kidney dialysis 1989 first living donor liver transplantation machine 1990 first living donor lung transplantation 1970 rubella vaccine 1994 robotic laparoscopy 1973 DNA cloning 1995 blood substitute 1974 first disposable syringe 1999 first human chromosome sequenced 1975 chorionic villi sampling (CVS) 2003 human genome mapping completed

424 APPENDIX XII NOBEL LAUREATES IN PHYSIOLOGY OR MEDICINE

Alfred Nobel (1833–1896), a successful Swedish several hundred each year—and selects the laure- businessman who invented dynamite, established ates. Up to three people, working independently the Nobel Prize in his will. Nobel intended for the or in collaboration, may share the Nobel Prize in prize to honor “those who, during the preceding Physiology or Medicine each year. No Nobel Prize year, shall have conferred the greatest benefit on in Physiology or Medicine was awarded in 1915, mankind.” Nobel stipulated five areas of award: 1916, 1917, 1918, 1921, 1925, 1940, 1941, and physics, chemistry, physiology or medicine, litera- 1942. ture, and peace. Complete information about Nobel laureates in The Nobel Assembly at Karolinska Institutet in all categories appears on the Nobel Prize Web site Stockholm, Sweden accepts nominations—up to (nobelprize.org).

LAUREATES, NOBEL PRIZE IN PHYSIOLOGY OR MEDICINE Year Laureate(s) Discovery 2005 Barry J. Marshall (b. 1951; Australia) Helicobacter pylori as the cause of peptic ulcer disease J. Robin Warren (b. 1937; Australia)

2004 Richard Axel (b. 1946; USA) mechanisms through which the sense of smell (olfactory system) Linda B. Buck (b. 1947; USA) recognizes and organizes odors

2003 Paul C. Lauterbur (b. 1929; USA) magnetic resonance imaging (MRI) Sir Peter Mansfield (b. 1933; UK)

2002 Sydney Brenner (b. 1927; UK) how genes regulate organ development and cell apoptosis (natural cell H. Robert Horvitz (b. 1947; USA) death) John E. Sulston (b. 1942; UK)

2001 Leland H. Hartwell (b. 1939; USA) mechanisms that control the life cycle of cells and cell division Tim Hunt (b. 1943; UK) Sir Paul Nurse (b. 1949; UK)

2000 Arvid Carlsson (b. 1923; Sweden) mechanisms by which neurotransmitters carry nerve impulses among Paul Greengard (b. 1925; USA) brain neurons Eric R. Kandel (b. 1929; USA)

1999 Günter Blobel (b. 1999; Germany) intrinsic signals that direct proteins to their target locations within cells 425 426 Appendix XII

Year Laureate(s) Discovery 1998 Robert F. Furchgott (b. 1916; USA) role of nitric oxide in the functions of the heart and blood vessels Louis J. Ignarro (b. 1941; USA) Ferid Murad (b. 1936; USA)

1997 Stanley B. Prusiner (b. 1942; USA) infectious prions

1996 Peter C. Doherty (b. 1940; Australia) mechanisms through which the immune system recognizes and attempts Rolf M. Zinkernagel (b. 1944; Switzerland) to contain cells infected with viruses

1995 Edward B. Lewis (1918–2004; USA) mechanisms through which genes control the development of cells and Christiane Nüsslein-Volhard (b. 1942; tissues into specialized structures and organs in the embryo Germany) Eric F. Wieschaus (b. 1947; USA)

1994 Alfred G. Gilman (b. 1941; USA) G-proteins, which regulate how cells receive and use other protein Martin Rodbell (1925–1998; USA) signals

1993 Richard J. Roberts (b. 1943; UK) split, or segmented, genes Phillip A. Sharp (b. 1944; USA)

1992 Edmond H. Fischer (b. 1920; USA) roles of the enzymes kinase and phosphatase to attach and remove Edwin G. Krebs (b. 1918; USA) molecules for energy (glucose) release and storage

1991 Erwin Neher (b. 1944; Germany) single ion channels and their functions in cell electrical activity Bert Sakmann (b. 1942; Germany)

1990 Joseph E. Murray (b. 1919; USA) organ transplantation to treat diseases such as kidney failure and heart E. Donnall Thomas (b. 1920; USA) failure, including management of the immune response to prevent organ rejection and host vs. graft disease

1989 J. Michael Bishop (b. 1936; USA) origin of oncogenes is within cells that become cancerous Harold E. Varmus (b. 1939; USA)

1988 Sir James W. Black (b. 1924; UK) Black: mechanisms by which drugs are effective in treating diseases Gertrude B. Elion (1918–1999; USA) such as heart disease and cancer George H. Hitchings (1905–1998; USA) Elion and Hitchings: mechanisms of RNA function resulting in new drugs to treat various diseases such as leukemia, malaria, and organ rejection after transplantation

1987 Susumu Tonegawa (b. 1939; Japan) role of genes in the production and function of antibodies

1986 Stanley Cohen (b. 1922; USA) nerve growth factor (NGF) and epidermal growth factor (EGF), Rita Levi-Montalcini (b. 1909; Italy) substances that regulate cell growth and differentiation

1985 Michael S. Brown (b. 1941; USA) mechanisms that regulate cholesterol metabolism Joseph L. Goldstein (b. 1940; USA) Nobel Laureates in Physiology or Medicine 427

Year Laureate(s) Discovery 1984 Niels K. Jerne (1911–1994; Denmark) Jerne: regulatory mechanisms of antibody production and function Georges J. F. Köhler (1946–1995; Germany) Köhler and Milstein: monoclonal antibodies (MAbs) César Milstein (1927–2002; Argentina)

1983 Barbara McClintock (1902–1992; USA) mobile genetic elements and genetic instability

1982 Sune K. Bergström (1916–2004; Sweden) prostaglandins Bengt I. Samuelsson (b. 1934; Sweden) John R. Vane (1927–2004; UK)

1981 Roger W. Sperry (1913–1994; USA) Sperry: specialized differences in the functions of the brain’s David H. Hubel (b. 1926; USA) hemispheres Torsten N. Wiesel (b. 1924; Sweden) Hubel and Weisel: mechanisms through which the brain’s visual cortex receives and interprets visual signals

1980 Baruj Benacerraf (b. 1920; USA) genetic regulation of major histocompatibility complex (MHC) antigens Jean Dausset (b. 1916; France) George D. Snell (1903–1996; USA)

1979 Allan M. Cormack (1924–1998; USA) computed tomography (CT) scanning Godfrey N. Hounsfield (1919–2004; UK)

1978 Werner Arber (b. 1929; Switzerland) restrictive enzymes and their roles in genetic functions Daniel Nathans (1928–1999; USA) Hamilton O. Smith (b. 1931; USA)

1977 Roger Guillemin (b. 1924; USA) Guillemin and Schally: hypothalamus production of “releasing Andrew V. Schally (b. 1926; USA) hormones” that direct the functions of other endocrine glands Rosalyn Yalow (b. 1921; USA) Yalow: radioimmunoassays to detect levels of peptide hormones in the blood circulation

1976 Baruch S. Blumberg (b. 1925; USA) mechanisms through which infectious diseases originate and perpetuate D. Carleton Gajdusek (b. 1923; USA)

1975 David Baltimore (b. 1938; USA) mechanisms by which viruses interact with cell DNA and RNA to cause Renato Dulbecco (b. 1914; USA) transformations that result in tumor development and growth Howard M. Temin (1934–1994; USA)

1974 Albert Claude (1899–1983; Belgium) cell components and composition and their effects on cell structure and Christian de Duve (b. 1917; Belgium) function George E. Palade (b. 1912; USA)

1973 Karl von Frisch (1886–1982; Germany) patterns of personal behaviors and social interactions as they relate to Konrad Lorenz (1903–1989; Austria) healthy and unhealthy psychosocial states Nikolaas Tinbergen (1907–1988; UK)

1972 Gerald M. Edelman (b. 1929; USA) chemical structures of antibody molecules Rodney R. Porter (1917–1985; UK) 428 Appendix XII

Year Laureate(s) Discovery 1971 Earl W. Sutherland Jr. (1915–1974; USA) mechanisms through which hormones function in the body

1970 Sir Bernard Katz (1911–2003; UK) neurotransmitters and their roles in the mechanisms through which Ulf von Euler (1905–1983; Sweden) nerve cells communicate with other cells in the body Julius Axelrod (1912–2004; USA)

1969 Max Delbrück (1906–1981; USA) genetic structure and replication mechanisms of viruses Alfred D. Hershey (1908–1997; USA) Salvador E. Luria (1912–1991; USA)

1968 Robert W. Holley (1922–1993; USA) role of genes in protein synthesis H. Gobind Khorana (b. 1922; USA) Marshall W. Nirenberg (b. 1927; USA)

1967 Ragnar Granit (1900–1991; Sweden) biochemical and physiologic mechanisms involved in the eye’s Haldan K. Hartline (1903–1983; USA) processing of visual input and information George Wald (1906–1997; USA)

1966 Peyton Rous (1897–1970; USA) Rous: viruses that cause tumors to develop Charles B. Huggins (1901–1997; USA) Huggins: effect of therapeutic hormones on prostate cancer

1965 François Jacob (b. 1920; France) role of genes in regulating enzyme synthesis and virus replication André Lwoff (1902–1994; France) Jacques Monod (1910–1976; France)

1964 Konrad Bloch (1912–2000; USA) relationship between metabolism of fatty acids and formation of Feodor Lynen (1911–1979; Germany) cholesterol in the body

1963 Sir John Eccles (1903–1997; Australia) role of ions and ion channels in the conduction of electrical impulses Alan L. Hodgkin (1914–1998; UK) through nerve cells Andrew F. Huxley (b. 1917; UK)

1962 Francis Crick (1916–2004; UK) double helix structure of DNA and its role in transmitting genetic and James Watson (b. 1928; USA) molecular information Maurice Wilkins (1916–2004; UK)

1961 Georg von Békésy (1899–1972; USA) mechanisms of function of the cochlea

1960 Sir Frank Macfarlane Burnet (1899–1985; characteristics and development of acquired immunity Australia) Peter Medawar (1915–1987; UK)

1959 Severo Ochoa (1905–1993; USA) synthesis of RNA and DNA Arthur Kornberg (b. 1918; USA)

1958 George Beadle (1903–1989; USA) Beadle and Tatum: biochemical mechanisms of gene activity Edward Tatum (1909–1975; USA) Lederberg: genetic recombination Joshua Lederberg (b. 1925; USA) Nobel Laureates in Physiology or Medicine 429

Year Laureate(s) Discovery 1957 Daniel Bovet (1907–1992; Italy) mechanisms through which certain drugs can block the actions and effects of endogenous substances

1956 André F. Cournand (1895–1988; USA) use of cardiac catheterization to diagnosis diseases of the heart and Werner Forssmann (1904–1979; Germany) blood vessels Dickinson W. Richards (1895–1973; USA)

1955 (Axel) Hugo (Theodor) Theorell (1903–1982; mechanisms through which enzymes that cause oxidation function Sweden)

1954 John F. Enders (1897–1985; USA) laboratory culture of the poliomyelitis virus in different kinds of tissues Thomas H. Weller (b. 1915; USA) Frederick C. Robbins (1916–2003; USA)

1953 Hans Krebs (1900–1981; UK) Krebs: metabolic process within the cell that converts nutrients to Fritz Lipmann (1899–1986; USA) energy (now called the Krebs cycle) Lipmann: coenzyme A and its role in cellular metabolism

1952 Selman A. Waksman (1888–1973; USA) streptomycin, first antibiotic to treat tuberculosis

1951 Max Theiler (1899–1972; South Africa) mechanisms of and treatment for yellow fever

1950 Edward C. Kendall (1886–1972; USA) isolation and functions within the body of cortisone and other Tadeus Reichstein (1897–1996; hormones of the adrenal cortex Switzerland) Philip S. Hench (1896–1965; USA)

1949 Walter Hess (1881–1973; Switzerland) Hess: activities of the midbrain as they regulate the body’s autonomic Egas Moniz (1874–1955; Portugal) vital functions Moniz: prefrontal leucotomy (surgery to sever connections between regions of the brain responsible for intense emotional responses, notably anger) to treat schizophrenia

1948 Paul Müller (1899–1965; Switzerland) use of the organic pesticide DDT to eradicate insects responsible for transmitting disease

1947 Carl Cori (1897–1984; USA) Cori and Cori: conversion of glycogen to glucose Gerty Cori (1897–1957; USA) Houssay: role of the hypophysis in carbohydrate metabolism and Bernardo Houssay (1887–1971; Argentina) diabetes

1946 Hermann J. Muller (1890–1967; USA) capability of X-rays to cause gene mutations

1945 Sir Alexander Fleming (1881–1955; UK) penicillin and its ability to cure infectious diseases Ernst B. Chain (1906–1979; UK) Sir Howard Florey (1898–1968; Australia)

1944 Joseph Erlanger (1874–1965; USA) varying conductivity and function of single fibers within nerves Herbert S. Gasser (1888–1963; USA) 430 Appendix XII

Year Laureate(s) Discovery 1943 Henrik Dam (1895–1976; Denmark) isolation and biochemical actions of vitamin K Edward A. Doisy (1893–1986; USA)

1939 Gerhard Domagk (1895–1964; Germany) antibacterial actions of prontosil, particularly against streptococcal bacteria

1938 Corneille Heymans (1892–1968; Belgium) functions of the cardio-aortic and carotid sinus areas in regulating the rate of respiration (breathing)

1937 Albert von Szent-Györgyi Nagyrapolt metabolic functions of vitamin C (1893–1986; Hungary)

1936 Sir Henry Dale (1875–1968; UK) role of neurotransmitters and other biochemicals in conducting nerve Otto Loewi (1873–1961; Austria) impulses

1935 Hans Spemann (1869–1941; Germany) embryonic organizer areas that regulate how cells form tissues, organs, and structures within the developing embryo

1934 George H. Whipple (1878–1976; USA) consumption of animal liver as treatment for anemia George R. Minot (1885–1950; USA) William P. Murphy (1892–1987; USA)

1933 Thomas H. Morgan 1866–1945; USA) chromosomes as primary units of heredity

1932 Sir Charles Sherrington (1857–1952; UK) structures and functions of neurons and nerves (afferent and efferent Edgar Adrian (1889–1977; UK) conductivity)

1931 Otto Warburg (1883–1970; Germany) identification and function of hydrogen-transferring enzymes in respiration

1930 Karl Landsteiner (1868–1943; Austria) human blood groups

1929 Christiaan Eijkman (1858–1930; Eijkman: role of vitamins in diseases such as beriberi Netherlands) Hopkins: role of vitamins in growth Sir Frederick Hopkins (1861–1947; UK)

1928 Charles Nicolle (1866–1936; France) transmission of typhus by the body louse

1927 Julius Wagner-Jauregg (1857–1940; Austria) inoculation with malaria as a treatment, by inducing fever high enough to alter brain function, for psychoses

1926 Johannes Fibiger (1867–1828; Denmark) Spiroptera carcinoma, a burrowing worm capable of causing cancerous tumors

1924 Willem Einthoven (1860–1927; Netherlands) electrocardiogram (ECG)

1923 Frederick G. Banting (1891–1941; Canada) insulin John Macleod (1876–1935; Canada) Nobel Laureates in Physiology or Medicine 431

Year Laureate(s) Discovery 1922 Archibald V. Hill (1886–1977; UK) Otto Meyerhof (1884–1951; Germany) muscle metabolism and the ability of muscle activity to generate heat

1920 August Krogh (1874–1949; Denmark) neuromuscular mechanisms that regulate capillary constriction and dilation

1919 Jules Bordet (1870–1961; Belgium) immunity and infectious diseases

1914 Robert Bárány (1876–1936; Austria) vestibular apparatus (receptors located within the inner ear that detect the body’s position relative to the external environment)

1913 Charles Richet (1850–1935; France) mechanisms of anaphylaxis (severe hypersensitivity reaction)

1912 Alexis Carrel (1873–1944; France) transplantation of blood vessels and organs

1911 Allvar Gullstrand (1862–1930; Sweden) refractive functions and errors of the eye (physiologic dioptrics)

1910 Albrecht Kossel (1853–1927; Germany) role of proteins and nucleic acids in cellular function

1909 Theodor Kocher (1841–1917; Switzerland) function and dysfunction of the thyroid gland

1908 Ilya Mechnikov (1845–1916; Russia) Mechnikov: function of phagocytosis in the immune response Paul Ehrlich (1854–1915; Germany) Ehrlich: salvarsan as the first effective treatment for syphilis

1907 Alphonse Laveran (1845–1922; France) role of protozoa in causing diseases such as malaria

1906 Camillo Golgi (1843–1926; Italy) structure of the nervous system, notably the spinal cord and spinal Santiago Ramón y Cajal (1852–1934; Spain) nerves

1905 Robert Koch (1843–1910; Germany) isolation and cultivation of the tubercle bacillus responsible for causing tuberculosis and the mechanisms of tuberculosis infection

1904 Ivan Pavlov (1849–1936; Russia) physiology of digestion

1903 Niels Ryberg Finsen (1860–1904; Denmark) therapeutic use of sunlight to treat conditions of the skin such as lupus vulgaris

1902 Ronald Ross (1857–1932; UK) transmission of malaria by mosquito bites

1901 Emil von Behring (1854–1917; Germany) serum antitoxin to treat diphtheria 432 Appendix I SELECTED BIBLIOGRAPHY AND FURTHER READING

The books listed in this section can provide com- Klabunde, Richard E. Cardiovascular Physiology Concepts. prehensive information about health and medical New York: Lippincott Williams & Wilkins, 2004. subjects. Many are reference books that publishers Levitzky, Michael G. Pulmonary Physiology. 6th ed. New periodically update and may be available in newer York: McGraw-Hill, 2002. editions than those listed here. “Appendix VI: Mohrman, David E., and Lois Jane Heller. Cardiovascular Physiology. 5th ed. New York: McGraw-Hill, 2002. Resources” contains Web sites and other sources West, John B. Respiratory Physiology: The Essentials. 7th that provide the most current information about ed. New York: Lippincott Williams & Wilkins, 2004. health topics, including research. Children’s Health Brazelton, T. Berry. Touchpoints, The Essential Reference: Aging and Health Your Child’s Emotional and Behavioral Development. Fries, James. Living Well: Taking Care of Yourself in the Mid- Cambridge, MA: Da Capo Press, 1992. dle and Later Years. 4th ed. Cambridge, MA: Da Capo Hays, William W. Jr., Myron J. Levin, Judith R. Sond- Press, 2004. heimer, and Robin R. Deterding, eds. Current Pediatric Kandel, Joseph, and Christine Adamec. Senior Health and Diagnosis and Treatment. 17th ed. New York: McGraw- Well-Being. New York: Facts On File, 2003. Hill, 2004. Kausler, Donald H., and Barry C. Kausler. The Graying of Pantell, Robert H., James F. Fries, and Donald M. Vick- America: An Encyclopedia of Aging, Health, Mind, and ery. Taking Care of Your Child: A Parent’s Illustrated Behavior Second Edition. Champaign: University of Illi- Guide to Complete Medical Care. 7th ed. Cambridge, nois Press, 2001. MA: Da Capo Press, 2005. Morley, John E., and Lucretia van den Berg, eds. Shelov, Steven P. Caring for Your Baby and Young Child: Endocrinology of Aging. Totowa, NJ: Humana Press, Birth to Age 5. 5th ed. New York: Bantam Books, 2000. 1998. Peterson, Elisabeth. Voices of Alzheimer’s: Courage, Humor, Hope, and Love in the Face of Dementia. Cambridge, MA: Drugs and Medicines Da Capo Press, 2004. Weil, Andrew T. Healthy Aging: A Lifelong Guide to Your Deglin, Judith Hopfer, and April Hazard Vallarand. Physical and Spiritual Well-Being. New York: Knopf, Davis’s Drug Guide for Nurses. 9th ed. Philadelphia: F. 2005. A. Davis, 2004. Griffin, H. Winter. Complete Guide to Prescription and Non- prescription Drugs. Edition 2005. Rev. and updated by Cardiovascular and Stephen Moore. New York: Berkeley Publishing Pulmonary Health and Conditions Group, 2004. Crapo, James D., Jeffrey L. Glassroth, Joel B. Karlinsky, Katzung, Bertram G. Basic and Clinical Pharmacology. 9th and Talmadge E. King, eds. Baum’s Textbook of Pul- ed. New York: McGraw-Hill, 2003. monary Diseases. 7th ed. New York: Lippincott Olson, James. Clinical Pharmacology Made Ridiculously Williams & Wilkins, 2003. Simple. 2nd ed. Miami: Medmaster, 2003. Frownfelter, Donna, and Elizabeth Dean. Cardiovascular Silverman, Harold M. The Pill Book: The Illustrated Guide and Pulmonary Physical Therapy: Evidence and Practice. to the Most Prescribed Drugs in the United States. 11th ed. 4th ed. New York: Mosby Elsevier, 2006. New York: Bantam, 2004. 433 434 Bibliography

Skidmore-Roth, Linda. 2006 Mosby’s Nursing Drug Refer- Daugirdas, John T., Peter Gerard Blake, and Todd S. Ing, ence. New York: Mosby Elsevier, 2005. eds. Handbook of Dialysis. 3rd ed. New York: Lippin- cott Williams & Wilkins, 2000. Friedman, Scott L., Kenneth R. McQuaid, and James H. Emergency and First Aid Gendell. Current Diagnosis and Treatment in Gastroen- Field, John, Mary Fran Hazinski, and David Gilmore, terology. 2nd ed. New York: McGraw-Hill, 2002. eds. Handbook of Emergency Cardiovascular Care for Greenberg, Arthur, ed. Primer on Kidney Diseases. 4th ed. Healthcare Providers. Dallas: American Heart Associa- Philadelphia: W. B. Saunders, 2005. tion, 2006. Hanno, Philip M., Alan J. Wein, and S. Bruce Malkow- Forgey, William W. Wilderness Medicine: Beyond First Aid. icz. Clinical Manual of Urology. 3rd ed. New York: 5th ed. Guilford, CT: Globe Pequot Press, 2000. McGraw-Hill, 2001. Krohmer, Jon R. American College of Emergency Physicians Johnson, Leonard R., and Thomas A. Gerwin, eds. Gas- First Aid Manual. 2nd ed. New York: DK Publishing, trointestinal Physiology. 6th ed. St. Louis: C. V. Mosby, 2004. 2001. Stone, C. Keith, and Roger L. Humphries. Current Emer- Koeppen, Bruce M., and Bruce A. Stanton, eds. Renal gency Diagnosis and Treatment. 5th ed. New York: Physiology. 3rd ed. St. Louis: C. V. Mosby, 2001. McGraw-Hill, 2003. Tanagho, Emil A., and Jack W. McAninch, eds. Smith’s General Urology. 16th ed. New York: McGraw-Hill, Endocrine and Hormonal Health and Conditions 2004. Bode, Bruce, ed. Medical Management of Type 1 Diabetes. Yamada, Tadataka, William L. Hasler, John M. Inadomi, 4th ed. Alexandria, VA: American Diabetes Associa- Michelle A. Anderson, and Robert S. Brown, eds. tion, 2003. Handbook of Gastroenterology. 2nd ed. New York: Lip- Burant, Charles F., ed. Medical Management of Type 2 Dia- pincott Williams & Wilkins, 2005. betes. 5th ed. Alexandria, VA: American Diabetes General Health and Medicine Association, 2004. Anderson, Douglas M., ed. Mosby’s Medical Dictionary. 7th Margioris, Andrew N., and George P Chrousos, eds. Con- ed. New York: Mosby Elsevier, 2005. temporary Endocrinology: Adrenal Disorders. Totowa, NJ: Beers, Mark H., and Robert Berkow, eds. The Merck Man- Humana Press, 2001. ual of Diagnosis and Therapy. 17th ed. White House Melmed, Shlomo, ed. The Pituitary. 2nd ed. Malden, MA: Station, NJ: Merck Research Laboratories, 1999. Blackwell Science, 2002. Beers, Mark H., and Thomas V. Jones, eds. The Merck Nieschlag, Eberhard, and Hermann M. Behre, eds. Testos- Manual of Health and Aging. White House Station, NJ: terone: Action, Deficiency, Substitution. 3rd ed. New York: Merck Research Laboratories, 2004. Cambridge University Press, 2004. Blau, Sheldon, and Dodi Shultz. Living with Lupus: The Porterfield, Susan P. Endocrine Physiology. 2nd ed. St. Complete Guide. 2nd ed. Cambridge, MA: Da Capo Louis, MO: C. V. Mosby, 2000. Press, 2004. Rothfeld, Glenn S., and Deborah S. Romaine. Thyroid Dorland’s Illustrated Medical Dictionary. 30th ed. Philadel- Balance: Traditional and Alternative Methods for Treating phia: W. B. Saunders, 2003. Thyroid Disorders. Avon, MA: Adams Media, 2001. Gray, Henry. Gray’s Anatomy: The Classic Collector’s Edition. Ruderman, Neil, John T. Devlin, Stephen H. Schneider, New York: Gramercy Books, 1988. and Andrea M. Kriska, eds. American Diabetes Associa- Griffith, H. Winter. Complete Guide to Symptoms, Illness, tion Handbook of Exercise in Diabetes. Alexandria, VA: and Surgery. 4th ed. Rev. and updated by Stephen American Diabetes Association, 2001. Moore and Kenneth Yoder. New York: Berkeley Pub- Wales, Jerry K. H. Clinician’s Guide to Growth Disorders. lishing Group, 2000. New York: Oxford University Press, 2001. Guyton, Arthur C., and John E. Hall, eds. Textbook of Medical Physiology. 11th ed. Philadelphia: Elsevier Gastroenterologic, Renal, Saunders, 2005. and Urologic Health and Conditions Kasper, Dennis L., Eugene Braunwald, Anthony Fauci, Eaton, Douglas C., and John P. Pooler, eds. Vander’s Stephen Hauser, Dan Longo, and J. Larry Jameson, Renal Physiology. 6th ed. New York: McGraw-Hill, eds. Harrison’s Principles of Internal Medicine. 16th ed. 2004. McGraw-Hill, 2004. Danovitch, Gabriel M., ed. Handbook of Kidney Transplan- Komaroff, Anthony L., ed.-in-chief. Harvard Medical tation. 3rd ed. New York: Lippincott Williams & School Family Health Guide. New York: Simon & Wilkins, 2001. Schuster, 1999. Bibliography 435

Leikin, Jerrold B., and Martin S. Lipsky, medical eds. Lyons, Albert S., and R. Joseph Petrucelli II. Medicine: An American Medical Association Complete Medical Encyclope- Illustrated History. New York: Abradale Press/Harry N. dia. New York: Random House, 2003. Abrams, 1987. Margolis, Simeon, medical editor. The Johns Hopkins Con- Magner, Lois. A History of Medicine. New York : Marcel sumer Guide to Medical Tests: What You Can Expect, How Dekker, 1992. You Should Prepare, What Your Results Mean. New York: Rebus, 2001. Immune Health and Disorders, Moore, Keith L, and Arthur F. Dalley. Clinically Oriented Allergies, and Infectious Diseases Anatomy. 5th ed. Baltimore: Lippincott Williams & Adkinson, N. Franklin, John W. Yunginger, William W. Wilkins, 2005. Busse, Bruce S. Bochner, Stephen T. Holgate, and Parker, Steven. Human Body (Eyewitness Science Series). Estelle R. Simons, eds. Middleton’s Allergy: Principles New York: Dorling Kindersley, Inc., 1993. and Practice. 6th ed. 2 vols. St. Louis: C. V. Mosby, Schlossberg, Leon, and George D. Zuidema, The Johns 2003. Hopkins Atlas of Human Functional Anatomy. 4th ed. Cassell, Dana K., and Noel R. Rose. The Encyclopedia of Baltimore: The Johns Hopkins University Press, Autoimmune Diseases. New York: Facts on File, 2003. 1997. Ewald, Paul W. Evolution of Infectious Disease. New York: Stedman’s Medical Dictionary. 28th ed. New York: Lippin- Oxford University Press, 1996. cott Williams & Wilkins, 2005. Fanta, Christopher H., Lynda M. Cristiano, and Kenan Tierney, Lawrence M., Stephen J. McPhee, and Maxine Haver, with Nancy Waring. The Harvard Medical School Papadakis, eds. 2006 Current Medical Diagnosis and Guide to Taking Control of Asthma: A Comprehensive Pre- Treatment. 45th ed. New York: McGraw-Hill, 2006. vention and Treatment Plan for You and Your Family. Venes, Donald, Taber’s Cyclopedic Medical Dictionary. 20th New York: Simon & Schuster, 2003. ed. Philadelphia: F. A. Davis, 2005. Fireman, Philip, M.D., ed. Atlas of Allergies and Clinical Vickery, Donald, and James Fries. Take Care of Yourself: Immunology. 3rd ed. St. Louis MO: C.V. Mosby, 2005. The Complete Illustrated Guide to Medical Self-Care. 8th Fisher, Margaret C., ed.-in-chief. Immunizations and Infec- ed. Cambridge, MA: Da Capo Press, 2003. tious Diseases: An Informed Parent’s Guide. Washington DC: American Academy of Pediatrics, 2005. Genetics and Molecular Medicine Gladwin, Mark, and Bill Trattler. Clinical Microbiology Gelehrter, Thomas D., Francis S. Collins, and David Made Ridiculously Simple. 3rd ed. Miami, FL: Medmas- Ginsburg. Principles of Medical Genetics. 2nd ed. New ter, 2004. York: Lippincott Williams & Wilkins, 1998. Gorbach, Sherwood L., John G. Bartlett, and Neil R. Nussbaum, Robert L., Roderick R. McInnes, and Hunt- Blacklow, eds. Infectious Diseases. 3rd ed. New York: ington F. Willard, eds. Thompson and Thompson Genet- Lippincott Williams & Wilkins, 2003. ics in Medicine. 6th rev. ed. Philadelphia: W. B. Hill, Stuart, and Michael A. Palladino, eds. Emerging Saunders, 2004. Infectious Diseases. San Francisco: Benjamin Cum- Pierce, Benjamin. Genetics: A Conceptual Approach. 2nd ed. mings, 2005. New York: W. H. Freeman, 2004. Karlen, Arno. Man and Microbes: Disease and Plagues in Ross, Dennis W. Introduction to Molecular Medicine. 3rd ed. History and Modern Times. New York: Simon & Shus- New York: Springer, 2002. ter, 1996. Shawker, Thomas H. Unlocking Your Genetic History: A Lahita, Robert G., ed. Systemic Lupus Erythematosus. 4th Step-by-Step Guide to Discovering Your Family’s Medical ed. Burlington, MA: Elsevier Academic Press, 2004. and Genetic Heritage. Nashville, TN: Rutledge Hill Leung, Donald Y. M., Hugh A. Sampson, Raif S. Geha, Press, 2004. and Stanley J. Szefler. Pediatric Allergy: Principles and Trent, R. J. Molecular Medicine. 3rd ed. Burlington, MA: Practice. St. Louis: C. V. Mosby, 2003. Elsevier Academic Press, 2005. Mandell, Gerald L., John E. Bennett, and Raphael Dolin, eds. Principles and Practice of Infectious Diseases. 6th ed. History of Medicine 2 vols. New York: Churchill Livingstone, 2004. Fenster, Julie M. Mavericks, Miracles, and Medicine: The Pio- Nelson, Kenrad E., Carolyn Masters Williams, and Neil neers Who Risked Their Lives to Bring Medicine into the M.H. Graham, eds. Infectious Disease Epidemiology: The- Modern Age. New York: Barnes & Noble Books, 2005. ory and Practice. Sudbury, MA: Jones and Bartlett, Friedman, Meyer, and Gerald W. Friedland. Medicine’s 10 2003. Greatest Discoveries. New Haven, CT: Yale University Wessner, David, and Michael A. Palladino, eds. HIV and Press, 1998. AIDS. San Francisco: Benjamin Cummings, 2005. 436 Bibliography

Integrative, Complementary, and Alternative Health Latchaw, Richard, John Kucharczyk, and Michael Mose- Cowan, Eliot. Plant Spirit Medicine. Columbus, NC: Swan ley, eds. Imaging of the Nervous System: Diagnostic and Raven, 1995. Therapeutic Applications. New York: Mosby Elsevier, Rothfeld, Glenn S., and Suzanne Levert. The Acupuncture 2004. Response: Balance Energy and Restore Health—A Western Mosley, Anthony D., and Deborah S. Romaine. The Ency- Doctor Tells You How. New York: Contemporary Books, clopedia of Parkinson’s Disease. New York: Facts On 2002. File, 2004. Wansink, Brian. Marketing Nutrition: Soy, Functional Foods, Noback, Charles R., Norman L. Strominger, Robert J. Biotechnology, and Obesity. Champaign: University of Demarest, and David A. Ruggiero. The Human Nervous Illinois Press, 2005. System: Structure and Function. 6th ed. Totowa, NJ: Weil, Andrew, Health and Healing: The Philosophy of Inte- Humana Press, 2005. grative Medicine and Optimum Health. Rev. ed. New Sanes, Dan H., Thomas A. Reh, and William A. Harris. York: Houghton Mifflin, 2004. Development of the Nervous System. 2nd ed. Burlington, Weil, Andrew, Natural Health, Natural Medicine: The Com- MA: Elsevier Academic, 2005. plete Guide to Wellness and Self-Care for Optimum Health. Scheld, Michael W., Richard J. Whitley, and Christina Rev. ed. New York: Houghton Mifflin, 2004. M. Marra, eds. Infections of the Central Nervous System. 3rd ed. New York: Lippincott Williams & Wilkins, 2004. Mental Health, Alcoholism, and Substance Abuse Watts, Ray L., and William C. Koller. Movement Disorders: Fehr, Scott Simon. Introduction to Group Therapy: A Practi- Neurologic Principles and Practice. 2nd ed. New York: cal Guide. 2nd ed. Binghamton, NY: Haworth Press, McGraw-Hill, 2004. 2003. Johnson, Bankole A., Pedro Ruiz, and Marc Galanter, eds. Handbook of Clinical Alcoholism Treatment. New Nutrition and Diet York: Lippincott Williams & Wilkins, 2003. Duyff, Roberta Larson. American Dietetic Association Com- Sadock, Benjamin J., and Virginia A. Sadock. Kaplan and plete Food and Nutrition Guide. 2nd ed. Hoboken, NJ: Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clini- John Wiley & Sons, 2002. cal Psychiatry. 9th ed. New York: Lippincott Williams Mahan, L. Kathleen, and Sylvia Escott-Stump. Krause’s & Wilkins, 2002. Food, Nutrition, and Diet Therapy. Philadelphia: W. B. Substance Abuse and Mental Health Services Adminis- Saunders, 2003. tration (SAMHSA). Overview of Findings from the 2004 McArdle, William D., Frank I. Katch, and Victor L. National Survey on Drug Use and Health [NSDUH Series Katch. Sports and Exercise Nutrition. New York: Lippin- H-27, DHHS Publication No. SMA 05-4061]. cott Williams & Wilkins, 1999. Rockville, MD: Office of Applied Studies, 2005. Whitney, Eleanor Noss, and Sharon Rady Rolfes. Under- standing Nutrition. 10th ed. Belmont, CA: Wadsworth/Thomson Learning, 2004. Neurologic and Neuromuscular Health and Conditions Williams, Melvin H. Nutrition for Health, Fitness, and Sport. Aminoff, Michael J., Robert R. Simon, and David Green- 7th ed. New York: McGraw-Hill, 2004. burg, eds. Clinical Neurology. 6th ed. New York: McGraw-Hill, 2005. Compston, Alastair, Ian R. McDonald, John Noseworthy, Orthopedics, Sports Medicine, and Exercise Hans Lassmann, David H. Miller, Kenneth J. Smith, Anderson, Marcia K. Fundamentals of Sports Injury Man- Hartmut Wekerle, and Christian Confavreux. agement. 2nd ed. New York: Lippincott Williams & McAlpine’s Multiple Sclerosis. 4th ed. New York: Wilkins, 2002. Churchill Livingstone, 2005. Baechle, Thomas R., and Roger W. Earle, eds. Essentials Donaghy, Michael, ed. Brain’s Diseases of the Nervous Sys- of Strength Training and Conditioning. 2nd ed. Cham- tem. 11th ed. New York: Oxford University Press, paign, IL: Human Kinetics, 2000. 2001. Bahr, Roald, and Sverre Maehlum, eds. Clinical Guide to Fox, Michael J. Lucky Man: A Memoir. New York: Hyper- Sports Injuries: An Illustrated Guide to the Management of ion, 2002. Injuries in Physical Activity. Champaign: Human Kinet- Jankovic, Joseph, and Eduardo Tolosa, eds. Parkinson’s ics, 2003. Disease and Movement Disorders. New York: Lippincott Dutton, Mark. Orthopaedic Examination, Evaluation, and Williams & Wilkins, 2004. Intervention. New York: McGraw-Hill, 2002. Bibliography 437

Emery, Alan E. H., ed. The Muscular Dystrophies. New Love, Susan, Dr. Susan Love’s Breast Book. 4th ed. Cam- York: Oxford University Press, 2002. bridge, MA: Da Capo Press, 2005. Griffin, Letha Yurko, ed. Essentials of Musculoskeletal Care. Moore, Keith L., and T. V. N. Persaud, eds. The Developing Rosemont, IL: American Academy of Orthopaedic Human: Clinically Oriented Embryology. 7th ed. Surgeons, 2005. Philadelphia: W. B. Saunders, 2003. Hislop, Helen J., and Jacqueline Montgomery. Daniels Murkoff, Heidi, Arlene Eisenburg, and Sandee Hath- and Worthington’s Muscle Testing: Techniques of Manual away. What to Expect When You’re Expecting. 3rd ed. Examination. 7th ed. Philadelphia: W. B. Saunders, New York: Workman Publishing, 2002. 2002. Northrup, Christiane, M.D. The Wisdom of Menopause: Cre- Kisner, Carolyn, and Lynn Allen Colby. Therapeutic Exer- ating Physical and Emotional Health and Healing during cise: Foundations and Techniques. 4th ed. Philadelphia: the Change. Rprnt. New York: Bantam Books, 2001. F. A. Davis, 2002. Northrup, Christiane. Women’s Bodies, Women’s Wisdom: Levangie, Pamela K., and Cynthia C. Norkin. Joint Struc- Creating Physical and Emotional Health and Healing. ture and Function: A Comprehensive Analysis. 4th ed. Rprnt. New York: Bantam Books, 2002. Philadelphia: F. A. Davis, 2005. Rothfeld, Glenn S., and Deborah S. Romaine. The Ency- Robergs, Robert A., and Steven J. Keteyian. Fundamen- clopedia of Men’s Health. New York : Facts On File, tals of Exercise Physiology: For Fitness, Performance, and 2005. Health. New York: McGraw-Hill, 2005. Stanley, Deborah A., ed. Sexual Information for Teens: Sahrmann, Shirley A. Diagnosis and Treatment of Movement Health Tips about Sexual Development, Human Reproduc- Impairment Syndromes. St. Louis: C. V. Mosby, 2001. tion, and Sexually Transmitted Diseases. Detroit, MI: Omnigraphics, 2003. Stoppard, Miriam. Woman’s Body: A Manual for Life. New Reproductive and Sexual Health York: Dorling Kindersley, 1994. Anderson, Barbara A. Reproductive Health: Women and Men’s Shared Responsibility. Sudbury, MA: Jones and Bartlett, 2005. Skin Health and Conditions Armstrong, Lance, and Sally Jenkins. It’s Not about the Habif, Thomas P., James L. Campbell, Jr., M. Shane Bike: My Journey Back to Life. New York: Penguin Put- Chapman, James G. H. Dinulos, and Kathryn A. Zug, nam, 2000. eds. Skin Disease: Diagnosis and Treatment. 2nd ed. New Aronson, Diane and the staff of RESOLVE. Resolving York: Mosby-Year Book, 2005. Infertility. New York: HarperCollins, 2001. McNally, Robert Aquinas. Skin Health Information for Blute, Michael, ed. Mayo Clinic on Prostate Health. New Teens: Health Tips about Dermatological Concerns and Skin York: Kensington Publishing, 2003. Cancer Risks. Detroit, MI: Omnigraphics, 2003. Bostwick, David G., American Cancer Society’s Complete Rigel, Darrell, Robert Friedman, Leonard M. Dzubow, Guide to Prostate Cancer. Atlanta, GA: American Can- Douglas Reintgen, Jean-Claude Bystryn, and Robin cer Society, 2004. Marks. Cancer of the Skin. Philadelphia: W. B. Saun- DeCherney, Alan H., and Lauren Nathan. Current Obstet- ders, 2004. ric and Gynecologic Diagnosis & Treatment. 9th ed. New Sheen, Barbara. Acne. San Diego, CA: Lucent Books, York: McGraw-Hill, 2002. 2004. Ganschow, Pamela S., Frances E. Norlock, Elizabeth A. Turkington, Carol, and Jeffrey S. Dover. Skin Deep: An Jacobs, and Elizabeth A. Marcus, eds. Breast Health A–Z of Skin Disorders, Treatments, and Health. New and Common Breast Problems: A Practical Approach. York: Facts On File, 1996. Philadelphia: American College of Physicians, 2004. Hywel C. Williams, ed. Atopic Dermatitis: The Epidemiology, Grimm, Peter D., John C. Blasko, and John E. Sylvester, Causes and Prevention of Atopic Eczema. New York: eds. The Prostate Cancer Treatment Book. New York: Cambridge University Press, 2000. Contemporary Books, 2003. Wolff, Klaus, Richard A. Johnson, and Dick Suurmond, Holmes, King K., ed. Sexually Transmitted Diseases. 4th ed. eds. Fitzpatrick’s Color Atlas and Synopsis of Clinical Der- New York: McGraw-Hill, 2006. matology. 5th ed. New York: McGraw-Hill, 2005. 438 Appendix I MEDICAL ADVISORY REVIEW PANEL

Kyra J. Becker, M.D., is codirector of the Uni- topics. Educated in Germany and the United States, versity of Washington Stroke Center in Seattle, she has extensive experience in natural therapies Washington. She is also an associate professor of and integrative medicine. Dr. Fleckenstein is board- neurology and neurological surgery at the Univer- certified in internal medicine. sity of Washington School of Medicine. Dr. Becker Dr. Fleckenstein received her medical degree provides patient care through her practice at Har- from Universität Hamburg, Germany. She com- borview Medical Center and is a primary investi- pleted her internship and residency in primary gator on several stroke-related research studies. care medicine at Carney Hospital in Boston, Mass- Dr. Becker received her bachelor of science achusetts, and a fellowship in ambulatory medi- (B.S.) degree in biology summa cum laude from Vir- cine at VA Brockton, Massachusetts. Her ginia Tech in Blacksburg, Virginia, and her doctor subspecialty certification in natural medicine is of medicine (M.D.) degree from Duke University from Ärztekammer Hamburg (German Board). School of Medicine in Durham, North Carolina. She completed her internship in internal medi- Nancy A. Lewis, Pharm.D., is a clinical phar- cine, residency in neurology, and clinical fellow- macist and medical science liaison for MGI ship in critical care neurology all at Johns Hopkins Pharma, Inc., a biopharmaceutical company spe- Hospital in Baltimore, Maryland. Dr. Becker is cializing in oncology and acute care products. Dr. board-certified in neurology and psychiatry with a Lewis frequently conducts workshops and focused special certification in vascular neurology. training presentations. She is an active member of the Washington-Alaska Cancer Pain Initiative. James C. Blair, III, PA-C, is director of Madrona Dr. Lewis received her bachelor of science Hill Urgent Care Center in Port Townsend, Wash- (B.S.) in pharmacy and her doctor of pharmacy ington. Mr. Blair is a physician assistant certified (Pharm.D.) degrees from the University of Wash- with special recognition in primary care and sur- ington in Seattle, Washington. She serves on the gery. He is an advanced cardiac life support clinical faculty at the University of Washington in (ACLS) instructor and has worked much of his Seattle, Washington and on the adjunct faculty at career to provide emergency services in small hos- Washington State University in Pullman, Wash- pitals and clinical care settings in rural communi- ington. ties. Mr. Blair received his associate of science Gary R. McClain, Ph.D., is a psychologist, coun- degree in nursing from Wenatchee Valley College selor, and consultant in New York City. Dr. McClain in Wenatchee, Washington, and completed the has more than 25 years of experience as a mental MEDEX Northwest Physician Assistant Program at health professional and in the business world. The the University of Washington School of Medicine focus of his practice is healthcare and wellness. in Seattle, Washington. Dr. McClain’s graduate studies were in clinical psychology and education, with a focus on adult Alexa Fleckenstein, M.D., writes books and con- personality development and learning. He ducts lectures and workshops about natural health received his doctor of philosophy (Ph.D.) from the 439 440 Medical Advisory Review Panel

University of Michigan. Dr. McClain has coau- care medicine at the University of Washington thored or edited 14 books and frequently conducts School of Medicine, Seattle, Washington. workshops. Maureen Pelletier, M.D., C.C.N., F.A.C.O.G.,is Maureen Ann Mooney, M.D., is a clinical, surgi- board-certified in obstetrics and gynecology as well cal, and cosmetic dermatologist in private practice as in clinical nutrition. A former aviation medical in Puyallup, Washington, where she specializes in examiner, Dr. Pelletier is also licensed as a medical treating skin cancer. Dr. Mooney is trained to per- acupuncturist and is a DAN! (Defeat Autism Now!) form Mohs’ Micrographic Surgery. Dr. Mooney is physician. She is in private practice in Cincinnati, board-certified in dermatology and dermato- Ohio, with an emphasis on integrative medicine. pathology. Dr. Pelletier received her medical degree (M.D.) Dr. Mooney received her bachelor of science from Tufts University School of Medicine in (B.S.) degree in biology summa cum laude from the Boston, Massachusetts, and completed her resi- University of Minnesota College of Biological Sci- dency in obstetrics and gynecology at the Univer- ences in St. Paul, Minnesota, and her doctor of sity of Cincinnati. She received clinical training in medicine (M.D.) degree from the University of mind-body medicine at the Mind-Body Institute at Minnesota School of Medicine in Minneapolis, Harvard University and completed the integrative Minnesota. She completed her internship at Hen- medicine program at the University of Arizona nepin County Medical Center in Minneapolis, School of Medicine. Dr. Pelletier is a national and Minnesota, and her residency in dermatology at international lecturer. New Jersey Medical School in Newark, New Jer- sey. Dr. Mooney also completed fellowships in Otelio S. Randall, M.D., F.A.C.C., is director of Dermatopathology at New Jersey Medical School the preventive cardiology program, hypertension and Mohs’ Micrographic Surgery at Louisiana and clinical trials, and the Cardiovascular Disease State University Healthcare network in New Prevention and Rehabilitation Center at Howard Orleans, Louisiana. University Hospital in Washington, D.C. Dr. Ran- dall is widely published in peer-reviewed journals Margaret J. Neff, M.D., M.Sc., is attending and has authored two books. He has received physician, pulmonary and critical care medicine, numerous awards during his career, including the at Harborview Medical Center in Seattle, Wash- 2004 Outstanding Faculty Research Award from ington. Dr. Neff is a medical monitor for the Cystic Howard University School of Medicine. Fibrosis Therapeutic Diagnostics Network, co-chair Dr. Randall received his bachelor’s degree (B.S.) of one of the biomedical committees of the Uni- in chemistry from Howard University and his versity of Washington Institutional Review Board, medical degree (M.D.) from the University of and a clinical investigator on several research Michigan Medical School in Ann Arbor, Michigan. studies. She is board-certified in internal medi- He completed his internship at the State Univer- cine, pulmonary disease, and critical care medi- sity of New York at Brooklyn, residencies in inter- cine. nal medicine at Baylor College of Medicine in Dr. Neff earned her bachelor’s degree in biologi- Houston, Texas, and University of Michigan Hos- cal sciences (B.S.) and medical degree (M.D.) from pital, and a fellowship in cardiology at the Univer- Stanford University in Stanford, California, and her sity of Michigan Hospital. Dr. Randall is designated master of science (M.S.) degree in epidemiology a specialist in hypertension by the ASH specialists from the University of Washington in Seattle, program in affiliation with the American Society Washington. She completed her internship and res- of Hypertension (ASH). idency in internal medicine and a fellowship in intensive care at Stanford University and a fellow- Susan D. Reed, M.D., M.P.H., is program director ship in pulmonary/critical care at the University of for the Women’s Reproductive Health Research Washington. Dr. Neff is an assistant professor of Program at the University of Washington in Seattle, medicine in the division of pulmonary and critical Washington. She is a clinician at Harborview Medical Advisory Review Panel 441

Medical Center and University of Washington Christina M. Surawicz, M.D., is gastroenterol- Medical Center. Dr. Reed is also an affiliate investi- ogy section chief of at Harborview Medical Center gator at the Center for Health Studies and Fred in Seattle, Washington. She is also professor of Hutchinson Cancer Research Center, and an associ- medicine and assistant dean for faculty develop- ate professor of obstetrics and gynecology, and an ment at the University of Washington School of adjunct professor in epidemiology at the University Medicine in Seattle. Dr. Surawicz is widely pub- of Washington School of Medicine. Dr. Reed’s areas lished in peer-reviewed journals and has of clinical and research interest are gynecologic authored, edited, and contributed to dozens of issues for women with genetic diseases, cross-cul- books. tural medicine, and management of menopause. Dr. Surawicz received her undergraduate Dr. Reed received her master’s degree (M.S.) in degree, a bachelor of arts (B.A.) in biology, from human genetics from Sarah Lawrence College in Barnard College in New York City and her medical Bronxville, New York, her medical degree (M.D.) degrees (M.D.), awarded with honors, from the from Stanford University Medical Center in Stan- University of Kentucky College of Medicine in ford, California, and her Master of Public Health Lexington, Kentucky. She completed her medical (M.P.H.) degree from the University of Washing- internship, medical residency, and gastroenterol- ton School of Public Health. Dr. Reed is a licensed ogy fellowship at the University of Washington in genetic counselor and board-certified in obstetrics Seattle. Dr. Surawicz is board-certified in internal and gynecology. medicine and gastroenterology.

Jerry Richard Shields, M.D., is an ophthalmol- Denise L. Wych, R.N. C.M., is a cardiac nurse ogist in private practice in Tacoma, Washington. case manager at Palmetto Health-Richland Heart He sees general ophthalmology patients and per- Hospital in Columbia, South Carolina, where she forms laser correction and cataract surgery. Dr. integrates clinical and medical appropriateness cri- Shields is board-certified in ophthalmology and teria in discharge planning and resource utiliza- VISIX-certified. tion within the framework of an interdisciplinary Dr. Shields received his bachelor of science health-care team. She has worked in medical-sur- (B.S.) degree in biology cum laude from Wake For- gical, intensive care unit, newborn, school nurs- est University in Winston-Salem, North Carolina, ing, and home health. and his medical degree (M.D.) from the Medical Ms. Wych received her diploma in nursing College of Georgia in Augusta, Georgia. He com- from Providence School of Nursing in Sandusky, pleted his internship in internal medicine and his Ohio. She served 10 years as an officer in the US residency in ophthalmology at the University of Navy Nurse Corps, during which she was twice Washington in Seattle, Washington. awarded the Navy Achievement Medal.

CUMULATIVE INDEX TO VOLUMES 1–4

Volume numbers appear in bold acetylcholine nociceptor 1:381 followed by a colon and the rele- Alzheimer’s disease 1:221–223 PMS 3:325 vant volume page reference. Pages botulinum therapy 1:141 rebound headache 1:375 in bold indicate major treatment of hyperhidrosis 1:165 somatization disorder 3:385 a topic. Pages with a t indicate muscle 1:336 TCM 4:102 tables. musculoskeletal system 1:294 vertigo 1:61 nervous system 1:217 vulvodynia 3:355 A neurotransmitter 1:272 acute lymphocytic leukemia (ALL) ABCD skin examination (for nicotine 4:345 2:122, 145 malignant melanoma) 1:197, tobacco 4:353 acute pain 1:321–322, 363–364, 198t, 199–200, 200t acetylcholinesterase inhibitors 363t, 367, 372, 379, 380, 383 abdomen 3:8–9, 322; 4:45 1:222, 262, 273 acute respiratory distress syndrome abdominal adiposity 4:284, 308 achalasia 3:9, 40 (ARDS) 2:181, 215, 311, 353, abdominal aorta 3:69, 169 Achilles tendon 1:297, 358, 359 357; 4:365 abdominal distention 3:8–9 Achilles tendon injury 1:297–298 acute stress disorder 3:66, 359; abdominal pain 2:324, 330; 3:9, 9t, achondroplasia 1:298, 334 4:251 15, 34; 4:332 acne 1:131–133, 132t; 4:322 addiction 1:368, 384; 4:314–315, abducens nerve 1:246, 247t acne, adult. See rosacea 314t abortifacients 3:240, 272 acoustic neuroma 1:7 barbiturates 4:323 abortion 3:240–241, 282; 4:39 acquired immunodeficiency buprenorphine 4:325 abrasions 4:361, 362, 366, 379 syndrome (AIDS) 2:333, 334. See cannabis 4:326 abscess 1:44, 143; 2:294, 306 also HIV/AIDS cocaine 4:328 abstinence 4:47, 320, 350 acrochordon 1:133 dependence 4:331 accidental injuries 4:5–7 acromegaly 3:104–106, 105t depressants 4:331 closed fracture 4:364 ACTH. See adrenocorticotropic detoxification 4:332 contact toxins 4:382 hormone dextromethorphan 4:332 dislocations 4:364 actinic keratosis 1:133–134, 135, ethchlorvynol 4:334 hip fracture in older adults 158 flunitrazepam 4:336 1:327 active immunity 2:239 glutethimide 4:336 nervous system 1:218 acupuncture 2:376, 387; 4:56–57, hallucinogens 4:337 poison prevention 4:41 56t heroin 4:338 site and situation assessment alternative methods for pain hypnotics 4:339 4:359 relief 1:365 LAAM 4:342 trauma prevention 4:48 depression 3:372 methadone 4:342 workplace stress 4:256 hot flashes 3:290 methamphetamine 4:342 ACE inhibitor. See angiotensin- IBS 3:66 naltrexone 4:344 converting enzyme inhibitor living with pain 1:378 narcotics 4:344 acetaldehyde dehydrogenase menopause 3:302 nicotine 4:345 4:316, 333 morning sickness 3:306 opiates 4:347 acetaminophen 1:364, 366–368, naturopathy 4:92 performance-enhancing 375; 4:5, 165 nausea 3:78 substances 4:348

443 444 Index

prescription drug abuse 4:349 adolescence 1:313; 4:215, 240, aerobic capacity 4:213 scheduled drug 4:170 240t, 250, 292 cross training 4:219 stimulants 4:350 adoption 3:241–242, 281, 289 physical activity substance abuse 4:311, 313 adrenal cortex 3:99, 106, 111 recommendations 4:228 substance abuse treatment adrenal glands 3:107–109, 108t, resistance exercise 4:229 4:351, 352 109t strength 4:232 tolerance 4:354 ACTH 3:110 training 4:233 withdrawal syndrome 4:354 Addison’s disease 3:106 walking for fitness 4:235 Addison’s disease 2:67, 256; adrenal insufficiency 3:109 aerobic fitness 2:9, 9t 3:106–107, 106t androgens 3:113 aging and pulmonary changes adrenal insufficiency 3:109 cortisol 3:116 2:183 aldosterone 3:112 CRH 3:116 asthma 2:188 cortisol 3:116 DHEA 3:119 breathing exercises 2:194 Cushing’s syndrome 3:118 dopamine 3:124 cardiac capacity 2:27 hyperaldosteronism 3:137 endocrine system 3:99 cardiac output 2:30 hypercalciuria 3:197 epinephrine 3:125 COPD 2:201 hyponatremia 3:143 estrogens 3:126 dyspnea 2:203 adenocarcinoma 2:208, 366; hyperaldosteronism 3:136 heart rate 2:60 3:17–18, 28, 40, 90, 91, 104 See hyperkalemia 3:138 AFP. See alpha fetoprotein also tumor, cancerous norepinephrine 3:152 African Americans 2:64, 165, 293, Adenocard. See adenosine pheochromocytoma 3:154 295, 296; 4:48, 255 adenoid hypertrophy 1:7–8 progesterone 3:156 age 2:220, 222; 4:278 adenoids 1:7–8, 58 renin 3:158 age-related macular degeneration adenoma 3:107. See also tumor, testosterone 3:160 (ARMD) 1:69, 70–71, 73, 78; noncancerous urinary system 3:171 4:60, 79, 80, 107 acromegaly 3:104 adrenal insufficiency 3:106, age spots. See lentigines adrenal glands 3:109 109–110, 110t, 131, 137, 138, aging, cancer and 2:365; 3:91, 251, Cushing’s syndrome 3:117 143, 154 253, 255, 256, 274, 275 hyperaldosteronism 3:137 adrenocorticotropic hormone aging, cardiovascular changes that hypernatremia 3:138 (ACTH) 3:101, 106, 109, 110, occur with 2:9–10, 27, 34, 49, hyperparathyroidism 3:138 112, 116, 117 98; 4:16 MEN 3:151 adult acne. See rosacea aging, changes in pain perception adenoma-to-carcinoma transition adult survivors of childhood cancer that occur with 1:364–365 2: 366 2:366–367 aging, changes in physical ability acromegaly 3:106 adverse drug reaction 1:365, 384; and fitness needs that occur with adenoma 3:107 4:148–149, 148t, 149, 163, 164, 4:214–215 adrenal glands 3:109 171, 318 aging, changes in the blood and colorectal cancer 3:31 Advil. See ibuprofen lymph that occur with esophageal cancer 3:41 AED. See automated external 2:123–124 FAP 3:43 defibrillator aging, effects on drug metabolism HNPCC 3:58 aerobic bacteria 2:308, 346 and drug response 1:364–365; intestinal polyp 3:64 aerobic capacity 2:9, 73, 123; 4:149–150 stomach cancer 3:91 4:213, 213t aging, effects on immune response adenomyosis 3:241 aerobic exercise 4:214 2:239, 275 adenosine (Adenocard) 2:77, 84t blood doping 4:324 aging, endocrine changes that occur adenosine triphosphate (ATP) conditioning 4:217 with 3:109, 110–111, 163, 164; 3:128; 4:134 disability and exercise 4:220 4:76, 88 adenovirus 2:221, 306 endurance 4:220 aging, gastrointestinal changes that ADH. See antidiuretic hormone fitness level 4:222 occur with 3:10, 32, 35, 46, 50, ADHD. See attention deficit physical activity 58, 64 hyperactivity disorder recommendations 4:228 aging, integumentary changes that adhesive capsulitis 1:298–299, 353 strength 4:232 occur with 1:134–135, 210–211 adipose (fat) cells 3:126, 156, 160, training 4:233 aging, musculoskeletal changes that 249 walking for fitness 4:235 occur with 1:298–299, 299–300, adipose tissue 1:128, 134–135, aerobic exercise 1:63; 2:27, 30, 97, 326–327, 341–342, 345–347, 350; 333–334 194; 4:213–214, 214t 4:72 Index 445 aging, neurologic changes that alcohol 1:313, 362; 2:17, 370; alkylating agents 2:375, 375t occur with 1:220–221, 221–223, 3:237, 337–338, 384; 4:315–318, alkyl nitrites 4:320–321, 320t 261, 268–269, 272, 273, 275–276, 317t ALL. See acute lymphocytic 288–289 accidental injuries 4:5 leukemia aging, nutrition and dietary changes addiction 4:314 allele 4:113, 113t, 127, 135 that occur with 4:176–177, 186, barbiturates 4:323 allergen 2:201, 236, 239–240, 240t, 194 benzodiazepines 4:324 243, 258, 260 aging, otolaryngologic changes that cancer prevention 4:14 allergic asthma 2:190, 240, 247, occur with 1:7, 8–9, 45–46, cannabis 4:326 258, 269, 280 52–54 cardiovascular disease allergic conjunctivitis 2:240–241, aging, pulmonary changes that prevention 4:16 258 occur with 2:181–183 chloral hydrate 4:327 allergic dermatitis 2:241–242 aging, reproductive and sexual club drugs 4:328 allergic reaction. See changes that occur with dependence 4:330 hypersensitivity reaction 3:242–243 depressants 4:332 allergic rhinitis 1:8, 51; 2:188, 240, andropause 3:244–245 drugs 4:145 241, 242–243, 258, 288 BPH 3:248 ethchlorvynol 4:334 allergy 1:18, 150, 368; 2:120, 236, erection 3:278 FAS 4:334, 335 243–244, 258, 298; 4:152, 381, fertility 3:283 flunitrazepam 4:336 382. See also hypersensitivity infertility 3:295 GABA 4:336 reaction; immune system and ovarian cancer 3:312 hangover 4:338 allergies prostate cancer 3:327–328 intoxication 4:341 allergy testing 2:241, 244, 258 prostate gland 3:330 naltrexone 4:344 alopecia 1:135, 136–138, 137t, 162, prostate health 3:331 overdose 4:164 173 PSA 3:333 sobriety 4:350 alopecia areata 1:137, 138 puberty 3:335 substance abuse 4:311 alpha adrenergic antagonists. See vagina 3:353 substance abuse treatment 4:351 alpha blockers aging, urinary system changes that water safety 4:50 alpha blockers 2:77–78, 78t, 84t occur with 3:175–176; 4:98 withdrawal syndrome 4:354 alpha fetoprotein (AFP) 3:243, 244, aging, vision and eye change that alcoholic hallucinosis 4:319 263, 345; 4:12, 130 occur with 1:71–72, 72t alcoholic hepatitis 3:56, 71 alphahydroxyl acid (AHA) 1:144, ARMD 1:70–71 alcohol interactions with 171 astigmatism 1:73 medications 4:318–319 alpha-1-antitrypsin (AAT) bilberry 4:60 alcoholism 1:262; 3:80, 81, 89, deficiency 2:200, 216 cataract 1:77–78 381, 385; 4:319–320 Alport’s syndrome 3:176–177, dacryocystitis 1:85 alcohol 4:317 208 dry eye syndrome 1:86 alcohol interactions with alternative and complementary ectropion 1:87 medications 4:318 approaches to conventional glaucoma 1:94 disulfiram 4:333 medicine 4:51–55, 51–108, 57, ischemic optic neuropathy hangover 4:338 81, 84, 93 1:97–98 aldosterone 2:80, 256; 3:111–112 alternative and complementary lutein 4:79 Addison’s disease 3:106 remedies for cancer 2:367–368 night blindness 1:102 adrenal glands 3:107, 108 alternative methods for pain relief presbyopia 1:108–109 endocrine system 3:99 1:365–366, 380 zeaxanthin 4:107 hyperaldosteronism 3:136 altitude sickness 2:205, 216, 217 AHA. See alphahydroxyl acid hyperkalemia 3:138 alveolus 2:183 AIDS. See acquired renin 3:158 berylliosis 2:192 immunodeficiency syndrome; stress response hormonal bronchoscopy 2:197 HIV/AIDS cascade 3:159 bronchus 2:198 AIDS-related Kaposi’s sarcoma urinary system 3:171 COPD 2:199 1:168, 169 aldosteronism. See lungs 2:212 albinism 1:135–136, 176 hyperaldosteronism oxygen-carbon dioxide albumin 2:124, 127, 129; 3:73–74, alimentary system. See exchange 2:214 176, 205, 227 gastrointestinal system pleura 2:218 albuminuria 3:176, 177, 191, 192, alkaline phosphatase (ALP) 1:348; pulmonary edema 2:223 205, 210, 211 3:75 pulmonary fibrosis 2:226 446 Index

smoking and pulmonary disease anal atresia 3:10, 40, 352. See also anesthesia 1:385; 4:257, 258, 2:230 bowel atresia 260–263, 261t, 262t, 277, 344, tuberculosis 2:359 anal fissure 3:10–11, 54, 85, 87, 88 347 Alzheimer’s disease 1:221–223; analgesic medications 1:366–368 aneurysm 1:233; 2:10–11, 21 3:358, 376, 379, 381 acute pain 1:363 anger and anger management 4:49, aging and nutrition/dietary aging and changes in pain 238, 240–241, 241t, 256 changes 4:176 perception 1:364 angina pectoris 2:11–12, 41, 44, aphasia 1:225 anesthesia 4:261 54–55, 70, 79, 111–112; 4:320 cognitive function and earache 1:21 angioedema 1:206; 2:244, 245 dysfunction 1:243 eudynia 1:372 angiogenesis 2:87, 253–254 dementia 1:252 headache 1:377 angiogenesis inhibitor drugs 2:368 Down syndrome 4:123 living with pain 1:378 angiogram 2:12 ginkgo biloba 4:70 maldynia 1:379 angioma 1:138 memory and memory methadone 4:342 angioplasty 2:12–13 impairment 1:262 neural blockade 1:380 angina pectoris 2:12 nervous system 1:217–219 opiates 4:347 CABG 2:43 neurotransmitter 1:272 pain and pain management CAD 2:44–45 organic brain syndrome 1:273 1:361, 362 cardiac catheterization 2:28 tai chi 4:101 rebound headache 1:374–375 heart attack 2:57 amblyopia 1:72–73, 100, 110, 118; terminal pain 1:384 medications to treat 4:123 anaphylaxis 1:206; 2:240, 243, cardiovascular disease 2:79 ambulatory surgery 4:260, 267, 244–245, 258, 260, 268, 270; myocardial infarction 2:87 268, 276 4:148, 369, 381 stent 2:106 amebiasis 2:306–307, 350 androgenic alopecia 1:137, 162 angiotensin-converting enzyme amenorrhea 3:243, 269, 270 androgens 2:256, 381; 3:113, 113t; (ACE) inhibitor 1:18, 42t; 2:77, American Cancer Society 1:168; 4:321 77t, 84t 2:368, 373; 4:28 aging and reproductive/sexual angiotensin II 2:77, 78; 3:111, 158, American College of Obstetricians changes 3:242 171 and Gynecologists (ACOG) estrogens 3:126 angiotensin II receptor blockers 3:278; 4:61 FSH 3:127 (ARBs) 2:78, 78t, 84t American Heart Association (AHA) hirsutism 3:134 ankle injuries 1:301–302 4:28, 212, 371 hormone 3:135 ankylosing spondylitis 1:302–303 amino acid 2:64, 280; 4:97, 114, ovaries 3:313 anorexia nervosa 3:94, 361, 374; 192, 226, 229 PCOS 3:320 4:202 amnesia 1:261; 4:342 progesterone 3:157 antacids 3:11–12, 11t; 4:155 amniocentesis 3:243–244, 244, testosterone 3:160 anthracosis 2:183, 185, 219 327; 4:130 uterine fibroids 3:350 anthrax 2:309–310, 310t; 4:386 amniotic fluid 3:243, 244, 320, 349 andropause 3:244–245 anti-aging approaches 4:57–58, 70, amphetamines 4:314, 321, 321t, anemia 2:124–126, 125t; 76, 77, 322 331, 338, 343, 350. See also 3:171–172, 192, 193, 219, 269, antianxiety medications 1:16; methamphetamine 371 3:359–360, 360t; 4:324, 331 ampicillin 2:341, 353, 360 aging and changes in antibiotic chemotherapy agents ampulla of Vater 3:4, 38 blood/lymph 2:123 2:376, 376t amputation 1:300–301, 323, 351, blood disorders 2:121 antibiotic medications 2:307–308, 382 blood doping 4:324 307t–308t Amsler grid 1:70, 71, 73, 117 bone marrow donation 2:132 adverse drug reaction 4:148 amygdala 1:231, 260–261 chemotherapy 2:376 antibiotic prophylaxis 4:7–8 amyloidosis 2:154, 155, 160; cyanosis 2:46 antibiotic resistance 4:150 3:112–113, 190; 4:125 EPO 2:138 drug 4:154 amyotrophic lateral sclerosis (ALS) erythrocytes 2:119 ginseng 4:72 1:223–225 G6PD deficiency 4:131 IND 4:160 anabolic steroids and steroid hemoptysis 2:204 preventive medicine 4:1 precursors 3:113, 119; 4:66, multiple myeloma 2:158 side effect 4:171 321–322, 322t, 348 myelofibrosis 2:160 antibiotic ointment 4:216, 280 anaerobic bacteria 2:308, 312–313, sickle cell disease 2:165 antibiotic prophylaxis 4:7–8, 7t, 346; 4:151 thalassemia 2:169 151, 251 Index 447 antibiotic resistance 2:197, 308, platelet aggregation 2:163 antimetabolites 2:375, 375t 329, 330, 349, 354, 359, 360; pulmonary embolism 2:225, 226 antimitochondrial antibodies 4:150–151 PVD 2:96 2:248–249, 248t antibody 2:245; 4:271 stroke 2:108 antioxidant 2:50, 237, 382; 4:177 active immunity 2:239 thrombolytic therapy 2:110–111 bilberry 4:60 aging and immune response valvular heart disease 2:114 cancer prevention 4:14 2:239 vitamin K 2:173 cardiovascular disease allergy 2:243 antidepressant medications prevention 4:16 antibody-mediated immunity 3:360–362, 361t, 362t coenzyme Q10 4:64 2:246 analgesic medications 1:366, ginkgo biloba 4:70 antigen 2:246 367 green tea 4:73 antimitochondrial antibodies dependence 4:331 lutein 4:79 2:248–249 hypericum 4:99 lycopene 4:79 antiphospholipid antibodies nervous system 1:217 melatonin 4:88 2:249 neurogenic pain 1:381 nutrients 4:193 complement cascade 2:255–256 neurotransmitter 1:272 vitamin and mineral therapy CVID 2:255 side effect 4:171 4:105 food allergies 2:260 toxic optic neuropathy 1:119 vitamins and health 4:206, 207 gammaglobulin 2:263 antidiarrheal medications 3:12–13, zeaxanthin 4:107 graft vs. host disease 2:263 12t antiphospholipid antibodies 2:249 HLAs 2:267 antidiuretic hormone (ADH) 3:99, antiplatelet agents 2:14, 78–79, 79t, hypersensitivity reaction 2:268 113, 113–114, 122, 145, 158, 84t immune response 2:272 171, 202 antipsychotic medications 1:252; immune system 2:236 antiemetic medications 3:13–14, 14t 3:362–363, 362t; 4:148 immunization 2:338 antifungal medications 1:204, 204t; antiretroviral medication 2:335, inflammation 2:277 2:308–309, 309t, 327 335t lymph node 2:151 antigen 2:246–247 antiseizure medication 1:281, 281t, MAbs 2:283 aging and immune response 282, 289, 367, 368, 382–383 passive immunity 2:289 2:239 antismoking efforts 4:8 virus 2:362 antibody 2:245 antispasmodic medications. See antibody-mediated immunity antibody-mediated immunity muscle relaxant medications 2:246 2:246 antitoxin 4:151 antibody 2:245 BALT 2:251 antivenin 4:152, 382 B-cell lymphocyte 2:251 B-cell lymphocyte 2:251 antiviral medications 1:269; 2:309, cell-mediated immunity 2:253 CA-125 2:373 309t; 4:36 immune response 2:272 CEA 2:373–374 anus 3:14 immune system 2:235 clusters of differentiation 2:254 anxiety 1:383; 3:358, 376, 380; MHC 2:282 complement cascade 2:255–256 4:62, 323 pathogen 2:348 CVID 2:255 anxiety disorders 3:359, 378 antibody response 3:200, 203 food allergies 2:261 aorta 1:352; 2:16 anticholinergic medication 1:50, gammaglobulin 2:263 aneurysm 2:10 320 HLAs 2:267–268 aortic stenosis 2:16 anticoagulants 2:78, 78t, 84t, 106, immune response 2:272 artery 2:20 113–114; 4:70 immune system 2:235–236 atherosclerosis 2:21 anticoagulation therapy 1:235; immunization 2:338 cardiac cycle 2:29 2:13–16, 15t immunoglobulin 2:275 cardiopulmonary bypass 2:33 aortic stenosis 2:16 lymph node 2:151 circulation 2:5 aspirin therapy 2:20–21 macrophage 2:282 coronary arteries 2:40 atrial fibrillation 2:23 MHC 2:282 heart 2:4 carotid stenosis 2:35 vaccine 2:298 heart transplantation 2:62 clotting factors 2:136 antihistamine medications IABP counterpulsation 2:70 coagulation 2:136 2:247–248, 248t, 266, 270; 4:152, LVEF 2:72 DIC 2:137 339 VALT 2:299 DVT 2:48 anti-inflammatory medications aortic stenosis 2:16, 32, 59, 60 medications to treat (corticosteroid medications) Apgar score 3:245, 245t cardiovascular disease 2:79 2:256–257 aphasia 1:225 448 Index aphrodisiac 4:71, 106 EPS 2:53 cardiovascular system 2:7 aplastic anemia 2:125, 157 frostbite 4:376 circle of Willis 2:37, 37, 37, 37 apnea 2:183–184, 191, 199 heart attack 2:56, 57 coronary arteries 2:40–41 apocrine sweat glands 1:128, 164, heart failure 2:58 nicotine 4:346 202 heart transplantation 2:61 platelet 2:163 apolipoprotein B100 (apoB100) hiccup 2:204 pulmonary arteries 2:98 2:16–17 ICD 2:69 pulse 2:99 apoptosis 4:113–114 LQTS 2:74–75 stent 2:106 adenoma-to-carcinoma medications to treat tobacco use other than smoking transition 2:366 cardiovascular disease 2:77 4:306 cancer 2:364 medicinal herbs and botanicals arthritis 1:302–303, 322–324. See Epstein-Barr virus 2:323 4:84 also specific forms of arthritis, e.g.: hemolysis 2:143 myocardial infarction 2:87 osteoarthritis molecularly targeted therapies obesity and cardiovascular arthrogryposis 1:303–304 2:384 disease 2:90 arthroscopy 1:295–296, 304 mononuclear phagocyte system omega fatty acids and art therapy 4:58–59 2:283 cardiovascular health 2:90 asbestosis 2:183, 184–185, 185, NK cell 2:286 palpitations 2:93, 94 185t, 193, 205, 210, 219 oncogenes 2:384 PAT 2:94 ascites 3:16, 195 stem cell therapy 4:141 pulse 2:100 ASD. See atrial septal defect telomere 4:143 PVC 2:97 aspergillosis 2:185–186, 221, 222 appearance 4:274, 275 radiofrequency ablation 2:101 Aspergillus 2:186, 327 appendectomy 3:6, 14–15, 15 sarcoidosis 2:293 asphyxia 2:184, 186–187 appendicitis 3:15, 86 sick sinus syndrome 2:104 aspiration 1:18, 25; 2:183, 187 appendicular skeleton 1:293, 355 sports drinks and foods 4:231 aspirin 1:59, 280, 361, 362, 368, appendix 3:14, 15, 15–16 sudden cardiac death 2:108 375; 2:56, 57, 71, 163, 287, 290, appetite 4:177–178, 201, 292, 294, valvular heart disease 2:113 316; 4:5, 82, 145, 165 295, 299, 321, 326 Wolff-Parkinson-White aspirin, dangers of. See Reye’s appetite suppressants 4:293, 309 syndrome 2:116–117 syndrome apraxia 1:225–226 ART. See assisted reproductive aspirin therapy 1:183; 2:12, 14, aqueous humor 1:67, 92, 93 technology 20–21, 35, 79, 136, 287; 4:16 arachidonic acid 2:279, 290 arterial plaque. See atherosclerotic assisted reproductive technology ARBs. See angiotensin II receptor plaque (ART) 3:245–247, 264, 283, 289, blockers arterioles 1:127; 3:69, 111, 113, 293, 295, 356 ARDS. See acute respiratory distress 136 asthma 1:356; 2:187–190, 188t, syndrome antihistamine medications 189t; 4:34 Arixtra. See fondaparinux 2:247 allergic asthma 2:240 ARMD. See age-related macular arteriosclerosis 2:19 bronchus 2:198 degeneration artery 2:20 byssinosis 2:198 aromatherapy 4:58, 58t, 68 blood vessels 2:5 COPD 2:199 arrhythmia 2:17–19, 18t capillary beds 2:27 desensitization 2:258 alkyl nitrites 4:320 histamine 2:267 leukotrienes 2:279 angioplasty 2:13 Raynaud’s syndrome 2:101–102 living with chronic pulmonary atrial fibrillation 2:22–23 arteriosclerosis 2:19, 107 conditions 2:207 bundle branch block 2:26 arteriovenous malformation (AVM) pneumonitis 2:223 CAD 2:44 2:11, 19–20 astigmatism 1:73, 80–82, 111 cardiac output 2:29 artery 2:20; 3:206, 302 ataxia 1:226–227 cardioversion 2:34 aneurysm 2:10–11 atelectasis 2:190–191, 196, 199, cocaine 4:329 angioplasty 2:12–13 201, 208 congenital heart disease 2:39 aorta 2:16 atherectomy 2:21, 96 CRT 2:31 arteriosclerosis 2:19 atheroma. See atherosclerotic dehydration 4:374 atherosclerosis 2:21–22 plaque dextromethorphan 4:332 atherosclerotic plaque 2:22 atherosclerosis 1:58, 261; 2:21–22; ECG 2:52 AVM 2:19–20 3:218, 338 ectopic beat 2:52 blood vessels 2:4 aging and drug metabolism/drug EECP 2:55 cardiac catheterization 2:28 response 4:149 Index 449

alcohol 4:317 homocysteine 2:64 Addison’s disease 3:106, 107 angina pectoris 2:11 lifestyle and cardiovascular aging and immune response apoB100 2:17 health 2:72 2:239 arteriosclerosis 2:19 minimally invasive cardiac alopecia 1:137 artery 2:20 surgery 2:86 alopecia areata 1:138 atherosclerotic plaque 2:22 omega fatty acids and antiphospholipid antibodies blood disorders 2:121 cardiovascular health 2:90 2:249 body shape and cardiovascular platelet aggregation 2:163 B-cell lymphocyte 2:251 health 2:25 PVD 2:96 bullous pemphigoid 1:142 CAD 2:43–45 TIA 2:111 chondritis 1:318 cardiovascular disease athetosis 1:227 chronic fatigue syndrome prevention 4:15 athlete’s foot. See tinea 1:369–370 cardiovascular system 2:7 athletic injuries 1:304–305, 305t cicatricial pemphigoid 1:79 carotid bruit 2:34 Achilles tendon injury colitis 3:25 carotid stenosis 2:35 1:297–298 complement cascade 2:255 cholesterol blood levels 2:36 ankle injuries 1:301–302 diabetes 3:119, 120 cholesterol, dietary 4:181 cross training 4:219 DLE 1:152–153 coronary arteries 2:41 knee injuries 1:332 DMARDs 2:258 c-reactive protein 2:45 meniscectomy 1:336 dry eye syndrome 1:86 diet and cardiovascular health Osgood-Schlatter disease 1:341 endometriosis 3:276 2:49 repetitive motion injuries 1:352 episcleritis 1:88 exercise and health 4:221 RICE 1:353 Goodpasture’s syndrome 3:193 garlic 4:70 rotator cuff impingement Graves’ disease 3:129 homocysteine 2:64 syndrome 1:353 HLAs 2:267 hyperlipidemia 2:64 soft tissue injuries 4:367 hypothyroidism 3:147 hypertension 2:66, 67 sprains and strains 1:356 IBD 3:64 immune system 2:238 atopic rhinits. See allergic rhinitis immune system 2:236, 238 interleukins 2:278 atopy 2:190, 249 immunoablation 2:274 medications to treat atria 2:4, 22–23, 28, 29, 88, 94, immunodeficiency 2:274 cardiovascular disease 2:76 116–117 immunoglobulin 2:275 PVD 2:96–97 atrial fibrillation 2:17, 22–23, 34, immunosuppressive medications risk factors for cardiovascular 76, 94, 225 2:276 disease 2:102 atrial septal defect (ASD) 2:38–40, immunosuppressive therapy smoking and cardiovascular 59; 4:120, 123 2:276 disease 2:105 atrioventricular (AV) node 2:4, 23, immunotherapy 2:276 soy and cardiovascular health 26, 28–29, 81, 94, 104 iritis 1:97 2:106 atrophic (dry) ARMD 1:70–71 islets of Langerhans 3:149 stroke 2:107 ATT deficiency. See alpha-1- living with immune disorders tobacco use other than smoking antitrypsin deficiency 2:280 4:306 attention deficit hyperactivity multiple sclerosis 1:263 VALT 2:299 disorder (ADHD) 3:364; 4:315, myasthenia gravis 1:339 atherosclerotic plaque (atheroma) 320, 321, 335 myocarditis 2:87 2:22 audiologic assessment 1:9–10, 41, narcolepsy 1:267 angioplasty 2:13 43 nephritis 3:207 aortic stenosis 2:16 auditory canal 1:14–15, 59 neutropenia 2:161 atherectomy 2:21 auricle 1:14, 41 pemphigus 1:182–183 atherosclerosis 2:21–22 auscultation 2:185, 190, 191, 196, POF 3:324 CAD 2:44, 45 219, 224 polyglandular deficiency cardiac catheterization 2:28 autism 3:364–365 syndrome 3:156 carotid bruit 2:34–35 autoantibody (antimitochondrial polymyositis 1:350 carotid stenosis 2:35 antibodies) 2:248–249 primary biliary cirrhosis 3:84 cholesterol blood levels 2:36 autocrine activity 2:257, 290 primary sclerosing cholangitis coagulation 2:136 autograft 1:198, 199 3:85 diet and cardiovascular health autoimmune disorders 2:249–250, SALT 2:295 2:50 249t–250t; 4:64 sarcoidosis 2:293–294 endarterectomy 2:53 5ASA medications 2:260 sialadenitis 1:50 450 Index

Sjögren’s syndrome 2:294–295 BALT. See bronchus-associated anger and anger management SLE 2:295–296 lymphoid tissue 4:241 somatostatin 3:159 barbiturates 4:323–324, 323t childhood obesity 4:292 thymectomy 2:172 benzodiazepines 4:324 conduct disorder 3:369 thymus 2:120–121, 172 depressants 4:331 conversion disorder 3:369 TNFs 2:297 ethchlorvynol 4:334 cyclothymic disorder 3:370 urticaria 1:206 glutethimide 4:336 detoxification 4:332 vasculitis 2:299–302 hypnotics 4:339 dysthymic disorder 3:373 vitiligo 1:207 substance abuse 4:312 hypochondriasis 3:376 autologous donation. See blood withdrawal syndrome 4:354 mind-body interactions 4:90 autodonation bariatric surgery 3:48, 86; obesity 4:300 automated external defibrillator 4:284–288, 285t, 292, 300, 310 OCD 3:378 (AED) 2:23, 27, 47; 4:371, 372 barium enema 3:17 oppositional defiant disorder autonomic nervous system 1:216, barium swallow 3:17, 41 3:378 277; 3:3, 82 barotrauma 1:11, 48 panic disorder 3:379 autosomal dominant pattern 3:176, Barrett’s esophagus 3:17–18, 37, phobia 3:379 214 40, 42, 58 psychotherapy 3:381 autosomal recessive disorder 4:125, Bartholin’s cyst 3:248, 306, 352 smoking cessation 4:305 137, 142–143 Bartholin’s gland 3:248, 353 substance abuse 4:313 autosomal recessive pattern 3:176, basal cell carcinoma 1:130, 176, substance abuse treatment 197, 214 196–197, 198t 4:351 autosomal trisomy 4:114, 119, 122, basal ganglia 1:227, 231, 238, 241, trichotillomania 3:386 124, 134, 136, 139 252, 256 weight loss and weight autosome 4:114, 118, 119, 127 basal metabolic rate (BMR) 4:193, management 4:309 AVM. See arteriovenous 225 Bell’s palsy 1:87, 228–229 malformation basophil 2:120, 138, 278 Benadryl. See diphenhydramine AV node. See atrioventricular node B-cell lymphocyte 2:251. See also benign essential tumor 1:286, 288 avulsion 1:322; 4:361–362, 366, plasma cells benign paroxysmal positional 380 aging and immune response vertigo (BPPV) 1:11–12; 3:164 avulsion fracture 1:301, 341 2:239 benign prostatic hyperplasia (BPH) axial skeleton 1:293, 355 allergy 2:243 3:248–249, 249t axon 1:216, 220, 270, 271, 283 antibody 2:245 aging and urinary system Ayurveda 4:52, 59, 59t, 91 antibody-mediated immunity changes 3:175 2:246 bladder 3:178 B antigen 2:246–247 cystoscopy 3:185 babesiosis 2:311, 311t BALT 2:251 erectile dysfunction 3:280 back pain 1:302, 306–307, bone marrow 2:119 hydronephrosis 3:196 316–317, 326–327, 333, 356, 365 clusters of differentiation 2:254 Kegel exercises 3:199 baclofen (Lioresal) 1:102, 259, 360 CVID 2:255 medicinal herbs and botanicals bacteria 1:39; 2:311–312, 312t, Epstein-Barr virus 2:323–324 4:83 346–347 immune system 2:235, 236 prostate gland 3:330 antibiotic resistance 4:150 immunization 2:338 retrograde ejaculation 3:336 drug 4:154 immunoglobulin 2:275 saw palmetto 4:98 food safety 4:24 lymphocyte 2:151 urinary incontinence 3:224 injecting drugs, risks of 4:340 lymphokines 2:281 urinary urgency 3:225 laser surgery 4:265 lymphoma 2:152 vesicoureteral reflux 3:230 preventive medicine 4:3 MALT 2:284 benign tumor. See tumor, radiation and biochemical mononucleosis, infectious 2:344 noncancerous injuries 4:386 NALT 2:287 benzodiazepines 1:16; 3:359–360; recombinant DNA 4:139 Peyer’s patches 2:289 4:324 side effect 4:171 T-cell lymphocyte 2:296 alcoholic hallucinosis 4:319 vitamins and health 4:207 Becker’s muscular dystrophy alcoholism 4:320 bad breath. See halitosis 1:337, 338t delirium tremens 4:330 Baker’s cyst 1:307 bedsore. See decubitus ulcer dependence 4:331 balance 1:3–4, 33–35; 4:101, 211 behavior modification therapy depressants 4:331, 332 balanitis 3:248 3:366 flunitrazepam 4:336 Index 451

hypnotics 4:339 magnet therapy 4:81 UTI 3:225 prescription drug abuse 4:349 panic disorder 3:379 vesicoureteral reflux 3:229 substance abuse 4:312 PMS 3:325 bladder cancer 3:179–182, 180t, withdrawal syndrome 4:354 sleep disorders 3:384 181t, 185, 194, 223, 249 beriberi 4:179–180, 205 somatization disorder 3:385 bladder capacity 3:175, 212 berylliosis 2:183, 185, 192–193, visualization 4:104 bladder catheterization 3:182, 222, 193t, 198, 219 vulvodynia 3:355 225 beta blocker 1:289, 367, 368 biological response modifier 2:148, bladder exstrophy 3:182 arrhythmia 2:18t 155, 160. See also immunotherapy bladder stones 3:196, 227, 229 atrial fibrillation 2:23 biotechnology 4:112, 139 blastocyst 4:140, 144 hypertension 2:67 bioterrorism 2:310, 354 blastoma 2:368–369, 369t LQTS 2:74 bipolar disorder 3:366–367, 366t; bleeding medications to treat 4:99 anesthesia 4:261 cardiovascular disease 2:79, cognitive therapy 3:369 bariatric surgery 4:287 80t, 85t cyclothymic disorder 3:370 bloodless surgery 4:263–264 valvular heart disease 2:114 depression 3:372 emergency and first aid 4:361 bezoar 3:18 ECT 3:375 gunshot wounds 4:377 bilateral orchiectomy 3:307, 308 psychiatric disorders and head and spinal cord injuries bilberry 4:60, 60t, 83 psychologic conditions 3:357, 4:378 bile 2:119, 143; 3:18 358 laser surgery 4:265 bile ducts 3:18 psychosis 3:381 motor vehicle accidents 4:378 cholestasis 3:23 suicidal ideation and suicide puncture wound 4:366 gallbladder 3:46 3:385 symptom assessment and care gastrointestinal system 3:1, 3, 4 birth control pills. See oral triage 4:360 jaundice 3:67 contraception traumatic amputation 4:380 liver 3:69 birth defects 2:19–20, 37, 64, 351, wound care 4:280, 281 primary biliary cirrhosis 3:84 357; 3:40, 323, 352; 4:9–12, bleeding control 1:22; 4:362–363 primary sclerosing cholangitis 10t–12t. See also congenital avulsion 4:362 3:84 anomaly body substance isolation 4:358 bile acid sequestrants 2:81, 81t acne medications 1:132 gunshot wounds 4:378 bile ducts 3:18–19 congenital anomaly 4:120 lacerations 4:365 bile 3:18 congenital hip dysplasia motor vehicle accidents 4:379 biliary atresia 3:19 1:318–319 multiple trauma 4:379 cholestasis 3:23 FAS 4:334 open fracture 4:366 duodenum 3:36 minoxidil and finasteride 1:138 symptom assessment and care ERCP 3:38 neural tube defects 4:39 triage 4:360 gastrointestinal system 3:1 spina bifida 1:282–283 traumatic amputation 4:380 liver 3:69 substance abuse 4:313 blepharitis 1:74, 96, 106 primary biliary cirrhosis 3:84 talipes equinovarus 1:358 blepharoplasty 1:75, 210 primary sclerosing cholangitis birthmark 1:139–141, 140t, 203 blepharospasm 1:75 3:84 bisphosphonates 1:346, 348 blind spot 1:117, 121. See also optic biliary atresia 3:19, 84 bites and stings 4:152, 381, disk bilirubin 3:19–20, 19t, 23, 67, 73, 381–382 blister 1:141, 141–142, 154, 159, 74, 306 black cohosh 4:61, 61t, 95 166, 190, 200; 4:235 bioavailability 4:153, 158, 172 black eye 1:74; 4:380 blister prevention 4:215–216 bioequivalence 4:153, 158, 172 bladder 3:178–179, 178t–179t bloating. See abdominal distention biofeedback 1:365, 375; 4:60–61, aging and urinary system blood 1:323; 2:127. See also blood 60t changes 3:175 and lymph acupuncture 4:57 cystoscopy 3:185 aging and changes in anger and anger management cystourethrogram 3:185 blood/lymph 2:123–124 4:241 nephritis 3:207 albumin 2:124 cyclothymic disorder 3:370 retrograde ejaculation 3:335 anemia 2:124–126 dysthymic disorder 3:373 ureter 3:221 antibody 2:245 hypnosis 4:78 urethra 3:221 antitoxin 4:151 IBS 3:66 urinary system 3:172 antivenin 4:152 Kegel exercises 3:199 uterine fibroids 3:349 blood and lymph 2:118 452 Index

body substance isolation 4:357 trough level 4:172 lifestyle and cardiovascular bone marrow 2:132 blood clots health 2:72, 73 breathing 2:193 anticoagulation therapy Lyme disease 2:342 cardiac output 2:29–30 2:13–16, 15t medications to treat cardiovascular system 2:1 aspirin therapy 2:20–21 cardiovascular disease 2:76 coronary arteries 2:41 cardiac rehabilitation 2:30 minerals and health 4:187 erythrocytes 2:119 DVT 2:47 nephrectomy 3:206 food allergies 2:260 medications to treat nephritis 3:208 gammaglobulin 2:263 cardiovascular disease obesity and cardiovascular hangover 4:338 2:82–83 disease 2:90 heart 2:4, 56 NSAIDs 2:287 omega fatty acids and hemapheresis 2:141 platelet aggregation 2:163 cardiovascular health 2:90 homocysteine 2:64 pulmonary embolism 2:224 shock 4:367 immune system 2:235 thrombolytic therapy 2:110–111 sleep disorders 3:384 injecting drugs, risks of 4:340 TIA 2:111 stroke 2:107, 108 oxygen-carbon dioxide valvular heart disease 2:114 tobacco 4:353 exchange 2:216 blood donation 1:189; 2:127–129, urinary system 3:171 oxygen saturation 2:216 128, 130, 131, 162 valvular heart disease 2:114 oxygen therapy 2:217 blood doping 4:324–325 blood stem cells 2:129 phlebotomy 2:162 bloodless surgery 4:263, 263–264, blood and lymph research and plasma 2:162 266 treatment advances 2:122 pleural effusion 2:218 bloodletting 2:122, 237 bone marrow 2:118, 132 poisoning 4:382 blood pressure 2:24–25, 24t bone marrow transplantation pulmonary embolism 2:224 ADH 3:113 2:133 Raynaud’s syndrome 2:101 aerobic exercise 4:214 cell structure and function septicemia 2:353 aging and changes in 4:115 thalassemia 2:169 blood/lymph 2:124 graft vs. host disease 2:265 thrombocytopenia 2:171 aging and physical ability/fitness leukemia 2:145 triglyceride blood level 2:112 4:215 myelofibrosis 2:160 tumor markers 2:395 aging and urinary system stem cell therapy 4:141 vitamin K 2:173 changes 3:175 blood tests 2:245, 248, 255, 285 blood and lymph 2:118–174, 121t aldosterone 3:111 alcoholism 4:319 blood autodonation 2:128, 130; alkyl nitrites 4:320 anabolic steroids and steroid 4:263 Alport’s syndrome 3:177 precursors 4:322 bloodborne pathogens 4:340, 351 anesthesia 4:262 delirium tremens 4:330 blood-brain barrier 1:229, 230, aneurysm 2:10 half-life 4:159 272; 4:316, 323, 345, 353 antidepressant medications sobriety 4:350 blood circulation 3:361 blood transfusion 2:129–130, 129t, alcohol 4:316 antihistamine medications 130t alcohol interactions with 2:248 anemia 2:125 medications 4:318 barbiturates 4:323 blood and lymph medical barbiturates 4:323 bites and stings 4:381 traditions 2:122 blood doping 4:324 breathing 2:193 blood autodonation 4:263 buprenorphine 4:325 cardiovascular system 2:4 blood doping 4:324 cannabis 4:327 circulation 2:5 blood type 2:130 carbohydrate loading 4:217 delirium tremens 4:330 bone marrow donation 2:133 cocaine 4:328 diet and cardiovascular health DIC 2:137 disulfiram 4:333 2:50 hemapheresis 2:141 drugs 4:147 drowning 4:368 HLAs 2:267 efficacy 4:158 frostbite 4:375 leukemia 2:147 NTI 4:161 glomerulonephritis 3:191 myelodysplasia syndrome overdose 4:166 hemophilia 2:144 2:160 route of administration human relations 4:238 myelofibrosis 2:160 4:169–170 hyperaldosteronism 3:136 plasma 2:162 substance abuse 4:313 hypertension 2:66–67 sickle cell disease 2:166 therapeutic level 4:172 hypotension 2:67–68 thalassemia 2:169 Index 453 blood type 2:62, 130–131, 131t, osteomalacia 1:343 thrombocythemia 2:171 246, 318; 3:76, 187, 200, 203; osteomyelitis 1:343–344 thrombocytopenia 2:171 4:113, 263 osteopetrosis 1:344–345 bone marrow donation 2:129, 130, blood vessels 1:127–128, 244, Paget’s disease of the bone 132–133 373–374; 2:1, 4–5, 20, 34, 368; 1:348 bone marrow transplantation 4:320 skeleton 1:355 1:345; 2:133; 4:141 bloody nose. See epistaxis talipes equinovarus 1:358 anemia 2:125 blowing the nose 1:12–13, 36 tendon 1:359 blood and lymph research and blunt trauma 4:49, 377, 379 vitamin and mineral therapy treatment advances 2:122 BMI. See body mass index 4:105 cancer treatment options and body dysmorphic disorder bone cancer 1:309–310 decisions 2:372 3:367–368, 385 bone cell 1:298, 299 CSFs 2:254 body fat 4:295, 297, 299 bone density 1:310–311, 313, graft vs. host disease 2:263–265 body fat percentage 4:288–289, 344–347; 3:154, 162, 303 immunoablation 2:274 289t aging and nutrition/dietary immunosuppressive therapy abdominal adiposity 4:284 changes 4:176 2:276 childhood obesity 4:291 aging and physical ability/fitness leukemia 2:147 fitness level 4:222 4:215 multiple myeloma 2:159 heat and cold injuries 4:374 conditioning 4:218 myelofibrosis 2:161 hGH supplement 4:77 disability and exercise 4:220 SCID 2:294 lean muscle mass 4:297 fitness: exercise and health sickle cell disease 2:167 metabolism 4:226 4:211 thalassemia 2:169 nutritional assessment 4:193 physical activity bone spur 1:311, 356 triceps skinfold 4:307 recommendations 4:228 borborygmus 3:20, 82 waist to hip ratio 4:308 resistance exercise 4:229 boswellia 4:61, 61t body mass index (BMI) 2:43, 89, strength 4:233 botulinum therapy 1:50, 75, 141, 89t; 4:289–290, 290t bone disease (osteogenesis 165, 210, 289, 320 bariatric surgery 4:284 imperfecta) 1:342–343 botulism 2:312–313, 327; 4:386 body fat percentage 4:289 bone marrow 1:308, 309, 344–345, bovine spongiform encephalopathy childhood obesity 4:291 355; 2:131–132, 132t; 3:100, 112, (BSE) 1:248; 2:350 fitness level 4:222 202 bowel atresia 3:20, 40, 77 health risk factors 4:29 aging and changes in bowel movement 3:20 malnutrition 4:186 blood/lymph 2:123 constipation 3:32 nutritional assessment 4:193 anemia 2:125 diarrhea 3:34 obesity 4:299 B-cell lymphocyte 2:251 enema 3:40 obesity and health 4:302 blood 2:127 fiber and gastrointestinal health physical activity blood and lymph 2:118–119 3:45 recommendations 4:229 blood doping 4:324 FOBT 3:44 waist circumference 4:308 chemotherapy 2:377 gastrointestinal system 3:1 walking for fitness 4:235 CSFs 2:254 laxatives 3:68 weight loss and weight EPO 2:137 proctitis 3:85 management 4:309 erythrocyte 2:137 rectum 3:87 body shape and cardiovascular hematopoiesis 2:140 bowel sounds 3:20, 20, 61, 82 health 2:25 immune system 2:235 Bowman’s capsule 3:169, 172, 193, body substance isolation leukemia 2:145 202, 209 4:357–358, 366, 386 leukocyte 2:148 BPH. See benign prostatic boil. See furuncle leukopenia 2:148 hyperplasia bone 1:307–309, 309t, 311t lymphocyte 2:151 bradycardia 2:17, 23, 93, 104 ankle injuries 1:301 monocyte 2:157 braille 1:75–76 calcium and bone health multiple myeloma 2:157 brain 1:230–233, 231t, 233t 1:313–315 myelodysplasia syndrome 2:160 alcohol 4:316 fracture 1:322–323 myelofibrosis 2:160, 161 Alzheimer’s disease 1:221 musculoskeletal system 1:293 platelet 2:163 amphetamines 4:321 open fracture 4:366 polycythemia vera 2:164 analgesic medications 1:367, osteogenesis imperfecta reticulocyte 2:165 368 1:342–343 stem cell 4:140 aneurysm 2:11 454 Index

aphasia 1:225 brain tumor 1:235–237, 235t, 236t; angioedema 2:245 AVM 2:19 3:358, 381, 383 apnea 2:183 blood-brain barrier 1:229 branchial motor nerves 1:246, 247t auscultation 2:191 cannabis 4:326 BRCA-1/BRCA-2 2:364, 369; Cheyne-Stokes respiration cardiovascular system 2:4 3:250, 253 2:199 cerebral palsy 1:238–241 breast 1:200; 3:249–250, 250t COPD 2:200 cerebrospinal fluid 1:241 breastfeeding 3:253 cystic fibrosis and the lungs circle of Willis 2:37 breast health 3:254 2:201 CJD 1:248–249 fibroadenoma 3:284 dehydration 4:374 coma 1:244 intraductal papilloma 3:295 diaphragm 2:202 concussion 1:244–245 mastalgia 3:298 dyspnea 2:203 deep brain stimulation 1:250 mastectomy 3:298 frostbite 4:376 delirium tremens 4:330 mastitis 3:299 Heimlich maneuver 4:372 dementia 1:251–252 pregnancy 3:322 hyperventilation 2:204 EEG 1:253–254 prolactin 3:157 inhaled toxins 4:384 encephalitis 2:322–323 relaxin 3:158 injected toxins 4:385 encephalopathy 1:254 breast cancer 3:250–253, 251t–253t interstitial lung disorders 2:205 food cravings 4:295 adult survivors of childhood mechanical ventilation 2:214 ginkgo biloba 4:70 cancer 2:367 motor vehicle accidents heart attack 2:57 aging and cardiovascular 4:378–379 Huntington’s disease 1:256 changes 2:10 multiple trauma 4:379 hydrocephaly 1:256–257 anabolic steroids and steroid narcotics 4:344 hypnosis 4:77 precursors 4:322 overdose 4:166 learning disorders 1:258–259 BRCA-1/BRCA-2 2:369 oxygen-carbon dioxide maldynia 1:378 breast 3:250 exchange 2:216 memory and memory breast self-examination 3:255 pleura 2:218 impairment 1:260–262 cancer 2:364 pneumothorax 2:223 meninges 1:262–263 cancer risk factors 2:370 positive airway pressure 2:223 meningitis 2:343, 344 cancer treatment options and pulmonary fibrosis 2:226 microinfarction 2:84 decisions 2:372 rescue breathing 4:369 musculoskeletal system 1:293 cancer vaccines 2:373 respiration rate 2:227 nervous system 1:215, 217, 218 CEA 2:374 symptom assessment and care organic brain syndrome endocrine system 3:103 triage 4:359 1:272–273 fibrocystic breast disease 3:285 tachypnea 2:232 pain and pain management hormone-driven cancers 2:381 tuberculosis prevention 4:49 1:361 mammogram 3:298 yoga 4:106 pneumococcal pneumonia mastectomy 3:298 breathing exercises 2:185, 194, 2:349 medicinal herbs and botanicals 205, 207; 4:101 prion 2:349–350 4:83 breath sounds 2:194–195 psychoneuroimmunology 2:290 Paget’s disease of the breast brief reactive psychosis 3:358, 368 rabies 2:350 3:315 brittle bone disease. See SAMe 4:97 sentinel lymph node dissection osteogenesis imperfecta seizure disorders 1:281–282 2:391 broad-spectrum antibiotics 2:307, smell and taste disturbances surgery for cancer 2:394 313, 347 1:52–54 breastfeeding 2:239, 289; 3:157, broken nose 1:13 stroke 2:107–108 250, 253–254, 262, 296, 300, bronchi 1:182; 2:194, 199, 223, TIA 2:111 304; 4:89–90, 176, 179 349 traumatic brain injury (TBI) breast health 3:157, 250, 254, bronchiectasis 2:195–196 1:287–289 254–255, 285, 295, 298 aspergillosis 2:186 tremor disorders 1:288–289 breast self-examination 3:250, 253, breathing exercises 2:194 tuberculosis 2:359 254, 255, 284, 285, 298 bronchitis 2:196 brain damage 1:241–242; 4:313, breathing 1:4, 5, 13, 16, 39, 63; bronchus 2:198 369, 371, 375, 378 2:193–194. See also respiration lung abscess 2:208 brain death 1:233, 244, 253; 4:272 aging and pulmonary changes pneumothorax 2:223 brain hemorrhage 1:233–235, 234t 2:182 pulmonary fibrosis 2:226 brainstem 1:54, 215, 232, 235, 277 anesthesia 4:262 thoracotomy 2:232 Index 455 bronchioles 2:183, 199, 212, 214, performance-enhancing aging and pulmonary changes 216, 230, 349 substances 4:348 2:182 bronchitis 2:196, 196–197, 198, sports drinks and foods 4:231 alcohol 4:318 201, 319; 4:150, 327 weight loss and weight antigen 2:247 bronchoalveolar lavage 2:197 management 4:309 Barrett’s esophagus 3:17–18 bronchoscopy 2:197 calcitonin 1:346, 348, 382; 3:99, blood disorders 2:121 bronchovesicular breath sounds 115, 137, 139, 153, 162–163; bone cancer 1:309–310 2:191, 194 4:187 cancer of the penis 3:256 bronchus 2:197, 197–198 calcitriol 3:169, 172; 4:187 cervical cancer 3:256 alveolus 2:183 calcium 1:355; 2:22, 379t complement cascade 2:255 aspiration 2:187 aging and nutrition/dietary depression 3:372 bronchiectasis 2:195 changes 4:176 environmental hazard exposure bronchoalveolar lavage 2:197 calcitonin 3:115 4:22 bronchoscopy 2:197 drug interaction 4:155 Epstein-Barr virus 2:323 lung abscess 2:208 hypercalcemia 3:137 esophageal cancer 3:40 pleura 2:218 hypercalciuria 3:196 exercise and health 4:221 positive airway pressure 2:223 hyperparathyroidism 3:138 FAP 3:43 trachea 2:233 hypocalcemia 3:141 gastrointestinal system 3:5 bronchus-associated lymphoid minerals and health 4:186, 187 green tea 4:73 tissue (BALT) 2:251–252, 284 parathyroid glands 3:153 HPV 2:337 bruise. See ecchymosis resistance exercise 4:229 immune system 2:237, 238 BSE. See breast self-examination rickets 4:200 immunosenescence 2:275 building-related illness 4:12–13, strength 4:233 IND 4:160 34, 40, 47 thyroid gland 3:162–163 influenza 2:339 bulimia nervosa 3:361, 374 urinary system 3:172 interferons 2:278 bulla 1:141–142, 142, 142t, vitamin and mineral therapy interleukins 2:278 154–155, 182 4:105 Kaposi’s sarcoma 1:168–169 bullous keratopathy 1:76 vitamins and health 4:207 laryngectomy 1:31 bullous pemphigoid 1:142 calcium and bone health 1:310, leukemia 2:145 bundle branch 2:4, 23, 25, 26. See 313–315, 313t, 314t, 343, leukocyte 2:148 also bundle of His 345–346 lung transplantation 2:213 bundle branch block 2:25–26, 31 calcium channel blockers 1:367, lutein 4:79 bundle of His 2:4, 23, 26, 26, 26, 368 lycopene 4:80 26, 29. See also bundle branch angina pectoris 2:12 lymph 2:120, 149 buprenorphine 4:315, 325 arrhythmia 2:18t lymphadenopathy 2:149 Burkitt’s lymphoma 2:323, 345 atrial fibrillation 2:23 lymph node 2:151 burns 4:266, 361, 363–364, 363t, hypertension 2:67 lymphoma 2:152 379, 382 medications to treat MALT 2:284 bursa 1:311–312 cardiovascular disease 2:76, monocyte 2:157 bursitis 1:312, 352 80, 80t, 85t multiple myeloma 2:157 buspirone 3:359, 360 pulmonary hypertension 2:99 obesity and health 4:302 bypass surgery. See coronary artery valvular heart disease 2:114 pancreatic cancer 3:80 bypass graft calculi 3:196, 208, 216, 227 pemphigus 1:182, 183 byssinosis 2:183, 185, 193, 198, callus 1:141, 143; 4:216 pericarditis 2:95 219 caloric test 1:12, 62 phytoestrogens 4:94 calorie 4:180, 190, 226, 293, 300 pneumonia 2:220 C camptothecins 2:376, 376t rectum 3:87 CABG. See coronary artery bypass campylobacteriosis 2:314 reproductive system 3:237 graft Campylobacter jejuni 1:255; 3:25 retinoblastoma 1:114 CAD. See coronary artery disease cancellous (spongy) bone 1:308, 309 skin cancer 1:196–198 caffeine 1:377; 2:17, 51, 52, 93, 97; cancer 2:364–397 smoking and health 4:303–304 3:183, 285, 384; 4:326 actinic keratosis 1:133 spleen 2:167 diet aids 4:293 aging and gastrointestinal terminal pain 1:384 drugs 4:145 changes 3:10 thrombocythemia 2:171 green tea 4:74 aging and immune response thymectomy 2:172 hydration 4:184 2:239 thymus 2:172 456 Index

tobacco use other than smoking candidiasis 1:179; 2:289, 314–315, cardiac rehabilitation 2:29, 30–31, 4:306 315t, 334 30t, 63, 73 tracheostomy 2:234 canker sore 1:14; 4:73 cardiac resynchronization therapy virus 2:362 cannabis 4:312, 326–327, 327t (CRT) 2:31 zeaxanthin 4:107 Cannabis sativa 4:326, 327 cardiac tamponade. See tamponade, cancer of the penis 3:256, 264 canned foods 2:312, 313 cardiac cancerous tumor. See tumor, CA-125 (cancer antigen 125) 2:373 cardiomyopathy 1:335; 2:31–33; cancerous capillary beds 2:5, 19, 24, 27, 142 4:324 cancer prevention 2:212, 277, carbamazepine 3:367, 377 cardiovascular system 2:7 378–380, 382–383, 391–392; carbohydrate intolerance CRT 2:31 4:14 4:180–181, 185 diabetes and cardiovascular antioxidant 4:177 carbohydrate loading 4:217 disease 2:49 antismoking efforts 4:8 carbohydrate metabolism 4:180, heart sounds 2:60 breast cancer 3:253 191 pacemaker 2:93 cervical cancer 3:258 carbohydrates 4:190, 293 pulse 2:100 colonoscopy 3:28 carbon dioxide 2:5, 27, 33, 119, valvular heart disease 2:113 DRE 3:35 216 cardiopulmonary bypass 2:33–34 endoscopy 3:40 carbon monoxide 2:105, 230 CABG 2:41, 42 esophageal cancer 3:41 carbuncle 1:143 cardiovascular system 2:7 FOBT 3:45 carcinoembryonic antigen (CEA) congenital heart disease 2:37 liver cancer 3:71 2:373–374 heart transplantation 2:62 mammogram 3:298 carcinogen 2:231, 374, 374t, 392; lung transplantation 2:213 prostate gland 3:331 4:43, 303, 306, 327, 353. See also mechanical ventilation 2:215 prostate health 3:331 environmental carcinogens open heart surgery 2:90–91 prostatitis 3:334 carcinoma 2:374–375, 374t cardiopulmonary resuscitation PSA 3:333 cardiac arrest 2:23, 27, 87; 4:370 (CPR) 2:23, 27, 47, 56, 57, 187; Sun’s Soup 4:100 cardiac capacity 2:27–28, 33, 60, 72 4:371–372 cancer risk factors 2:155, 370, 371t, cardiac catheterization 2:28 body substance isolation 374, 381–383, 392; 3:41, 53, 64, angiogram 2:12 4:358 82, 94; 4:22, 30 angioplasty 2:12–13 cardiac arrest 4:371, 372 cancer treatment options and atherosclerosis 2:22 cardiovascular disease decisions 1:176, 310, 384; heart transplantation 2:63 prevention 4:16 2:372–373; 4:78 IABP counterpulsation 2:70 cold water drowning 4:368 breast cancer 3:251 medications to treat electrocution 4:372 cancer of the penis 3:256 cardiovascular disease 2:79 emergency and first aid 4:356, cancer vaccines 2:373 minimally invasive cardiac 357 cervical cancer 3:257 surgery 2:86 frostbite 4:376 chemotherapy 2:375–377 radiofrequency ablation 2:101 Heimlich maneuver 4:373 CIN 3:259 cardiac cycle 2:28–29 ingested toxins 4:384 endometrial cancer 3:274 blood pressure 2:24 inhalation burns 4:365 hysterectomy 3:292 coronary arteries 2:41 inhaled toxins 4:385 MAbs 2:283 ectopic beat 2:51 injected toxins 4:385 mastectomy 3:299 EECP 2:54 motor vehicle accidents molecularly targeted therapies heart 2:4 4:378–379 2:384 heart rate 2:60 multiple trauma 4:379 ovarian cancer 3:311–312 IABP counterpulsation 2:70 911 4:371 Paget’s disease of the breast LQTS 2:74 rescue breathing 4:369 3:315 LVEF 2:72 responder safety and personal prostate cancer 3:330 myocardial infarction 2:87 protection 4:358 prostatectomy 3:333 cardiac enzymes 2:29 shock 4:367 radiation therapy 2:388–390 cardiac intensive care unit (CICU) warm water drowning 4:370 surgery for cancer 2:393–394 2:29 cardiovascular disease (CVD) thyroid cancer 3:162 cardiac output 2:16, 27–30, 67, 72, 1:221, 233, 335, 384; 2:34; 3:84, cancer vaccines 2:277, 373; 3:258 79 243, 279, 301, 372 Candida albicans 1:57, 58, 180, 181t; cardiac papillary fibroelastoma. See addiction 4:314 2:314, 315 fibroelastoma aerobic capacity 4:213 Index 457 aging and drug metabolism/drug syncope 2:108 catecholamines 3:99, 154 response 4:149 tai chi 4:101 catheter 4:261, 274, 276 aging and physical ability/fitness tobacco 4:353 cauliflower ear 1:14 4:215 tobacco use other than smoking cavities, dental. See dental caries aging and pulmonary changes 4:306 CD4 cell (helper T-cell) 2:246, 253, 2:182 triglyceride blood level 2:112 254, 269, 296, 334, 335 alcohol 4:317 valvular heart disease 2:113–114 CDC. See US Centers for Disease atherosclerosis 2:21–22 cardiovascular disease prevention Control and Prevention bariatric surgery 4:288 4:14–17 cecum 3:4, 21, 61 cardiovascular system 2:5 aspirin therapy 2:20–21 celiac disease 3:21–22 chelation therapy 4:62 CVD 2:34 cell division 4:111, 113, 117, 143 cholesterol, dietary 4:181 DASH eating plan 2:47 cell-mediated hypersensitivity cholesterol blood levels 2:37 diet and cardiovascular health reaction. See type IV coenzyme Q10 4:64 2:49–50 hypersensitivity reaction diabetes and cardiovascular lifestyle and cardiovascular cell-mediated immunity 2:235, disease 2:48–49 health 2:72–73 246, 253, 272, 275, 286, 296, disability and exercise 4:220 omega fatty acids and 334, 348 drugs 4:146 cardiovascular health 2:90 cell structure and function 1:270, exercise and health 4:221 Ornish program 2:91–92 340; 4:115–116 fitness: exercise and health physical exercise and antigen 2:246–247 4:210 cardiovascular health 2:97 bone marrow 2:132 fitness level 4:222 cardiovascular health, body shape cancer risk factors 2:370 garlic 4:69 and 2:25 dysplasia 2:380 health risk factors 4:28 cardiovascular system 1:3, 4; granulocyte 2:139 heart rate 2:60 2:1–117, 2, 5t, 341; 4:241, 346, hematopoiesis 2:141 heredity and heart disease 376 hemolysis 2:143 2:63–64 cardioversion 2:18, 23, 34, 69 hyperplasia 2:381 immune system 2:237–238 carotenoids 2:379t; 4:79, 107, 177 leukocyte 2:148 integrative medicine 4:78 carotid arteries 2:21, 35, 37, 53 lymphocyte 2:152 lifestyle and cardiovascular carotid bruit 2:34–35, 35 monocyte 2:157 health 2:72 carotid stenosis 2:35, 111 oncogenes 2:384–385 lifestyle variables: smoking and carpal tunnel syndrome 1:275, phagocyte 2:162 obesity 4:282 315–316 platelet 2:163 living with cardiovascular carrier 2:315 reticulocyte 2:165 disease 2:73–74 cartilage 1:316; 4:64 tumor suppressor genes 2:397 medications to treat achondroplasia 1:298 cellular metabolism 4:168, 187, cardiovascular disease aging and musculoskeletal 221, 303, 304 2:76–85 changes 1:299 cellulitis 1:143–144, 155 nutrients 4:191 back pain 1:306 central nervous system 1:238; nutrition and diet 4:175 cauliflower ear 1:14 2:267, 341, 345, 350 obesity and cardiovascular chondritis 1:318 aging and drug metabolism/drug disease 2:89–90 crepitus 1:319 response 4:149 obesity and health 4:301 herniated nucleus pulposus aging and neurologic changes preventive medicine 4:3 1:326 1:220 pulmonary edema 2:224 knee injuries 1:330 alcohol interactions with rheumatic heart disease 2:103 kyphosis 1:332 medications 4:318 risk factors for cardiovascular meniscectomy 1:336 amphetamines 4:321 disease 2:102–103 musculoskeletal system 1:294 barbiturates 4:323 sexual activity and osteoarthritis 1:341–342 benzodiazepines 4:324 cardiovascular disease 2:104 spinal cord 1:283 brain 1:230–233 smoking and cardiovascular catabolism 4:225, 226 caffeine 4:326 disease 2:105 cataract 1:67, 77–78, 78t, 103; cocaine 4:328 smoking and health 4:303 4:60, 79, 83 cranial nerves 1:246–247 soy 4:98 cataract extraction and lens depressants 4:331 substance abuse treatment replacement 1:68–69, 76, 78–79; dextromethorphan 4:332 4:351 4:79 drug interaction 4:155 458 Index

GABA 4:336 pelvic examination 3:316 chi (energy of life) 1:365; 4:56 ginseng 4:72 sperm 3:342 child abuse 1:287; 4:242–243, 245, hallucinogens 4:338 uterus 3:351 251 hypnotics 4:339 cesarean section 1:303; 3:259–261, childbirth 3:261–262; 4:47 MDMA 4:343 260t aging and urinary system methamphetamine 4:342 amniotic fluid 3:244 changes 3:175 multiple sclerosis 1:263–265 childbirth 3:261 amniotic fluid 3:244 muscle relaxant medications episiotomy 3:278 Apgar score 3:245 1:337 gestational diabetes 3:288 breast 3:250 narcotics 4:344 prenatal care 3:327 cervix 3:259 nervous system 1:215 reproductive system 3:238 cesarean section 3:259 neural blockade 1:380 VBAC 3:355 episiotomy 3:277 neurogenic pain 1:380–381 chafing 4:217, 235 fetus 3:284 nociceptor 1:381 chalazion 1:79 genitalia 3:287 pain and pain management chambers, of heart 2:4, 7 genital trauma 3:288 1:361 chamomile 4:62, 62t Kegel exercises 3:199 peripheral nerves 1:276 Charcot-Marie-Tooth (CMT) disease oxytocin 3:152 side effect 4:171 1:317–318 placenta 3:320 stimulants 4:350 Charcot’s disease. See amyotrophic postpartum depression 3:380 centromere 4:116, 117, 119, 143 lateral sclerosis preeclampsia 3:321 Centruroides sculpturatus 4:381, 382 charleyhorse 4:217 premature birth 3:324 cerebellum 1:215, 232 chelation therapy 4:62–63 rectal prolapse 3:87 cerebral cortex chemical burns 4:365, 382 rectocele 3:87 anger and anger management chemical peel 1:144–145, 210 relaxin 3:158 4:240 chemokines 2:253–254, 326 reproductive system 3:236 appetite 4:178 chemotherapy 1:42t, 169, 169t, sexual dysfunction 3:338 forebrain 1:230, 231 237, 310; 2:375–377, 375t, 376t STDs 3:340 hyperhidrosis 1:164 adult survivors of childhood stillbirth 3:342 lobes of 1:231t cancer 2:366, 367 uterine prolapse 3:350 nervous system 1:215 adverse drug reaction 4:148 uterus 3:351 pain and pain management angiogenesis inhibitor drugs vagina 3:352 1:361 2:368 VBAC 3:355 seizure disorders 1:281 blood and lymph research and childbirth fever 4:1, 258 cerebral palsy 1:217, 227, 238–241, treatment advances 2:122 childhood diseases 4:17, 17t. See 240t; 4:101 blood doping 4:324 also Reye’s syndrome; specific cerebrospinal fluid 1:41, 47, 230, bone marrow transplantation diseases, e.g.: chickenpox 241, 241t, 256–257, 259, 263; 2:133 childhood obesity 4:215, 291–292, 4:261 cancer 2:365 291t cerumen 1:14–15, 15, 21, 29, 40, cancer treatment options and children 2:71, 260, 306, 322–323 41 decisions 2:370, 372 aging and changes in pain cervical cancer 2:337, 365, 370, cannabis 4:326 perception 1:364 373; 3:256–258, 257t, 258t; 4:14 carcinogen 2:374 aging and integumentary bladder cancer 3:182 goldenseal 4:73 changes 1:134 cervix 3:259 immunoablation 2:274 aging and nutrition/dietary CIN 3:258 immunodeficiency 2:274 changes 4:176 Pap test 3:315 radiation and biochemical aging and physical ability/fitness STDs 3:340 injuries 4:386 4:214 cervical intraepithelial neoplasia tumor markers 2:395 BMI 4:290 (CIN) 3:256, 258–259, 276, 315 chest pain 1:363; 2:35, 35t, 95 carbohydrate intolerance 4:180 cervical spondylosis 1:316–317 chest percussion and postural concussion 1:245 cervix 2:330, 336, 337; 3:259 drainage 2:190, 195, 199, 202; hearing loss 1:29 cervical cancer 3:256 4:121 heavy-metal poisoning 4:30 childbirth 3:261 Cheyne-Stokes respiration 2:184, Heimlich maneuver 4:373 CIN 3:258 199 impetigo 1:166 nabothian cyst 3:306 chickenpox 1:103; 2:315–316, 332, ingested toxins 4:383 Pap test 3:315 350 organic solvents 4:347 Index 459

overdose 4:165 chondrocyte 1:293, 298, 316 adhesive capsulitis 1:298–299 parenting 4:249 chondroitin 1:366; 4:64, 72 aging and changes in pain physical activity chordee 3:188, 197, 262, 263 perception 1:364, 365 recommendations 4:228–229 chorea 1:241–242 alternative methods for pain rhabdomyoma 1:353 chorionic gonadotropin 3:115 relief 1:365 scoliosis 1:354, 355 chorionic villi sampling (CVS) analgesic medications 1:367 triceps skinfold 4:307 1:155; 3:244, 262–263; 4:130 biofeedback 4:60 verbal apraxia 1:225–226 choroid 1:113, 120 cervical spondylosis 1:316–317 vision impairment 1:122–123 chromatid 4:116, 116–117, 140, complex regional pain syndrome child-resistant containers 4:166, 143 1:371–372 167 chromosomal disorders 2:63, 143; fentanyl 4:334 China, ancient 2:6, 304 3:243, 244, 296, 335; 4:117–119 fibromyalgia 1:321–322 Chinese medicine 4:52, 56 chromatid 4:117 living with pain 1:378 chiropractic 1:365, 378; 4:63–64, 65 chromosome 4:119 magnet therapy 4:81 chlamydia 1:80, 352; 2:317, 317t; congenital anomaly 4:120 maldynia 1:378–379 3:248, 277 genetic counseling 4:128 methadone 4:342 Chlamydia sp. 1:352; 3:184 genetic disorder 4:128 neural blockade 1:380 chloasma 1:145 genetic imprinting 4:129 neurolysis 1:380 chloral hydrate 4:327–328, 328t genetics and molecular medicine polymyositis 1:350 chlordiazepoxide (Librium) 3:359; 4:110 prescription drug abuse 4:349 4:319, 330 genetic testing 4:130 psychogenic pain 1:383 cholecystectomy 3:6, 22–23, 23t, mosaicism 4:134 temporomandibular disorders 47 replication error 4:139 1:359 cholelithiasis 3:46, 189 translocation 4:143 TENS 1:384–385 cholera 2:317–318 chromosome 1 4:132, 138 trigger-point injection 1:385 cholestasis 3:23–24, 23t, 84 chromosome 4 1:256, 298 chyme 3:3, 36, 45, 46 cholesteatoma 1:15, 48 chromosome 6 2:267, 282 cicatricial pemphigoid 1:79, 87 cholesterol, dietary 2:36, 49; 4:181 chromosome 15 4:129, 142 cigar 4:306, 345 cholesterol, endogenous 3:24 chronic fatigue syndrome cigarettes. See smoking cholesterol blood levels 1:124, 211; 1:369–370; 4:98 cigarette smoking. See smoking and 2:35–37, 35t, 36t; 3:24, 119, 135, chronic obstructive pulmonary cancer; smoking and health 160, 303 disease (COPD) 2:199–201, 200t; cilia 1:15; 2:230, 233 apoB100 2:16–17 3:350 CIN. See cervical intraepithelial atherosclerosis 2:21, 22 aging and physical ability/fitness neoplasia atherosclerotic plaque 2:22 4:215 ciprofloxacin 2:353, 360 cardiovascular disease anthracosis 2:183 circadian cycle 1:65; 3:101, 116, prevention 4:16 breathing exercises 2:194 151, 154, 382, 384; 4:88, 89 diabetes and cardiovascular bronchitis 2:196 circle of Willis 2:5, 37 disease 2:48–49 cannabis 4:327 circumcision 3:263–264 exercise and health 4:221 cyanosis 2:46 balanitis 3:248 garlic 4:69 dyspnea 2:203 cancer of the penis 3:256 green tea 4:74 interstitial lung disorders 2:205 chordee 3:262 heart attack 2:57 living with chronic pulmonary genital trauma 3:287 hyperlipidemia 2:64–66 conditions 2:207 paraphimosis 3:316 hypertension 2:67 oxygen-carbon dioxide penis 3:318 lifestyle and cardiovascular exchange 2:216 phimosis 3:319 health 2:73 pneumoconiosis 2:220 circumflex artery 2:40–41, 43 nutrients 4:191, 192 pulmonary fibrosis 2:226 cirrhosis 1:221; 3:16, 24–25, 55, nutrition and diet 4:174–175 smoking and pulmonary disease 83, 133; 4:89, 149 rickets 4:199 2:230 cisterna chyli 2:134, 149, 155, 165, soy 4:98 thoracotomy 2:232 170 soy and cardiovascular health tobacco 4:353 CJD. See Creutzfeldt-Jakob disease 2:106 chronic organ rejection 4:271, 272 class 1 obesity 4:300, 309 triglyceride blood level 2:112 chronic pain 1:370–371, 371t; class 2 obesity 4:283, 293, 300 triglycerides, dietary 4:202, 203 3:334, 355, 384 class 3 obesity 4:283, 293, 300, chondritis 1:318 acute pain 1:363 302, 310 460 Index cleaning the ear 1:15, 21 drugs 4:145 colitis 3:25–26, 61, 88 cleft palate/cleft palate and lip 1:6, ethchlorvynol 4:334 collagen 1:170, 316, 342; 2:119, 16, 60; 4:110, 120 illicit drug use 4:340 266; 4:206 clitoris 3:264 stimulants 4:350 colon 2:260, 307; 3:26, 26t cloning 4:119 substance abuse 4:313 cecum 3:21 closed-angle glaucoma 1:92, 93t coccidioidomycosis 2:318–319, colitis 3:25 closed fracture 1:322; 4:364, 377 318t colonoscopy 3:26 Clostridium botulinum 1:141; 2:312, cochlea 1:3, 16–17, 30, 37 colorectal cancer 3:28 313; 4:151 cochlear implant 1:6, 17 constipation 3:32 clotting factor inhibitors 2:14, 78 codeine 4:155, 311, 347 enema 3:40 clotting factors 2:134–136, coenzyme Q10 4:14, 16–17, 64–65, FAP 3:43 134t–135t 65t, 74, 134, 177 fecal impaction 3:43 anticoagulation therapy 2:14 cognitive function and dysfunction fecal incontinence 3:44 blood 2:127 1:242–244, 243t; 2:107, 344, 356 fiber and gastrointestinal health blood transfusion 2:129 ataxia 1:226–227 3:45 coagulation 2:136 chronic fatigue syndrome flatulence 3:45 DIC 2:137 1:369–370 gastrointestinal system 3:4 hemophilia 2:143 CJD 1:248–249 Hirschsprung’s disease 3:58 platelet 2:163 consciousness 1:245 HNPCC 3:58 platelet aggregation 2:163 delirium 1:250–251 IBD 3:61 vitamin K 2:173 dementia 1:251–252 ileoanal reservoir 3:60 clozapine 3:363, 363t, 367, 377 Huntington’s disease 1:256 ileostomy 3:60 club drugs 4:328, 332, 338 learning disorders 1:258–259 ileum 3:61 clubfoot. See talipes equinovarus memory and memory intestinal polyp 3:64 cluster headache 1:374, 376t, 377 impairment 1:260–262 laxatives 3:68 clusters of differentiation 2:254 neurologic examination 1:270 rectum 3:87 CMV. See cytomegalovirus organic brain syndrome small intestine 3:89 coagulation 1:183; 2:136, 136 1:272–273 toxic megacolon 3:93 alcohol 4:317 sign language 1:51 colonoscopy 3:26–28; 4:14 anticoagulation therapy cognitive therapy 3:369 colorectal cancer 3:29 2:13–16, 15t addiction 4:315 FAP 3:43 antiphospholipid antibodies anger and anger management FOBT 3:45 2:249 4:241 gastrointestinal system 3:5, 7 clotting factors 2:134 art therapy 4:59 HNPCC 3:58 DIC 2:137 behavior modification therapy intestinal polyp 3:64 feverfew 4:68 3:366 rectum 3:87 garlic 4:69 body dysmorphic disorder 3:368 colony-stimulating factors (CSFs) ginger 4:70 conduct disorder 3:369 2:254, 276 ginkgo biloba 4:71 conversion disorder 3:369 color deficiency 1:80 hematopoiesis 2:141 cyclothymic disorder 3:370 colorectal cancer 2:370, 374, 394; medications to treat detoxification 4:332 3:28–31, 29t, 30t cardiovascular disease 2:83 dysthymic disorder 3:373 acromegaly 3:105 platelet 2:119, 163 hypochondriasis 3:376 cancer prevention 4:14 thrombocythemia 2:170 OCD 3:378 colonoscopy 3:26 thrombocytopenia 2:171 oppositional defiant disorder colostomy 3:31 vitamin K 2:173 3:378 diarrhea 3:34 von Willebrand’s disease 2:174 panic disorder 3:379 FAP 3:43 coagulation cascade 2:144, 163, phobia 3:379 FOBT 3:44 173, 266 psychotherapy 3:381 gastrointestinal system 3:5 coal worker’s pneumoconiosis substance abuse 4:313 HNPCC 3:57 (CWP) 2:183, 205, 219 violence 4:255 obesity and health 4:302 cocaine 1:49, 361; 2:11, 17, 111; colds 1:19, 28–29, 32; 2:303, 319, stomach cancer 3:91 4:328–329, 328t 354; 4:67 colostomy 3:6, 31–32, 60, 87 addiction 4:314, 315 cold sore 1:17–18; 4:333 colposcopy 3:257, 264, 292 dependence 4:331 cold water drowning 4:50, coma 1:244, 244t, 277, 288; 4:198, depressants 4:332 368–369, 369, 370, 376 202 Index 461 common variable kyphosis 1:332 rectal prolapse 3:87 immunodeficiency (CVID) 2:255 lactose intolerance 4:185 steatorrhea 3:90 community sanitation 2:360, 363; laryngocele 1:32 consumption (tuberculosis) 2:304, 4:2, 17–18, 19–21, 41 lordosis 1:334 359 co-morbidities 4:292, 302 meconium 3:77 contact dermatitis 1:150, 185; compact bone 1:308, 309 nephrectomy 3:206 4:382 complement 2:239, 255 neural tube defects 4:39 contact lens 1:67, 83–84, 90, 109 complementary therapies 4:78, 91 optic nerve hypoplasia 1:106 contact lens, implantable 1:101, complement cascade 2:255–256 ovarian cyst 3:313 112 antibody-mediated immunity phimosis 3:319 contact toxins 4:42, 381, 382–383, 2:246 rectal fistula 3:86 383t, 386 corticosteroid medications 2:256 retinoblastoma 1:114 continuous positive airway pressure hypersensitivity reaction 2:268 talipes equinovarus 1:358 (CPAP) 1:39; 2:214, 223 immune response 2:272–273 temporomandibular disorders contraception 3:264–267, immune system 2:236 1:359 265t–266t; 4:46 immunoglobulin 2:275 torticollis 1:360 breastfeeding 3:253 immunosuppressive medications urethral stricture 3:222 conception 3:264 2:276 VACTERL 3:352 dysmenorrhea 3:270 mononuclear phagocyte system vesicoureteral reflux 3:229 fallopian tubes 3:281 2:283–284 congenital cataracts 1:77; 4:123 family planning 3:281 complement factors 2:236, 255, congenital heart disease 1:16; sexual health 3:339 277 2:5–6, 34, 37–40, 38t, 61, 102, tubal ligation 3:347 complex regional pain syndrome 183; 3:87, 352 vasectomy 3:354 1:371–372 congenital hip dysplasia 1:318–319 contracture 1:319 computed tomography (CT) scan congenital vision loss 1:106, 114 conversion disorder 3:369 1:311; 3:27 congestive heart failure 2:16, 31, cool laser. See excimer laser conception 1:217; 3:236, 242, 264, 58, 76, 124 COPD. See chronic obstructive 267, 272, 282, 287, 293 conjunctiva 1:80, 108, 110 pulmonary disease concussion 1:244–245, 245t; 4:378 conjunctivitis 1:80, 87, 95–97, 352; coping mechanisms 3:369–370, conditioning 4:217, 217–218 2:240, 317 373, 377 conduct disorder 3:369; 4:335 connective tissue 2:55, 391; 4:265 coping with cancer 2:377 cones 1:91, 113, 114 Achilles tendon 1:297 copper 4:31, 177, 187 confidentiality 4:272, 358 Achilles tendon injury cornea 1:80–81 congenital anomaly 4:120 1:297–298 astigmatism 1:73 albinism 1:135–136 aging and integumentary bullous keratopathy 1:76 amniocentesis 3:244 changes 1:134–135 cicatricial pemphigoid 1:79 anal atresia 3:10 dermatofibroma 1:152 cold sore 1:17 arthrogryposis 1:303–304 fascia 1:321 conjunctivitis 1:80 bladder exstrophy 3:182 fibromyalgia 1:321–322 corneal injury 1:81 bowel atresia 3:20 integumentary system 1:128 corrective lenses 1:82 chordee 3:262 Kaposi’s sarcoma 1:168–169 ectropion 1:87 cleft palate/cleft palate and lip Marfan syndrome 1:335–336 entropion 1:87 1:16 consciousness 1:245; 4:77, 166, eye 1:89 congenital hip dysplasia 262, 344, 385. See also keratitis 1:99 1:318–319 unconsciousness keratoconus 1:99 CVS 3:262 constipation 3:32–33 ocular herpes simplex 1:103 Down syndrome 4:122 antidepressant medications pterygium 1:110 enuresis 3:187, 188 3:361 PTK 1:108 epispadias 3:188 enema 3:40 corneal injury 1:81, 91, 103 esophageal atresia 3:40 exercise and health 4:221 corneal transplantation 1:81–82 fecal incontinence 3:44 Fanconi’s syndrome 3:190 corns 1:145–146 Hirschsprung’s disease 3:58 fecal impaction 3:43 coronary arteries 2:40–41; 4:320 horseshoe kidney 3:195 fiber and gastrointestinal health angina pectoris 2:11 hydrocele 3:290 3:45 aorta 2:16 hydronephrosis 3:196 Hirschsprung’s disease 3:58 atherectomy 2:21 hypospadias 3:197 narcotics 4:344 atherosclerosis 2:21 462 Index

CABG 2:41–43 smoking and cardiovascular CRH 3:116 cardiac catheterization 2:28 disease 2:105 Cushing’s syndrome 3:116 echocardiogram 2:51 tobacco use other than smoking endocrine system 3:99, 101 heart 2:4, 56 4:306 glucose 3:128 IHD 2:70 corpus luteum 3:115, 148, 156, insulin 3:148 Kawasaki disease 2:71 158, 303 melatonin 4:89 myocardial infarction 2:86 corrective lenses 1:67, 82–84, 96, metabolism 4:225 myocardium 2:88 101, 109, 111 stress and stress management stent 2:106 cortex 3:107, 108 4:253 coronary artery bypass graft corticosteroid medications cosmetic surgery 4:274, 275 (CABG) 2:41–43 2:256–257, 256t cough 1:18–19 angina pectoris 2:12 adverse drug reaction 4:148 atelectasis 2:190 angioplasty 2:12–13 asthma 2:188 bronchiectasis 2:195 CAD 2:44 atelectasis 2:190 bronchitis 2:196 cardiac catheterization 2:28 berylliosis 2:192 cannabis 4:327 cardiac rehabilitation 2:30 bronchiectasis 2:195 Heimlich maneuver 4:373 cardiovascular system 2:7 bulla 1:142 interstitial lung disorders 2:205 EECP 2:55 bullous pemphigoid 1:142 lung abscess 2:208 heart attack 2:57 candidiasis 2:315 narcotics 4:344 myocardial infarction 2:87 cystic fibrosis and the lungs pertussis 2:348, 349 open heart surgery 2:90 2:202 pleurisy 2:218 coronary artery disease (CAD) dependence 4:331 pneumoconiosis 2:219 1:211; 2:43–45, 45t DLE 1:153 pneumonitis 2:222 angina pectoris 2:11 encephalitis 2:323 pneumothorax 2:223 anticoagulation therapy 2:14 5ASA medications 2:260 silicosis 2:229 apoB100 2:16 food allergies 2:261 sputum 2:231 arrhythmia 2:17 glossitis 1:25 cough reflex 4:262, 332, 347, 354 atherosclerotic plaque 2:22 graft vs. host disease 2:264 Coumadin. See warfarin CABG 2:41–43 hypersensitivity reaction 2:270 COX. See cyclooxygenase cardiac catheterization 2:28 immunosuppressive medications coxsackievirus 2:95, 221 cardiovascular disease 2:276 CPR. See cardiopulmonary prevention 4:15 ischemic optic neuropathy 1:98 resuscitation cholesterol, dietary 4:181 multiple myeloma 2:158 crackles (rales) 2:195, 224 coagulation 2:136 osteoporosis 1:346 cradle cap 1:146 coronary arteries 2:41 plaque, skin 1:186 cramp 1:319, 356 diet and cardiovascular health retrobulbar optic neuritis 1:116 cranial nerves 1:246–247, 247t 2:50 spinal cord injury 1:284 acoustic neuroma 1:7 exercise and health 4:221 synovitis 1:357 Bell’s palsy 1:228 fitness: exercise and health corticotropin-releasing hormone brain 1:230 4:210 (CRH) 3:115–116 functions of the mouth 1:5 heart attack 2:58 ACTH 3:110 hindbrain 1:232 heart failure 2:58 adrenal insufficiency 3:109 midbrain 1:232 heart transplantation 2:63 aldosterone 3:112 multiple sclerosis 1:263 heredity and heart disease 2:64 cortisol 3:116 optic nerve 1:105 homocysteine 2:64 endocrine system 3:101 peripheral nerves 1:276 hyperlipidemia 2:64 hypoglycemia 3:142 peripheral nervous system IHD 2:70 hypothalamus 3:145 1:276 medications to treat cortisol 2:256, 257, 266; 3:116 salivary glands 1:49 cardiovascular disease 2:76 Addison’s disease 3:106 smell and taste disturbances myocardial perfusion imaging adrenal glands 3:107, 108 1:53 2:87 adrenal insufficiency 3:109 sneeze 1:54 myocardium 2:88 aging and endocrine changes craniosacral massage 4:65, 93 obesity and cardiovascular 3:111 cranium 1:235, 256–257 disease 2:90 aldosterone 3:112 c-reactive protein 2:45–46, 136, platelet aggregation 2:163 anger and anger management 163, 291, 302 PVD 2:96–97 4:240 crepitus 1:319 Index 463

Creutzfeldt-Jakob disease (CJD) cystitis 3:183–185, 184t, 186, 187, deep brain stimulation (DBS) 1:248–249, 263; 2:128, 350 225 1:250, 276 CRH. See corticotropin-releasing cystocele 3:87, 175, 185 deep vein thrombosis (DVT) hormone cystoscopy 3:185, 188, 222 2:47–48, 78, 110, 115, 136, 225, Crick, Francis 4:111, 122, 132 cystourethrogram 3:185, 185–186, 226; 4:211 cross training 4:218–219 188, 212 defibrillation 2:23, 34, 47, 57, 116; croup 1:19 cytochrome P450 (CYP450) 4:371, 372, 372 cryptococcosis 2:319–320, 320t enzymes 1:362; 4:147, 153–154, deformity 1:185; 4:200 cryptorchidism 3:267, 308, 346 155, 318 degenerative neurologic disease cryptosporidiosis 2:320 cytokines 1:127, 316; 2:257, 257t 1:251, 256, 275–276 c-section. See cesarean section antibody-mediated immunity dehydration 2:317, 320, 324, 327; CSFs. See colony-stimulating factors 2:246 4:374–375, 375t cultural and ethnic health-care antihistamine medications aging and urinary system perspectives 4:243 2:247 changes 3:175 end of life concerns 4:246 cell-mediated immunity 2:253 anuria 3:177 human relations 4:238 DMARDs 2:258 Fanconi’s syndrome 3:190 lifestyle variables: smoking and EPO 2:137 gastroenteritis 3:48 obesity 4:283 5ASA medications 2:260 heat and cold injuries 4:374 obesity 4:299 granulocyte 2:138 heat exhaustion 4:375 preventive medicine 4:3–4 granuloma 2:265 heat stroke 4:375 quality of life 4:43 histamine 2:266 hydration 4:184 curvature of the spine. See scoliosis immunotherapy 2:276 hypernatremia 3:138 Cushing’s syndrome 3:109, 116, inflammation 2:277 hyponatremia 3:143 116–118, 137 interferons 2:278 mitochondrial disorders 4:134 cutaneous lupus erythematosus. See interleukins 2:278 nephropathy 3:210 discoid lupus erythematosus lymph 2:120 nephrotoxins 3:212 CVD. See cardiovascular disease lymphokines 2:280–281 oliguria 3:213 CVS. See chorionic villi sampling monokines 2:283 renal failure 3:218 CWP. See coal worker’s mononuclear phagocyte system urolithiasis 3:227 pneumoconiosis 2:284 dehydroepiandrosterone (DHEA) cyanosis 2:46 pain management in cancer 3:119, 245; 4:66, 66t asbestosis 2:185 2:386 delayed-type hypersensitivity congenital anomaly 4:120 psychoneuroimmunology 2:290 (DTH) reaction. See type IV congenital heart disease 2:37, T-cell lymphocyte 2:296 hypersensitivity reaction 39 TGFs 2:296–297 delirium 1:250–251 hypoxia 2:205 TNFs 2:297 delirium tremens 4:330, 354 methemoglobinemia 2:156 cytomegalovirus (CMV) 2:274, delta islet cells 3:149, 158 pneumothorax 2:223 320–321 delusion 3:367, 368, 371, 379, 381, Raynaud’s syndrome 2:101 cytotoxic reaction. See type II 382 shock 4:367 hypersensitivity reaction dementia 1:218, 251–252; 4:70, cyclic vomiting syndrome 3:33, 78, cytotoxic T-cells 2:253, 296 176 94 dendrite 1:270, 271, 361 cyclooxygenase (COX) 2:286, 287, D dental caries 1:20, 39, 44, 57, 294, 290 dacryocystitis 1:85 358; 4:24, 306 cyclosporiasis 2:320 dacryostenosis 1:85 deoxygenated blood 2:4, 7, 115, cyclosporine 2:258, 270, 275–276; dandruff 1:147–148, 148t, 151 115, 115, 115 3:174, 202; 4:173, 270 dark adaptation test 1:85–86 depressants 4:331–332, 339 cyclothymic disorder 3:367, 370, DASH eating plan 2:47 depression 1:174, 265, 383; 2:30, 372 date rape 4:327, 336, 337 257; 3:371–372 cyst 1:62, 131, 185–186, 307; DBS. See deep brain stimulation addiction 4:315 2:306–307, 320, 329, 348, 357 D&C. See dilation and curettage alcoholism 4:320 cystic fibrosis 1:36; 4:110, 119, death 4:37, 48, 246, 347, 377, 386 anabolic steroids and steroid 120–121 debridement 4:361, 362, 365 precursors 4:322 cystic fibrosis and the lungs 2:191, decompression sickness 2:205, 216, andropause 3:245 199, 201–202, 205, 216, 226 217; 4:50 bipolar disorder 3:366 cystinuria 3:183 decubitus ulcer 1:148–149, 148t cognitive therapy 3:369 464 Index

cyclothymic disorder 3:370 dextromethorphan 1:19; nephrotoxins 3:212 dysthymic disorder 3:373 4:332–333, 333t, 350 obesity and cardiovascular ECT 3:375 diabetes 3:119–122, 121t, 122t disease 2:90 exercise and health 4:221 acromegaly 3:105 osteomyelitis 1:344 GAD 3:376 aging and drug metabolism/drug paresthesia 1:275 hallucinogens 4:337 response 4:149 pharmacodynamics 4:168 hypericum 4:99 aging and neurologic changes PVD 2:96 hypnotics 4:339 1:221 rapid gastric emptying 3:86 medicinal herbs and botanicals aging and urinary system recombinant DNA 4:139 4:83 changes 3:175, 176 renal failure 3:218, 219 OCD 3:378 alcoholism 4:319 retinopathy 1:115 psychiatric disorders and amputation 1:300 sexual dysfunction 3:338 psychologic conditions 3:357, atherosclerosis 2:22 stroke 2:108 358 bariatric surgery 4:288 triglyceride blood level 2:112 PTSD 3:380 bilberry 4:60 Turner’s syndrome 3:348 SAD 3:382 blood disorders 2:121 urinary system 3:173 SAMe 4:97 body shape and cardiovascular urinary urgency 3:225 schizophrenia 3:383 health 2:25 diabetes and cardiovascular disease sexual dysfunction 3:338 CAD 2:45 2:6, 19, 48–49 suicidal ideation and suicide candidiasis 2:315 diabetes insipidus 3:114, 122–124 3:385 carbuncle 1:143 diabetes mellitus. See diabetes therapeutic equivalence 4:172 cardiac rehabilitation 2:30 diabetes prevention 4:19 dermabrasion 1:149, 210 cataract 1:77 diagnosing cancer 2:232, 378, dermatitis 1:74, 79, 141, 146, cellulitis 1:143 391–392, 395–397 149–152, 152 cognitive function and diaper rash 1:152 dermatofibroma 1:152 dysfunction 1:244 diaphragm 2:96, 202–203, 204, dermatome 1:252, 268 congenital heart disease 2:40 212 dermis CVD 2:34 diarrhea 1:152; 3:34, 34t abrasions 4:361 drugs 4:146 adverse drug reaction 4:148 bleeding control 4:362 endocrine system 3:102–103 antidiarrheal medications integumentary system enuresis 3:187 3:12–13 1:127–128 erythrasma 1:157 campylobacteriosis 2:314 melanocyte 1:175–176 furuncle 1:160 chemotherapy 2:376 skin 1:195 gingivitis 1:25 cholera 2:317, 318 sunburn 1:201 glomerulonephritis 3:192 cryptosporidiosis 2:320 sweat glands 1:202 glucagon 3:128 cyclosporiasis 2:320 desensitization 2:258 healing 2:266 fiber and gastrointestinal health allergen 2:240 hemochromatosis 3:133 3:45 allergic asthma 2:240 hydronephrosis 3:196 foodborne illnesses 2:326 allergic rhinitis 2:243 hyperkalemia 3:138 GAD 3:376 allergy testing 2:244 hypertension 2:66 gastrointestinal system 3:5 anaphylaxis 2:244 hypoglycemia 3:142 giardiasis 2:329 food allergies 2:261 immune system 2:238 narcotics 4:344 hypersensitivity reaction 2:271 immunocompromised 2:274 normal flora 2:347 designer drugs 4:332, 343 immunodeficiency 2:274 parasite 2:348 detoxification 4:332 influenza 2:339 salmonellosis 2:352 alcoholism 4:320 islet cell transplantation 3:149 shigellosis 2:353 buprenorphine 4:325 islets of Langerhans 3:149 short bowel syndrome 3:88 naltrexone 4:344 kidney donor 3:200 side effect 4:171 narcotics 4:345 kidneys 3:202 steatorrhea 3:90 substance abuse 4:313 lifestyle and cardiovascular diastole 2:41, 70, 217 substance abuse treatment health 2:73 diastolic measure 2:24, 66 4:351 melatonin 4:89 diazepam (Valium) 3:359; 4:330 withdrawal syndrome 4:354 necrotizing fasciitis 2:346 DIC. See disseminated intravascular Detrol. See tolterodine nephrectomy 3:207 coagulation detrusor muscle 3:178, 226 nephropathy 3:210 diet aids 4:293 Index 465 diet and cancer 2:378–380, 379t, diphtheria 1:6; 2:298, 322; 4:4, 17 SAMe 4:97 382 diploid cell 4:127, 140, 144 tobacco 4:353 diet and cardiovascular health diplopia 1:86, 86t, 94, 118 dorsal ganglia 1:361, 382 2:49–50 disability and exercise 2:194, 203; dosage 4:154 cardiomyopathy 2:33 4:220 dextromethorphan 4:332 cholesterol blood levels 2:37 disaccharide 4:185, 191 OTC drug 4:166 DASH eating plan 2:47 discoid lupus erythematosus (DLE) peak level 4:168 hypertension 2:66–67 1:152–153, 153t therapeutic level 4:172 lifestyle and cardiovascular disease-modifying antirheumatic therapeutic window 4:172 health 2:72–73 drugs (DMARDs) 1:302, 357; tolerance 4:354 omega fatty acids and 2:258–259, 258t, 270, 276 vitamin and mineral therapy cardiovascular health 2:90 dislocations 1:320 4:105 Ornish program 2:91–92 disseminated intravascular dose 4:154 soy and cardiovascular health coagulation (DIC) 2:130, 137, double vision. See diplopia 2:106 172, 357 Down syndrome 1:16; 2:37, 38, 40, triglyceride blood level 2:112 dissociative amnesia 3:359, 372 59, 63, 160; 4:122–123, 123t diet and health 3:44, 90; 4:19, dissociative disorder 3:372–373, autosomal trisomy 4:114 28–29, 174, 175, 182 381, 385 birth defects 4:9 dietary supplement 4:73, 97, 169, disulfiram 4:315, 320, 333, 354 chromatid 4:117 196 Ditropan. See oxybutynin chromosomal disorders 4:117 dieting 4:185, 293–294, 295 diuretic 2:76, 80–81, 85t, 99; 4:73, chromosome 4:119 digestion 1:366; 4:176, 284 194, 293 genetics and molecular medicine digestive enzymes 3:34–35; 4:120 diverticular disease 3:35–36, 36t, 4:111 digestive hormones 3:35 65 mosaicism 4:134–135 duodenum 3:36 DMARDs. See disease-modifying replication error 4:139 gastrointestinal system 3:3 antirheumatic drugs doxycycline 2:335, 336, 350, 356 insulin 3:148 DNA (deoxyribonucleic acid) DRE. See digital rectal examination islets of Langerhans 3:149 2:119, 361, 362, 375, 376, 388; drinking water standards 4:17, 18, malabsorption 3:77 3:57, 244; 4:109, 122, 192 19–21, 20t, 41 pancreas 3:79 domestic violence 4:244, 245 drug dosage 4:159, 318 small bowel transplantation dong quai 1:366; 4:66–67, 67t, 83, drug interaction 1:365, 366; 2:76, 3:89 95 309, 367; 4:154–157, 155t–157t somatostatin 3:159 dopamine 3:124 aging and drug metabolism/drug stomach 3:90 adrenal glands 3:107, 108 response 4:149 stomach cancer 3:90 aging and neurologic changes hypericum 4:99 digestive hormones 3:35; 4:178 1:221 nutritional supplements 4:196 digestive enzymes 3:35 alcohol 4:316, 317 OTC drug 4:167 gallbladder 3:46 aldosterone 3:112 TCM 4:102–103 gastrointestinal system 3:1, 3 antidepressant medications vitamin and mineral therapy glucagon 3:128 3:361 4:105 glucose 3:128 antipsychotic medications 3:363 yohimbe 4:107 H2 antagonist medications 3:59 delirium tremens 4:330 zeaxanthin 4:107 insulin 3:148 dystonia 1:320 drug resistance 2:305, 360. See also pancreas 3:79 ECT 3:375 antibiotic resistance small bowel transplantation endocrine system 3:99 drug(s) 4:145–173 3:89 epinephrine 3:126 dry eye syndrome 1:76, 79, 86 digestive system. See gastrointestinal hypothalamus 3:145 DTH (delayed-type system integumentary system 1:127 hypersensitivity) reaction. See digitalis 2:76, 81; 4:145 midbrain 1:232 type IV hypersensitivity reaction digital rectal examination (DRE) nervous system 1:217 DUB. See dysfunctional uterine 3:35, 54, 86, 249 neurotransmitter 1:272 bleeding digoxin 2:76, 81, 114; 4:145, 153 nevus 1:178 Duchenne’s muscular dystrophy dilation and curettage (D&C) nicotine 4:345 1:337, 338t 3:268, 275 norepinephrine 3:152 ductus arteriosus 2:10, 38 diphenhydramine (Benadryl) 1:25, Parkinson’s disease 1:275 duodenum 3:36–37; 4:286 206; 2:243, 267 pheochromocytoma 3:154 bowel atresia 3:20 466 Index

ERCP 3:38 cauliflower ear 1:14 lifestyle variables: smoking and gallbladder 3:46 cerumen 1:14–15 obesity 4:283 gastrointestinal bleeding 3:51 cholesteatoma 1:15 malnutrition 4:186 gastrointestinal system 3:3, 4 cleaning 1:15 nutritional assessment 4:193 gastroparesis 3:52 cochlea 1:16–17 nutritional supplements 4:197 Helicobacter pylori 3:53 eustachian tube 1:23 nutritional therapy 4:92 peptic ulcer disease 3:81 foreign objects in 1:24 obesity 4:299, 300 small intestine 3:89 functions of 1:3–4 pellagra 4:199 dura mater 1:262, 263 mastoiditis 1:33 physical activity DVT. See deep vein thrombosis myringitis 1:35 recommendations 4:228 dwarfism. See skeletal dysplasia myringotomy 1:35 sports drinks and foods 4:231 dysfunctional uterine bleeding noise exposure and hearing weight loss and weight (DUB) 3:268, 268–269, 318 1:36–37 management 4:309, 310 dyskinesia 1:252, 256; 4:321 otitis 1:40 ecchymosis 1:154; 2:137, 142; dysmenorrhea 1:366; 3:243, 269, otoplasty 1:41 4:280 269–270, 270t; 4:67 otorrhea 1:41 eccrine sweat glands 1:128, 164, dyspepsia 3:11, 37, 42, 323 otosclerosis 1:41 202 dysphagia. See swallowing otoscopy 1:41, 43 ECG. See electrocardiogram disorders ototoxicity 1:43 echinacea 2:237, 239, 319; 4:67, dysplasia 1:318–319; 2:337, 366, tinnitus 1:58 67t, 73, 196 380, 381 tympanic membrane 1:59 echocardiogram 2:51, 51t dyspnea 2:203, 203t; 4:367 ear, nose, mouth, and throat eclampsia 3:271, 289 allergic asthma 2:240 1:1–64, 2 ecstasy (drug) 4:328, 338, 343, apnea 2:184 breakthrough research and 343, 343t atelectasis 2:190 treatment advances 1:6 ECT. See electroconvulsive therapy auscultation 2:191 ear 1:3–4 ectopic beat 2:51–52 breathing 2:193 functions of 1:1–5 ectopic pregnancy 3:8, 271–272, breath sounds 2:194 health and disorders of 1:5 293, 347–348 bronchitis 2:196 mouth and throat 1:4–5 ectropion 1:87 bronchus 2:198 nose 1:4 edema 1:201; 2:40, 58, 99, 115, Cheyne-Stokes respiration overview 1:1–6 376 2:199 structures of 1:1 Edward’s syndrome 4:114, 117, COPD 2:200 traditions in medical history 124, 124t hantavirus pulmonary syndrome 1:5–6 efficacy 4:158 2:331 earache 1:20–21 eggs. See ova heart failure 2:58 ear lavage 1:15, 21 Egypt, ancient 2:6, 76, 304 heart murmur 2:59 ear wax. See cerumen ejaculation 3:272 histoplasmosis 2:333 eating disorders 3:94, 243, 361, erection 3:278 hypoxia 2:205 374–375 infertility 3:293 interstitial lung disorders 2:205 eating habits 1:265; 2:31, 47, 50, Kegel exercises 3:199 Legionnaires’ disease 2:206 280, 302, 382; 4:294–295. See also nocturnal emission 3:306 lung abscess 2:208 diet orgasm 3:308 pleural effusion 2:218 aging and nutrition/dietary semen 3:337 pneumoconiosis 2:219 changes 4:176 sexual intercourse 3:339 pneumonitis 2:222 appetite 4:177 sperm 3:342 pneumothorax 2:223 bariatric surgery 4:284, 288 sperm donation 3:342 SARS 2:353 beriberi 4:179 urethra 3:222 silicosis 2:229 cardiovascular disease vas deferens 3:354 dyspraxia. See apraxia prevention 4:15 elastin 1:316, 335 dysthymic disorder 3:372, 373 childhood obesity 4:291 elder abuse 4:244–246 dystonia 1:256, 286, 320 diabetes prevention 4:19 elderly. See aging dysuria 3:179, 186, 186t, 227 diet and health 4:182 electrocardiogram (ECG) 2:52–53, dieting 4:293 52t; 4:330 E drugs 4:147 defibrillation 2:47 ear 1:20 fitness level 4:222 echocardiogram 2:51 barotrauma 1:11 health risk factors 4:28–29 EECP 2:54 Index 467

heart attack 2:57 depression 3:371 syncope 2:108 stress test 2:106 disulfiram 4:333 testicular torsion 3:346 torsade de pointes 2:111 ectopic pregnancy 3:271 thyroid storm 3:165 electroconvulsive therapy (ECT) electrocution 4:372 toothache 1:57 3:367, 372, 375 emergency and first aid 4:355, toxic megacolon 3:93 electrocution 4:372 357 toxic shock syndrome 2:357 electroencephalogram (EEG) encephalitis 2:323 trauma prevention 4:48 1:253–254; 3:384 epiglottitis 1:21–22 traumatic amputation 4:380 electrolarynx 1:21, 64 eye pain 1:90 urticaria 1:206 electrolyte fracture 1:322 ventricular fibrillation 2:116 aging and urinary system frostbite 4:375, 376 vision impairment 1:123 changes 3:175 glaucoma 1:92 emergency and first aid Fanconi’s syndrome 3:190 glossitis 1:25 4:355–386 gastrointestinal system 3:4 gunshot wounds 4:377–378 burns, bleeding, breaks kidneys 3:201 headache 1:373 4:361–367 RTA 3:219 heart attack 2:56, 57 cardiac arrest 4:371–373, 371t uremia 3:221 heat exhaustion 4:375 drowning 4:368–370 urinary system 3:171, 172 heat stroke 4:375 first response 4:357–360 urine 3:227 herniated nucleus pulposus heat and cold injuries electrolytes 1:365; 4:105, 184, 217, 1:326 4:374–376 374 hypersensitivity reaction 2:268 major trauma 4:377–380 electrophysiology study (EPS) 2:53 hypertension 2:66 overview 4:355–356 electroretinography 1:87 ileus 3:61 poisoning 4:381–385 embryo 1:212; 3:272–273, 283, ingested toxins 4:383, 384 radiation and biochemical 356 inhalation burns 4:365 injuries 4:386 embryonic development 1:125, 293 inhaled toxins 4:384, 385 emesis. See vomiting emergencies, medical injected toxins 4:385 emesis center 3:77, 94 abdominal pain 3:9 intussusception 3:64 emphysema 2:199, 216 acute pain 1:363 major trauma 4:377 enamel 1:358; 4:306 Addison’s disease 3:106 motor vehicle accidents encephalitis 1:6, 33, 272; allergic asthma 2:240 4:378–379 2:322–323, 322t, 345, 350 allergic conjunctivitis 2:241 multiple trauma 4:379 encephalopathy 1:218, 233, 254, allergy testing 2:244 nasogastric aspiration and lavage 254t, 280 ambulatory surgery 4:260 3:77 endarterectomy 2:35, 53, 106 aneurysm 2:11 nephrolithiasis 3:208 endocarditis 2:13, 39, 53–54, 54t; angioedema 2:245 orbital cellulitis 1:106 4:312 appendicitis 3:15 organ transplantation 4:271 endocardium 2:4, 53–55, 54, 88 arrhythmia 2:17 overdose 4:164 endocrine disorders 3:119, aspirin therapy 2:21 pancreatitis 3:80 126–127, 131, 136, 143, 237 back pain 1:306 paraphimosis 3:315 endocrine gland 3:79, 96, 125, bariatric surgery 4:287 pericarditis 2:95 153–156, 162 Bell’s palsy 1:228 peritonitis 3:82 endocrine system 2:273, 366; black eye 1:74 pharyngitis 1:45 3:96–168, 97, 144, 159, 291 bleeding control 4:362 photophobia 1:108 end of life concerns 1:223–225, bowel atresia 3:20 poisoning 4:381, 382 233, 277, 384; 4:43, 95, 182–183, brain hemorrhage 1:233–234 radiation and biochemical 246 burns 4:363 injuries 4:386 endolymphatic hydrops. See CAD 2:43 retinal detachment 1:113 Ménière’s disease cardiac arrest 4:371 Reye’s syndrome 1:279–280 endometrial cancer 2:372, 373, cardiovascular disease SAMe 4:97 381; 3:182, 273–275, 273t prevention 4:16 shock 4:367 endometrial hyperplasia 3:269, concussion 1:245 spinal cord injury 1:283 273, 275–276 contact toxins 4:382 stroke 2:107 endometriosis 3:129, 276–277 corneal injury 1:81 stupor 1:285 endometrium 3:241, 268, 273, 292, cough 1:18 symptom assessment and care 351 dehydration 4:375 triage 4:359–360 endorphin 1:362, 371, 379 468 Index endoscopic retrograde berylliosis 2:193 erectile dysfunction 3:278–280 cholangiopancreatography bronchitis 2:196 amphetamines 4:321 (ERCP) 3:23, 38 carcinogen 2:374 andropause 3:245 endoscopy 2:86, 197, 378; 3:7, 38, environmental cigarette smoke antidepressant medications 38–40, 38t–39t, 42, 292 4:22–23 3:362 endotracheal intubation 4:258, 262 heavy-metal poisoning 4:30–31 colostomy 3:32 endotracheal tube 2:214, 217 methemoglobinemia 2:157 depression 3:371 end-stage renal disease (ESRD) myelodysplasia syndrome 2:160 erection 3:278 1:344; 3:187; 4:273 radiation and biochemical ginkgo biloba 4:71 aging and urinary system injuries 4:386 medicinal herbs and botanicals changes 3:175 radon exposure 4:44 4:84 Alport’s syndrome 3:176, 177 eosinophil 2:120, 138, 162, 256, nicotine 4:346 Fanconi’s syndrome 3:190 276, 279 orgasm 3:309 glomerulosclerosis 3:192 EPA. See US Environmental Peyronie’s disease 3:319 Goodpasture’s syndrome 3:193 Protection Agency priapism 3:327 hemolytic uremic syndrome ephedra 4:231, 348 reproductive system 3:238 3:195 epicondylitis 1:320–321 yohimbe 4:106 kidney donor 3:200 epidemics 2:303, 304; 4:2, 18 erection 3:278, 293, 327, 338 kidney transplantation 3:202 epidermis 1:127, 135, 154, ergonomics 4:23–24, 23t Medicare coverage for 156–157, 170, 180, 195 erysipelas 1:155–156 permanent renal failure 3:205 epidermolysis bullosa 1:154–155 erythema multiforme 1:156 nephritis 3:207 epididymis 3:340, 342, 343 erythema nodosum 1:156, 156t nephropathy 3:210 epididymitis 2:330, 358; 3:277, 308 erythrasma 1:156–157 polycystic kidney disease 3:214 epidural 3:260, 262; 4:261 erythrocyte 2:137 renal dialysis 3:218 epiglottis 1:5, 21–22; 2:193, 195 aging and changes in renal failure 3:218, 219 epiglottitis 1:21–22 blood/lymph 2:123, 124 uremia 3:221 epilepsy 1:218, 281 anemia 2:124, 125 urinary system 3:171, 172, 174 epinephrine 1:161, 206, 272; 2:77, antigen 2:246 endurance 4:220 79, 244, 245, 270; 3:125t babesiosis 2:311 aerobic capacity 4:213 adrenal glands 3:107, 108 bilirubin 3:19 blood doping 4:324 aldosterone 3:112 blood and lymph 2:119 carbohydrate loading 4:217 anesthesia 4:261 blood disorders 2:121 sports drinks and foods 4:231 anger and anger management blood doping 4:324 strength 4:232 4:240 bloodless surgery 4:263 training 4:233 antianxiety medications 3:359 blood vessels 2:5 enema 3:40 antivenin 4:152 capillary beds 2:27 enhanced external counterpulsation dopamine 3:124 chromosome 4:119 (EECP) 2:54–55 ECT 3:375 DNA 4:122 enkephalin 1:362, 371 endocrine system 3:99 E. coli infection 2:324 Entamoeba sp. 2:306, 307; 3:25 metabolism 4:225 G6PD deficiency 4:131 enteral nutrition 4:182–183, 198, nicotine 4:345 hematopoiesis 2:140 202 norepinephrine 3:152 hematuria 3:194 entropion 1:87 pheochromocytoma 3:154 hemoglobin 2:142 enucleation 1:88, 109–110, 114; tobacco 4:353 hemolysis 2:143 4:380 epiphysis 1:308, 341 jaundice 3:67 enuresis 3:187–188 episcleritis 1:88 kidneys 3:201, 202 environmental carcinogens 2:370, episiotomy 3:88, 277–278, 338 leukocyte 2:148 382 epispadias 3:188 malaria 2:342 environmental cigarette smoke epistaxis 1:22; 4:362 monocyte 2:157 2:105, 188, 201, 212; 4:22–23, epithelial cells 2:54, 233, 284, 290, myelofibrosis 2:160 34, 282 374–375 oxygen-carbon dioxide environmental hazard exposure epithelium 1:229; 2:265, 299–302 exchange 2:216 3:71, 237; 4:22, 22t EPO. See erythropoiesis; polycythemia vera 2:164 aging and pulmonary changes erythropoietin renal failure 3:219 2:183 Epstein-Barr virus 2:221, 303, reticulocyte 2:165 asbestosis 2:185 323–324, 324t, 344, 345 sickle cell disease 2:165 Index 469

thalassemia 2:169 ESWL. See extracorporeal shock pulse 2:100 vesicoureteral reflux 3:230 wave lithotripsy PVD 2:96 erythromycin 2:341, 349, 353 ethchlorvynol 4:334 rheumatoid arthritis 2:291 erythropoiesis (EPO) 2:125, ethical issues in genetics and substance abuse treatment 140–141, 167; 3:171–172, 202 molecular medicine 4:124–125 4:351–352 erythropoietin (EPO) 2:125, 132, etoposide 2:376, 376t training 4:233 137–138, 148, 157, 160; 3:169, eudynia 1:363, 372, 379. See also waist circumference 4:308 192, 201, 202 acute pain weight loss and weight blood doping 4:324 eustachian tube 1:3, 7–8, 15, 20, management 4:309, 310 bloodless surgery 4:263 22, 40 yoga 4:106 performance-enhancing euthyroid sick syndrome 3:127, exophthalmos 1:88, 94, 95, 106 substances 4:348 127t, 129 extracorporeal shock wave Erythroxylum coca 1:361; 4:328 excimer (cool) laser 1:108, 109, lithotripsy (ESWL) 3:183, 189, Escherichia coli 3:277; 4:74 184 208, 227–228 Escherichia coli infection 2:324–325, exercise and health 1:357, 365, eye 1:66, 70–124, 89t; 4:326 327; 3:184, 194, 225 371, 378, 379; 4:221. See also aging and vision/eye change Escherichia coli O157:H7 2:311, 324 physical activity 1:71–72 esophageal atresia 3:40 recommendations astigmatism 1:73 esophageal cancer 3:40–41; 4:306 abdominal adiposity 4:284 black eye 1:74 esophageal spasm 3:41 aerobic fitness 2:9, 9t breakthrough research and esophageal speech 1:22, 31, 64 anger and anger management treatment advances 1:69 esophageal varices 3:41–42 4:241 cataract 1:77–78 esophagitis 3:42 bariatric surgery 4:284, 288 cluster headache 1:374 esophagus 3:3, 9, 17, 42, 42t, 50, body shape and cardiovascular cornea 1:80–81 58; 4:166 health 2:25 corneal injury 1:81 ESRD. See end-stage renal disease CABG 2:43 corrective lenses 1:82–84 estrogens 1:145, 345, 346; 2:10, calorie 4:180 enucleation 1:88 372, 381; 3:126–127; 4:215 cardiac rehabilitation 2:30–31 functions 1:65, 67–68 adrenal glands 3:107, 108 cardiomyopathy 2:33 Graves’ ophthalmopathy aging and endocrine changes cardiovascular disease 1:94–95 3:111 prevention 4:16 health and disorders of 1:68 aging and reproductive/sexual diabetes prevention 4:19 how the eye “sees” 1:67 changes 3:242 dieting 4:294 lens 1:100 aging and urinary system DVT 2:48 overview 1:65–69 changes 3:175 “fat burners” 4:295 physics of vision 1:67–68 androgens 3:113 fitness: exercise and health 4:210 retina 1:113 breast 3:249 health risk factors 4:29 structures 1:65 cystocele 3:185 heart rate 2:60 traditions in medical history DHEA 3:119 heat exhaustion 4:375 1:68–69 DUB 3:268 heat stroke 4:375 eyeglasses 1:67, 83, 109 endocrine system 3:100, 103 intermittent claudication 2:69 eyelids endometrial hyperplasia 3:276 lean muscle mass 4:297 blepharitis 1:74 euthyroid sick syndrome 3:127 lifestyle and cardiovascular blepharoplasty 1:75 fibroadenoma 3:284 health 2:73 blepharospasm 1:75 FSH 3:127 lifestyle variables: smoking and chalazion 1:79 GnRH 3:129 obesity 4:283 cicatricial pemphigoid 1:79 gynecomastia 3:289 living with chronic pulmonary ectropion 1:87 hormone 3:135 conditions 2:207 entropion 1:87 hypothyroidism 3:147 malnutrition 4:186 hordeolum 1:96 LH 3:151 MET 4:225 orbital cellulitis 1:106 libido 3:296 metabolism 4:226 ptosis 1:110 menopause 3:302 obesity 4:299, 300 xanthelasma 1:124 ovaries 3:313 obesity and health 4:302 xanthoma 1:211 progesterone 3:157 physical exercise and eye pain 1:85, 89–90, 89t uterine fibroids 3:350 cardiovascular health 2:97 eye patch 1:72, 81 uterus 3:351 preventive medicine 4:3 eye strain 1:90 470 Index

F inhibin 3:148 aging and physical ability/fitness facelift. See rhytidoplasty menarche 3:300 4:215 facial nerve 1:49, 53, 228–229, menopause 3:301 conditioning 4:217 246, 247t ovaries 3:313 cross training 4:219 facioscapulohumeral muscular ovulation 3:314 fitness: exercise and health 4:210 dystrophy 1:337, 338t PCOS 3:320 physical activity factitious disorders 3:375–376, 385 perimenopause 3:318 recommendations 4:228 fallopian tubes 3:271, 281, 342, PID 3:317 shin splints 4:231 347, 351 pregnancy 3:323 strength 4:233 familial adenomatous polyposis prostatectomy 3:331 training 4:233 (FAP) 3:43, 60, 64 reproductive system 3:237 walking for fitness 4:235 familial Mediterranean fever spermatocele 3:342 Fitzpatrick skin type 1:158, 158t 4:125–126 testicular cancer 3:345 5-aminosalicylate (5ASA) family medical pedigree 4:126 testicular self-examination medications 2:260, 260t family planning 3:281–282; 4:130 3:346 flashback 3:359, 380; 4:337 adoption 3:241 testicular torsion 3:347 flashes 1:91 ART 3:247 uterine fibroids 3:349–350 flat feet 4:222–224, 223t conception 3:264 vas deferens 3:354 flatulence 3:20, 45 contraception 3:267 fertilization 3:342, 356 flavonoids 2:379t; 4:89, 177 gestational surrogacy 3:289 fetal alcohol syndrome (FAS) 4:9, flexibility 1:300, 365, 366; 4:224 prenatal care 3:327 312–313, 316, 334–336 conditioning 4:217 vasectomy 3:355 fetus 1:303; 3:283–284, 284t; 4:81 cross training 4:219 Fanconi’s syndrome 3:189–190 amniocentesis 3:243 disability and exercise 4:220 FAP. See familial adenomatous amniotic fluid 3:244 endurance 4:220 polyposis eclampsia 3:271 fitness: exercise and health farsightedness. See hyperopia; gestational diabetes 3:288 4:211 presbyopia placenta 3:319 fitness level 4:222 fascia 1:294, 321, 349–350 stillbirth 3:342 OMT 4:93 fat. See adipose tissue umbilical cord 3:349 physical activity fat burners 4:201, 293, 295 uterine fibroids 3:350 recommendations 4:228 fatigue. See chronic fatigue uterus 3:351 resistance exercise 4:230 syndrome fever 2:236, 326, 338; 4:281, 375. strength 4:233 fats (lipids) 4:191, 229 See also specific fevers, e.g.: typhoid tai chi 4:101 fatty acids 4:191, 202, 301 fever training 4:233 FDA. See US Food and Drug feverfew 1:366, 377; 4:67–68, 68t warmup 4:236 Administration fiber and gastrointestinal health weekend warrior 4:237 fecal impaction 3:33, 43–44, 44 3:5, 33, 44, 45, 68 floaters 1:74, 91, 113, 124 fecal incontinence 3:33, 44 fibrillation 2:17, 23, 116; 4:372 flower essences 4:58, 68 fecal occult blood test (FOBT) fibrin 2:83, 110 flu. See influenza 3:44–45, 45t, 51, 91 fibrinogens 1:127; 2:49, 110 fluid balance 3:171, 201; 4:187 feces 3:1, 4, 14, 20; 4:357 fibroadenoma 3:284–285 flunitrazepam (Rohypnol) 4:328, fentanyl 4:334 fibrocystic breast disease 3:253, 332, 336 fertility 3:282–283; 4:117 285, 285–286, 295, 300 fluorescein staining 1:81, 91, 104, aging and reproductive/sexual fibroelastoma 2:55 108 changes 3:242 fibromyalgia 1:321–322, 385 fluoridation 4:24–25 amenorrhea 3:243 fibrosis 2:183, 216, 223, 229, 291 fluoroscopy 2:12, 13, 28, 53; 3:17, chorionic gonadotropin 3:115 fibula 1:301, 330 189 conception 3:264 filtrate 3:169, 193, 202, 209 FOBT. See fecal occult blood test cryptorchidism 3:267 finasteride (Proscar/Propecia) folic acid 1:16, 217, 282, 355; 2:40, ectopic pregnancy 3:272 1:137; 4:98 64, 125, 126, 379t; 4:12, 39, 118 endometrial cancer 3:274 finger 1:210, 350, 357 follicles. See hair follicles endometriosis 3:276 fingernails 1:129, 167 follicle-stimulating hormone (FSH) erection 3:278 fitness: exercise and health 3:100, 111, 127, 129, 148 fallopian tubes 3:281 4:210–212, 210–237 folliculitis 1:158–159 family planning 3:281 fitness level 4:222 fondaparinux (Arixtra) 2:14, 15t, hemochromatosis 3:133 aerobic exercise 4:214 78, 78t Index 471 food allergies 2:236, 244, 258, gangrene 1:144, 159, 323 generalized anxiety disorder (GAD) 260–262, 261t, 269 garlic 4:69–70, 70t 2:257, 284–285; 3:280, 360, 369, foodborne illnesses 2:261, gas-permeable contact lens 1:83, 376, 380, 385; 4:104 311–313, 326–327, 327t, 348; 4:2, 99 generational health-care 24, 26, 31. See also waterborne gastrectomy 3:48 perspectives 4:3–4, 247 illnesses; specific foodborne illnesses, gastric acid 3:11, 50, 85, 90 generic drug 4:146, 153, 158–159, e.g.: salmonellosis gastric binding 4:284–287 163 food poisoning. See foodborne gastric mucosa 3:3, 90, 94 gene therapy 1:296; 3:7, 43; 4:119, illnesses gastrin 3:3, 35, 94 121, 125, 127–128, 139 food pyramid 4:186, 194 gastritis 3:48 genetic carrier 4:128 food safety 1:248, 249; 4:24 gastroenteritis 3:33, 48–50, 49t, 88, genetic code 2:305, 330; 4:128 foot 1:297, 298, 349–350, 358 89, 94; 4:2 chromosome 4:118, 119 foreign objects in the ear or nose gastroesophageal reflux disorder DNA 4:122 1:24, 47 (GERD) 1:18, 45; 2:188, 201, genetics and molecular medicine foreskin (prepuce) 3:263, 315, 318 202, 267; 3:50–51, 51t 4:109 formaldehyde 2:365, 392 antacids 3:12 genotype 4:131 formulary 4:158 Barrett’s esophagus 3:17 nucleotide 4:135 foxglove 4:84, 145 esophageal cancer 3:40 RNA 4:139 fracture 1:322–323 esophagitis 3:42 sex chromosome 4:140 fragile X syndrome 3:364, 365; gastrointestinal system 3:5 genetic counseling 1:256; 2:144, 4:126 hiatal hernia 3:58 170; 4:128 freckles. See lentigines gastrointestinal bleeding 1:368; Down syndrome 4:123 free radicals 2:50, 376; 4:62, 105, 2:20, 204; 3:45, 51–52, 51t, 77; genetic testing 4:131 177, 193, 207 4:363 mitochondrial disorders 4:134 frontal lobe 1:231t, 242; 4:240 gastrointestinal disorders 3:34, 62, PKU 4:138 frostbite 1:159–160, 159t 90; 4:179, 319 porphyria 4:138 FSH. See follicle-stimulating gastrointestinal irritation 4:62, 72 Tay-Sachs disease 4:143 hormone gastrointestinal system 3:1–95, 2 genetic disorders 4:128–129 fungal infection 1:179, 204–205. antidepressant medications achondroplasia 1:298 See also yeast infection; specific 3:362 AFP 3:243 infections, e.g.: candidiasis anus 3:14 Alport’s syndrome 3:176 fungus 2:308–309, 327, 327t, borborygmus 3:20 amenorrhea 3:243 346–347; 4:34 bowel movement 3:20 blood disorders 2:121 furuncle 1:160 bowel sounds 3:20 cardiomyopathy 2:31, 32 cecum 3:21 CMT disease 1:317–318 G colon 3:26 congenital anomaly 4:120 gabapentin 3:367, 377 digestive hormones 3:35 congenital heart disease GAD. See generalized anxiety endoscopy 3:38 2:37–40 disorder ERCP 3:38 CVS 3:262 gag reflex 1:25 fiber and gastrointestinal health cystic fibrosis and the lungs Galen 2:6, 121, 122 3:45 2:201 gallbladder 3:1, 18, 22, 36, 46 gallbladder 3:46 ethical issues in genetics and gallbladder disease 3:22, 46–48, hemochromatosis 3:133 molecular medicine 46t, 67; 4:287, 302 IBD 3:61 4:124–125 gallop 2:55 IBS 3:65 familial Mediterranean fever gallstones 3:46, 80, 189; 4:302 nausea 3:78 4:125 GALT. See gut-associated lymphoid peristalsis 3:82 family medical pedigree 4:126 tissue small intestine 3:89 Fanconi’s syndrome 3:190 gamete 3:233, 340, 356; 4:115, stomach 3:90 FAP 3:43 118, 122, 124, 127, 139 gastrointestinal tract 2:263, 265, gene 4:127 gamma-aminobutyric acid (GABA) 306–307, 346, 347, 366; 4:150, hemochromatosis 3:133 3:360; 4:316–317, 323, 330–332, 171 hemophilia 2:143, 144 339 gastroparesis 3:52 heredity and heart disease 2:63 gammaglobulin 2:239, 263, 275, 289 gene 2:397; 4:109, 113, 119, 127, hirsutism 3:134 gamma hydroxybutyrate (GHB) 132, 135, 299 hypogonadism 3:291 4:328, 336 gene mutation. See mutation ichthyosis 1:166 472 Index

immune disorders 2:272 genital trauma 3:287–288 metabolism 4:225 inborn disorders of metabolism genitourinary tract 3:186, 362 nephropathy 3:210 4:227 genome 4:109–110, 114, 131, 143 nutrients 4:190 karyotype 4:133 genotype 4:110, 130, 131, 136, 143 obesity and health 4:301 Klinefelter’s syndrome 3:296 GERD. See gastroesophageal reflux protein loading 4:229 Marfan syndrome 1:335–336 disorder urinary system 3:173 MEN 3:151, 152 German measles. See rubella glutamate 1:224; 4:316–317, 330 methemoglobinemia 2:157 germ cells 4:115, 127 glutethimide 4:336 muscular dystrophy 1:337–339 germline mutations 1:114; 4:135 glycogen 3:128, 142, 148; 4:217, mutation 4:135 gestation 3:272, 324 220, 229 myopathy 1:340 gestational diabetes 3:119, 120, GnRH. See gonadotropin-releasing myotonia 1:340 271, 288–289, 321 hormone neurofibromatosis 1:269 gestational surrogacy 3:242, 282, goiter 3:127, 128–129, 146 nevus 1:178 289 goldenseal 2:76, 237, 239; 4:73, 73t osteogenesis imperfecta GH. See growth hormone gonadotropin-releasing hormone 1:342–343 GHRH. See growth hormone- (GnRH) 3:129 osteopetrosis 1:344–345 releasing hormone aging and endocrine changes polydactyly 1:350, 350 giant-cell arteritis 1:98; 2:300t 3:110 RTA 3:219 giardiasis 2:329, 329t androgens 3:113 SCID 2:294 ginger 2:243, 376; 4:70, 70t estrogens 3:126 skeletal dysplasia 1:355 gingivitis 1:25 FSH 3:127 syndactyly 1:357 ginkgo biloba 1:223, 244; 4:70–71, hypothalamus 3:145 von Willebrand’s disease 2:174 71, 71t, 177 inhibin 3:148 Wilson’s disease 3:168 ginseng 4:71–72, 71t, 72t, 231, 348 LH 3:151 genetic imprinting 4:117, 129 glaucoma 1:92–94, 93t; 4:326 prolactin 3:157 genetic predisposition 1:222; 2:114, cataract 1:78 uterine fibroids 3:350 145, 193, 216, 241, 243; 4:129, eye pain 1:90 gonorrhea 1:80; 2:329–330, 330t; 129–130, 135 eyes 1:67 3:277, 340; 4:150 genetics and molecular medicine Graves’s ophthalmopathy 1:94 Goodpasture’s syndrome 3:193, 4:109–144 intraocular pressure 1:97 193t genetic screening 4:130 mydriasis 1:100 Good Samaritan laws 4:358, 358 amniocentesis 3:244 ocular herpes zoster 1:103 goose bumps 1:160–161 autism 3:364 tonometry 1:119 gout 1:323–324, 324t cystic fibrosis 4:121 glomeruli 3:173, 176, 202, grading, of cancer. See staging and ethical issues in genetics and 210–212 grading of cancer molecular medicine 4:124 glomerulonephritis 3:176, graft vs. host disease 1:173; gastrointestinal system 3:7 191–192, 207 2:263–265, 264t; 3:76, 150 HNPCC 3:58 glomerulosclerosis 3:192–193 bone marrow transplantation karyotype 4:133 glomerulus 3:169, 192, 193, 201, 2:133 MEN 3:151 209 cell-mediated immunity 2:253 polycystic kidney disease 3:214 glossitis 1:25 complement cascade 2:255 Turner’s syndrome 3:348 glossopharyngeal nerve 1:49, 53 corticosteroid medications 2:256 genetic testing 1:136, 155; 2:33, glucagon 3:79, 100, 128, 128, 149 HLAs 2:267 170, 202, 369; 4:130–131 glucosamine 1:366; 4:64, 72–73, immunosuppressive medications congenital anomaly 4:120 73t 2:276 ethical issues in genetics and glucose 1:77, 285, 377; 2:49, 118, immunosuppressive therapy molecular medicine 4:124 120; 3:128, 128t 2:276 fragile X syndrome 4:126 appetite 4:178 MHC 2:282 genetics and molecular medicine beriberi 4:179 granulocyte 2:138–139 4:112 carbohydrate loading 4:217 granuloma 2:265 genetic screening 4:130 diabetes 3:119 human ehrlichiosis 2:335 porphyria 4:138 endocrine system 3:100 immune system 2:235 Tay-Sachs disease 4:142 gestational diabetes 3:288 leukocyte 2:120 genital herpes 2:327–329, 328t, glucagon 3:128 lymph 2:120 332; 3:339, 340 insulin 3:148 lymphocyte 2:152 genitalia 3:287 insulin resistance 3:149 neutropenia 2:161 Index 473 granuloma 2:265, 269, 282, 293, halitosis 1:20, 26, 44 routine medical examination 359, 360 hallucination 3:367, 368, 376, 381, 4:45 granuloma telangiectaticum 1:161 382 sexually transmitted disease Graves’ disease 1:88, 94–95; 2:172, alcoholic hallucinosis 4:319 prevention 4:47 249; 3:129–131, 164 amphetamines 4:321 substance abuse 4:311 Graves’ ophthalmopathy 1:88, benzodiazepines 4:324 Healthy People 2001 4:283, 291 94–95, 119; 3:100, 141 delirium tremens 4:330 Healthy People 2010 4:29–30, 50, gray matter 1:216, 283, 284 designer drugs 4:332 212 Greece, ancient 2:6, 76, 304 dextromethorphan 4:332 hearing aid 1:6, 10, 26–28, 29–30 green tea 2:237, 297; 4:73–74, 74t, ethchlorvynol 4:334 hearing impairment (sign language) 177 hallucinogens 4:337 1:51 grief 4:247–248 ketamine 4:342 hearing loss 1:28–30; 4:123 group A beta-hemolytic MDMA 4:343 acoustic neuroma 1:7 streptococcal bacteria 2:352, 354, organic solvents 4:347 audiologic assessment 1:9–10 357 withdrawal syndrome 4:354 barotrauma 1:11 growth hormone (GH) 3:104, 111, hallucinogens 4:312, 328, 331, BPPV 1:12 131, 149, 157 337–338, 338t breakthrough research and growth hormone deficiency 3:131, hand washing 4:2, 26, 41, 258 treatment advances 1:6 131, 132 hangover 4:338 cholesteatoma 1:15 growth hormone-releasing hantavirus pulmonary syndrome cochlear implant 1:17 hormone (GHRH) 3:110–111, 2:331 disorders of the ears, nose, 131, 131–132, 142, 145 hapten. See allergen mouth, and throat 1:5 G6PD deficiency 2:157, 351; 4:131 Harvey, William 2:7, 122 ear 1:20 gum disease 1:39, 44 hashish 4:312, 326, 327 hearing aid 1:26–28 gum tissue 1:25, 39 hay fever. See allergic rhinitis labyrinthitis 1:31 gunshot wounds 4:367, 377–378, HBV. See hepatitis B Ménière’s disease 1:33–35 379 hCG. See human chorionic myringitis 1:35 gut-associated lymphoid tissue gonadotrophin hormone noise exposure and hearing (GALT) 2:265, 284, 289; 3:15, 89 HDL-C. See high-density lipoprotein 1:36–37 gynecomastia 3:289, 298; 4:322 cholesterol otosclerosis 1:41 headache 1:235, 373–377, 376t; ototoxicity 1:42t, 43 H 3:105, 371, 379 presbycusis 1:45–46 Haemophilus influenzae type b (Hib) adverse drug reaction 4:148 sign language 1:51 1:21; 2:221, 256, 305, 344 amphetamines 4:321 speech disorders 1:54–55 hair 1:125, 127–129, 162, 162t, anesthesia 4:261 tinnitus 1:58 166–167; 3:134, 386 caffeine 4:326 hearing loss, age-related. See hair cell (ear) 1:16–17, 30, 36, 37, drugs 4:145 presbycusis 58 hangover 4:338 heart 2:56, 56t. See also hair follicles 2:377 head and spinal cord injuries cardiovascular disease acne 1:131 4:378 angina pectoris 2:11–12 carbuncle 1:143 workplace stress 4:256 angiogram 2:12 furuncle 1:160 head and spinal cord injuries aorta 2:16 goose bumps 1:160–161 4:362, 368, 369, 378 arrhythmia 2:17–19, 18t hidradenitis suppurativa 1:164 healing 1:194, 361; 2:266 atrial fibrillation 2:22–23 integumentary system 1:125, health education 4:26 AV node 2:23 129 health insurance 4:26–27, 125, 278 cardiac arrest 2:27 keratosis pilaris 1:170, 171 health risk factors 4:27–29 cardiac capacity 2:27–28 nasal vestibulitis 1:36 anti-aging approaches 4:58 cardiac catheterization 2:28 sebaceous glands 1:194 BMI 4:289, 290 cardiac cycle 2:28–29 skin 1:195 diet and health 4:182 cardiac enzymes 2:29 skin cancer 1:196–197 fitness: exercise and health 4:210 cardiac output 2:29–30 sweat glands 1:202 fitness level 4:222 cardiomyopathy 2:31–33 hair loss. See alopecia life expectancy 4:37 cardiopulmonary bypass hair replacement 1:162–164, 163t personal health history 4:41 2:33–34 hairy tongue 1:26 physical activity cardiovascular system 2:1, 4, 6, half-life 4:159, 325 recommendations 4:228 7 474 Index

chest pain 2:35 vein 2:115 adult survivors of childhood congenital heart disease ventricular fibrillation 2:116 cancer 2:366 2:37–40 Wolff-Parkinson-White aging and physical ability/fitness coronary arteries 2:40–41 syndrome 2:116–117 4:215 CRT 2:31 heart attack 1:57, 211; 2:56–58; aging and pulmonary changes CVD 2:34 3:245, 379. See also myocardial 2:182 defibrillation 2:47 infarction alkyl nitrites 4:320 ECG 2:52–53 AED 2:23 aortic stenosis 2:16 echocardiogram 2:51 aging and cardiovascular apnea 2:184 EECP 2:54–55 changes 2:10 ARDS 2:181 endocarditis 2:53–54 angina pectoris 2:11, 12 arrhythmia 2:17 endocardium 2:54 angioplasty 2:13 berylliosis 2:193 EPS 2:53 anticoagulation therapy 2:13 blood doping 4:324 hypertension 2:66 aspirin therapy 2:20, 21 cardiac output 2:29 IABP counterpulsation 2:70 atherosclerosis 2:21 cardiomyopathy 2:31 ICD 2:69 blood doping 4:324 Cheyne-Stokes respiration 2:199 IHD 2:70 CABG 2:41 coenzyme Q10 4:64 Kawasaki disease 2:71 CAD 2:43 COPD 2:201 lifestyle and cardiovascular cardiac arrest 2:27; 4:372 CRT 2:31 health 2:72–73 cardiac catheterization 2:28 dyspnea 2:203 LQTS 2:74–75 cardiac enzymes 2:29 heart sounds 2:60 microinfarction 2:84 cardiac rehabilitation 2:30–31 heart transplantation 2:61 minimally invasive cardiac cardiovascular disease lung transplantation 2:213 surgery 2:86 prevention 4:16 LVEF 2:72 myocardial infarction 2:86–87 chest pain 2:35 medications to treat myocardial perfusion imaging cholesterol blood levels 2:37 cardiovascular disease 2:76 2:87 CICU 2:29 nicotine 4:346 myocarditis 2:87–88 coagulation 2:136 obesity and cardiovascular myocardium 2:88 cocaine 4:328–329 disease 2:90 myxoma 2:88 coenzyme Q10 4:64 pleural effusion 2:218 open heart surgery 2:90–91 conditioning 4:218 pulmonary hypertension 2:98 oxygen saturation 2:217 c-reactive protein 2:45 pulse 2:100 oxygen therapy 2:217 fitness: exercise and health VADs 2:116 pacemaker 2:93 4:211 valvular heart disease 2:113 palpitations 2:93–94 heart transplantation 2:63 heart murmur 2:59–60, 60, 103, PAT 2:94 heredity and heart disease 2:64 113 pericarditis 2:95–96 hypertension 2:66 heart rate 2:60; 3:106, 245, 359, pericardium 2:96 IHD 2:70 379, 384 pulmonary arteries 2:98 living with cardiovascular aerobic exercise 4:213 pulmonary embolism 2:225 disease 2:73 aerobic fitness 2:9 pulmonary veins 2:99 medications to treat aging and physical ability/fitness pulse 2:99 cardiovascular disease 2:79 4:215 rheumatic heart disease 2:103 NSAIDs 2:287 anesthesia 4:262 risk factors for cardiovascular pericarditis 2:95 barbiturates 4:323 disease 2:102–103 progeria 4:139 breathing 2:193 SA node 2:104–105 pulmonary embolism 2:225 cardiac output 2:29 sarcoidosis 2:293 smoking and cardiovascular dehydration 4:374 sick sinus syndrome 2:104 disease 2:105 delirium tremens 4:330 stress test 2:106 smoking and pulmonary disease dextromethorphan 4:332 sudden cardiac death 2:108 2:230 drowning 4:368 tamponade, cardiac 2:110 heartbeat 2:4, 51–52, 97–98; 4:360, frostbite 4:375 TMLR 2:111–112 369, 372, 379 hallucinogens 4:337 torsade de pointes 2:111 heart disease. See cardiovascular heart transplantation 2:63 VADs 2:116 disease (CVD) human relations 4:238 valvular heart disease heart failure 2:58–59, 58t, 59t; lifestyle and cardiovascular 2:113–114 3:105, 133, 210, 219 health 2:72 Index 475

obesity and cardiovascular hemochromatosis 2:122, 129, 169; hepatitis C 1:173; 2:158, 278; 3:54, disease 2:90 3:133–134 339 overdose 4:166 hemodialysis 3:171, 217, 219 blood doping 4:325 pacemaker 2:93 hemoglobin 2:142; 3:133, 167 hepatitis prevention 4:31, 32 PAT 2:94 aging and changes in injecting drugs, risks of 4:340 physical activity blood/lymph 2:123 sexually transmitted disease recommendations 4:228 alkyl nitrites 4:320 prevention 4:46 respiration rate 2:227 alveolus 2:183 substance abuse 4:312 sports drinks and foods 4:231 anemia 2:124 hepatitis prevention 4:31–32, 358 tobacco 4:353 blood doping 4:324 hepatocytes 3:18, 69, 70, 75; 4:89 valvular heart disease 2:114 EPO 2:138 hepatomegaly 2:160, 164, 168; walking for fitness 4:235 erythrocyte 2:137 3:57, 57t heart sounds 2:55, 59–60, 60, 106, erythrocytes 2:119 hepatorenal failure 3:195 191, 195 heavy-metal poisoning 4:31 hepatotoxins 3:57, 72; 4:90 heart transplantation 2:6, 30, 39, methemoglobinemia 2:156 her-2 gene 3:250–252 60–63, 116, 214 oxygen-carbon dioxide HER-2/neu. See her-2 gene heart valves 2:54, 55, 86, 103, 353. exchange 2:216 herbal remedies 1:26, 366; 2:76, See also valvular heart disease oxygen saturation 2:216 237, 367; 4:92, 348 heat exhaustion 4:374, 375, 375, porphyria 4:138 hereditary nonpolyposis colorectal 376 reticulocyte 2:165 cancer (HNPCC) 3:57–58 heat rash. See miliaria sickle cell disease 2:165 heredity and heart disease 2:63–64 heat stroke 4:374, 375, 375, 376 smoking and cardiovascular hernia 1:325–326 heavy-metal poisoning 1:275; 2:46, disease 2:105 herniated nucleus pulposus 193, 362–363; 3:71, 190; 4:30–31, smoking and pulmonary disease 1:326–327; 4:211 62, 386 2:230 heroin 4:338–339, 339t Heimlich maneuver 1:18; 2:187, thalassemia 2:169 addiction 4:314, 315 203; 4:372–373 hemolysis 2:119, 125, 141, buprenorphine 4:325 Helicobacter pylori 2:284, 370; 3:37, 142–143, 143t, 167, 169, 324 dependence 4:330 48, 53, 81, 82, 85; 4:74 hemolytic anemia 2:125, 311; drugs 4:145 helper T-cell (CD4 cell). See CD4 cell 4:207 fentanyl 4:334 hemapheresis 2:130, 132–133, hemolytic uremic syndrome (HUS) illicit drug use 4:340 141–142, 141t, 142t, 163 2:311, 324; 3:194–195 LAAM 4:342 hematoma 1:234; 2:142 hemophilia 2:121, 136, 143–144; methadone 4:342 hematopoiesis 2:140, 140–141, 4:110, 135, 140 opiates 4:347 140t, 141t hemoptysis 2:195, 197, 204, 204, scheduled drug 4:170 anemia 2:125 204, 204, 204t substance abuse 4:311, 313 blood 2:127 hemorrhage 2:19, 110 herpes, genital. See genital herpes blood stem cells 2:129 hemorrhagic fevers 2:331–332, herpes simplex 1:17–18, 74, 99, bone marrow 2:132 331t 103, 207, 210; 2:332 EPO 2:138 hemorrhagic stroke 1:234; 2:107, herpesvirus 2:315, 320–321, erythrocyte 2:137 110 323–324, 327–329, 350 leukemia 2:146 hemorrhoids 3:11, 32, 53–54, 85, herpes zoster 1:74, 99, 103, 269; leukocyte 2:148 88 2:316, 332–333, 332t lymphocyte 2:152 heparin 2:14, 15t, 76, 78, 96 hiatal hernia 1:325; 3:58 monocyte 2:157 hepatic abscess 3:54 Hib. See Haemophilus influenzae myelodysplasia syndrome 2:160 hepatic cyst 3:54 type b reticulocyte 2:165 hepatitis 2:130, 136, 263, 315, 327, hiccup 2:204 thalassemia 2:170 345; 3:54–57, 55t, 217 hidradenitis suppurativa 1:164 hematospermia 3:277, 290 addiction 4:314 high-density lipoprotein cholesterol hematuria 3:194, 194t blood autodonation 4:263 (HDL-C) 2:36, 49, 82, 90 Alport’s syndrome 3:176–177 cancer prevention 4:14 hip fracture in older adults 1:327 bladder cancer 3:179 heroin 4:339 hippocampus 1:231, 260 ESWL 3:189 milk thistle 4:89 Hirschsprung’s disease 3:58–59, 93 glomerulonephritis 3:191 substance abuse treatment 4:351 hirsutism 3:134 nephropathy 3:211 hepatitis B 2:315, 373; 3:54, 339, histamine 1:187, 206; 2:240, 245, urolithiasis 3:227 340; 4:31, 312, 325, 340 247, 258, 260, 266–267, 273 476 Index histocompatability locus antigens. tuberculosis 2:359, 360 soy 4:99 See human leukocyte antigens virus 2:362 hormone replacement therapy histoplasmosis 2:265, 333 HIV/AIDS prevention 4:32–33 (HRT) 1:346; 2:10, 381; 3:112, HIV. See human immunodeficiency hives. See urticaria 127, 136, 238–239, 301–302, 361; virus HLAs. See human leukocyte 4:95 HIV/AIDS 2:333–335, 334t, 335t antigens hormone therapy 1:355; 2:372, addiction 4:314 HLHS. See hypoplastic left heart 381; 3:136; 4:77 alkyl nitrites 4:320 syndrome horseshoe kidney 3:195–196 anabolic steroids and steroid Hodgkin’s lymphoma 2:152–153, hospital infections (nosocomial precursors 4:322 319, 366 infections) 2:347 antiviral medications 2:309 holistic healing 4:91, 92, 101 hot flashes 3:290, 301, 361; 4:61 aspergillosis 2:185 homeopathy 4:52, 58, 68, 75–76, HPV. See human papillomavirus blood and lymph medical 75t, 78 HPV vaccine 3:258, 259 traditions 2:122 homocysteine 2:64 HRT. See hormone replacement blood donation 2:128 H1 receptor 2:247, 248, 267 therapy blood transfusion 2:130 honey, unpasteurized 2:312, 313 HSV. See herpes simplex body substance isolation 4:358 honey urine 3:103, 119 H2 antagonist (blocker) medications cancer risk factors 2:370 hordeolum 1:79, 96, 106 3:59, 59t candidiasis 2:315 hormonal cascade 3:113, 142, 144, H3 receptor 2:247–248, 267 cannabis 4:326 146, 148, 166. See also stress human chorionic gonadotrophin clusters of differentiation response hormonal cascade hormone (hCG) 3:246, 305 2:254 hormonal responses 3:135, 159 human ehrlichiosis 2:335–336 CMV 2:320 hormone 1:131, 145, 310, 362, human epidural growth factor cryptococcosis 2:319, 320 374; 2:5, 137, 172, 374; receptor 2. See her-2 gene CYP450 enzymes 4:154 3:134–136, 135t human genome 1:130; 4:4 Epstein-Barr virus 2:324 aging and reproductive/sexual Human Genome Project 4:109, genital herpes 2:328 changes 3:242 111, 119, 122, 127, 132, 132t glomerulosclerosis 3:192 androgens 3:113 human growth hormone (hGH) heroin 4:339 blood doping 4:324 1:248, 298; 3:131, 219; 4:58, 66, histoplasmosis 2:333 breast 3:250 76–77, 77t, 348 immune system 2:236–237 DHEA 3:119 human immunodeficiency virus immunodeficiency 2:274 dopamine 3:124 (HIV) 2:305, 338, 362. See also infection 2:338 endocrine gland 3:125 HIV/AIDS infectious diseases 2:305 endocrine system 3:96 human leukocyte antigens (HLAs) influenza 2:339 fibrocystic breast disease 3:285 1:267, 303, 352; 2:131, 264–265, injecting drugs, risks of 4:340 GABA 4:336 267–268, 282; 3:200, 203 Kaposi’s sarcoma 1:168, 169 gestational diabetes 3:289 human papillomavirus (HPV) leukoplakia 1:32 norepinephrine 3:152 1:133, 180, 209; 2:295, 336–337, listeriosis 2:341 performance-enhancing 337t, 362, 370, 373; 3:248, 256, milk thistle 4:89 substances 4:348 259, 340; 4:14 necrotizing fasciitis 2:346 pharmacodynamics 4:168 human relations 4:238–239, neutropenia 2:161 puberty 3:334 238–256 opportunistic infections 2:347 SAD 3:382 humoral immunity. See antibody- pericarditis 2:95 sleep disorders 3:384 mediated immunity pneumonia 2:221 hormone-driven cancers 2:381, hunger 4:177, 183–184, 294, 295, preventive medicine 4:4 382 299 responder safety and personal andropause 3:245 Huntington’s disease 1:218, 242, protection 4:358 BPH 3:249 256 SALT 2:295 breast cancer 3:251 cloning 4:119 sexual health 3:339 DHEA 4:66 ethical issues in genetics and STDs 3:340 endometrial cancer 3:275 molecular medicine 4:125 syphilis 2:356 menopause 3:301–302 genetic counseling 4:128 T-cell lymphocyte 2:296 obesity and health 4:302 genetics and molecular medicine terminal pain 1:384 oophorectomy 3:307 4:110 thrombocytopenia 2:171 orchiectomy 3:308 genetic testing 4:131 toxoplasmosis 2:357 prostate cancer 3:327 orphan drug 4:163 Index 477

HUS. See hemolytic uremic allergy testing 2:244 CAD 2:45 syndrome analgesic medications 1:368 coenzyme Q10 4:64 hyaline cartilage 1:293, 316 anaphylaxis 2:244–245 cognitive function and hydration 4:184, 217, 231, 233, angioedema 2:245 dysfunction 1:244 237, 276 antibiotic medications 2:308 DASH eating plan 2:47 hydrocele 3:290–291, 345, 346 antihistamine medications diabetes and cardiovascular hydrocephaly 1:256–257, 298 2:247 disease 2:48, 49 hydrocodone 4:311, 330 asthma 2:190 eclampsia 3:271 hydrocortisone 3:106, 107; 4:381 atopy 2:249 EECP 2:55 hydronephrosis 3:195, 196, 230 berylliosis 2:192 EPO 2:138 hygiene. See personal hygiene cardiac catheterization 2:28 exercise and health 4:221 hyperaldosteronism 3:109, 112, corticosteroid medications 2:256 fitness: exercise and health 136–137, 138 erythema multiforme 1:156 4:210 hyperbaric oxygen therapy 2:205, food allergies 2:260 garlic 4:70 215–217 headache 1:377 ginseng 4:72 hypercalcemia 3:137, 138, 154, immune disorders 2:272 glomerulonephritis 3:192 163, 209 immune system 2:235, 236 glomerulosclerosis 3:192 hypercalciuria 3:196–197 immunoglobulin 2:275 Goodpasture’s syndrome 3:193 hyperhidrosis 1:128, 141, 164–165 immunosuppressive medications heart attack 2:58 hyperkalemia 3:137–138, 143 2:276 heart failure 2:58 hyperkeratosis 1:170, 173–174 leukocyte 2:120 heart sounds 2:60 hyperlipidemia 1:124, 211; leukotrienes 2:279 hemolytic uremic syndrome 2:64–66, 65t; 4:301 living with allergies 2:279–280 3:194 aging and cardiovascular mast cell 2:283 hepatorenal failure 3:195 changes 2:10 multiple chemical sensitivity heredity and heart disease 2:64 apoB100 2:16 syndrome 2:285 hydronephrosis 3:196 body shape and cardiovascular myoclonus 1:265 hyperaldosteronism 3:137 health 2:25 NALT 2:288 kidney donor 3:200 CAD 2:45 neural blockade 1:380 kidneys 3:202 diabetes and cardiovascular piercings 1:185 lifestyle and cardiovascular disease 2:48 SALT 2:295 health 2:72 hypertension 2:67 SLE 2:295–296 lifestyle variables: smoking and lifestyle and cardiovascular urticaria 1:205–206 obesity 4:283 health 2:72 hypertension 2:66–67, 66t, 67t medications to treat obesity and cardiovascular acromegaly 3:105 cardiovascular disease 2:76, disease 2:90 aging and neurologic changes 78 physical exercise and 1:221 melatonin 4:89 cardiovascular health 2:97 aging and pulmonary changes nephrectomy 3:207 PVD 2:97 2:182 nephritis 3:208 risk factors for cardiovascular aging and urinary system nephropathy 3:210 disease 2:102 changes 3:175, 176 nephrotic syndrome 3:211 triglyceride blood level 2:112 alcohol 4:317 nephrotoxins 3:212 hypernatremia 3:138 alcohol interactions with nicotine 4:346 hyperopia 1:73, 82, 96, 111 medications 4:318 obesity and health 4:301 hyperoxaluria 3:197 aldosterone 3:111 ototoxicity 1:42t hyperparathyroidism 3:137, alkyl nitrites 4:320 pheochromocytoma 3:154 138–139, 151, 154, 163, 197 Alport’s syndrome 3:177 polycystic kidney disease 3:214 hyperpigmentation 1:145, 175 aneurysm 2:11 preeclampsia 3:321 hyperplasia 2:380, 381 antidepressant medications pulmonary hypertension hyperprolactinemia 3:139, 144 3:361 2:98–99 hypersensitivity reaction arteriosclerosis 2:19 renal failure 3:218, 219 2:268–271, 269t, 270t. See also blood pressure 2:24 retinopathy 1:115 specific allergic conditions, e.g.: body shape and cardiovascular risk factors for cardiovascular allergic dermatitis health 2:25 disease 2:102 allergen 2:240 brain 1:233 smoking and cardiovascular allergy 2:243 brain hemorrhage 1:235 disease 2:105 478 Index

stress response hormonal diabetes insipidus 3:122, 123 ibuprofen (Advil) 1:375; 2:79, 202, cascade 3:159 dopamine 3:124 286 stroke 2:107 endocrine system 3:98 ICD. See implantable cardioverter sudden cardiac death 2:108 estrogens 3:126 defibrillator TIA 2:111 FSH 3:127 ice 4:381, 382 tinnitus 1:58 GH 3:131 ichthyosis 1:166 tobacco use other than smoking GHRH 3:131 IgA. See immunoglobulin A 4:306 hyperprolactinemia 3:139 IgE. See immunoglobulin E urinary system 3:173 hyperthyroidism 3:139 IgG. See immunoglobulin G hyperthyroidism 1:88, 94–95; 2:60, hypoglycemia 3:142 IgM. See immunoglobulin M 94; 3:139–141; 4:168 inhibin 3:148 IHD. See ischemic heart disease endocrine system 3:99 kidneys 3:202 ileoanal reservoir 3:32, 60 enuresis 3:187 LH 3:151 ileostomy 3:32, 60 euthyroid sick syndrome 3:127 melatonin 3:151; 4:88 ileum 3:60–61, 61t; 4:286 goiter 3:129 menstrual cycle 3:303 bowel atresia 3:20 Graves’ disease 3:129 metabolism 4:225 cecum 3:21 mania 3:377 oxytocin 3:152 colon 3:26 polyglandular deficiency pituitary gland 3:155 diverticular disease 3:35 syndrome 3:156 prolactin 3:157 gastrointestinal system 3:4 thyroid storm 3:165 T4 3:166 ileoanal reservoir 3:60 TSH 3:165 TRH 3:166 ileostomy 3:60 hypertrophic cardiomyopathy TSH 3:164 small intestine 3:89 2:31–32, 39, 40 T3 3:166 illicit drug use 4:340, 340t hyperventilation 2:194, 204, urinary system 3:171 alcohol interactions with 204–205, 232 hypothermia 1:159–160; 4:50, medications 4:318 hypnosis 1:365, 375; 3:366, 370, 375–376 cannabis 4:326 373, 376, 379, 384; 4:77–78, 304 hypothyroidism 3:145–147 designer drugs 4:332 hypnotics 4:327, 328, 331, 334, bipolar disorder 3:367 GABA 4:336 336, 339, 339t depression 3:371 hallucinogens 4:338 hypocalcemia 3:141, 143, 154, 163 Down syndrome 4:123 injected toxins 4:385 hypochondriasis 3:376 endocrine system 3:99, 102 MDMA 4:343 hypoglossal nerve 1:246, 247t goiter 3:129 methamphetamine 4:342 hypoglycemia 3:141–142 hyperprolactinemia 3:139 performance-enhancing hypogonadism 3:291 hyperthyroidism 3:141 substances 4:348 hypokalemia 3:138, 142–143 hyponatremia 3:143 substance abuse 4:311 hyponatremia 3:143 pharmacodynamics 4:168 immune complex (IC) reaction. See hypoparathyroidism 3:139, 143, psychiatric disorders and type III hypersensitivity reaction 143, 154, 163 psychologic conditions 3:358 immune disorders 1:25, 58, 150, hypopigmentation 1:175, 207–208 hypoxia 1:238; 2:205 168, 268–269; 2:272, 272t, 274, hypopituitarism 3:139, 143–144, ARDS 2:181 280; 4:67. See also autoimmune 144t asphyxia 2:187 disorders; specific immune disorders hypoplastic left heart syndrome dyspnea 2:203 immune response 2:272–273 (HLHS) 2:39, 61 EPO 2:137 acute pain 1:363 hypospadias 3:197, 262, 263 hemoglobin 2:142 adverse drug reaction 4:148 hypotension 2:22–24, 67–68, 83, hyperventilation 2:205 aging and immune response 223, 357; 3:42, 83, 106, 177 pneumonitis 2:223 2:239 hypothalamic hormones 3:98, 144 pulmonary edema 2:224 allergen 2:240 hypothalamus 1:161, 231–232; pulmonary fibrosis 2:226 anthracosis 2:183 2:247, 267; 3:144–145, 145t SARS 2:353 antibody-mediated immunity ACTH 3:110 hysterectomy 3:274, 291–292 2:246 aging and endocrine changes hysteroscopy 3:264, 292 antigen 2:246–247 3:110 antihistamine medications androgens 3:113 I 2:247 appetite 4:178 IBD. See inflammatory bowel appendix 3:15 cortisol 3:116 disease autoimmune disorders CRH 3:115 IBS. See irritable bowel syndrome 2:249–250 Index 479

BALT 2:251–252 monokines 2:283 immunoglobulin 2:275 bladder cancer 3:181 multiple myeloma 2:157 immunotherapy 2:276–277 blood and lymph 2:118 NALT 2:288 incubation period 2:338 blood autodonation 4:263 necrotizing fasciitis 2:346 infection 2:338 blood transfusion 2:130 NK cell 2:286 lifestyle and cancer 2:382 blood type 2:131 normal flora 2:346 macrophage 2:282 bone marrow 2:119 organ transplantation 4:271 measles 2:343 bone marrow transplantation phagocyte 2:162 minerals and health 4:187 2:133 phagocytosis 2:162 mononuclear phagocyte system cancer 2:364 phototherapy 1:184 2:283–284 cancer vaccines 2:373 prayer and spirituality 4:95 organ transplantation 4:271 celiac disease 3:21 prostaglandins 2:289–290 psychoneuroimmunology 2:290 cell-mediated immunity 2:253 psoriasis 1:188 silicosis 2:230 chemokines 2:253 psychoneuroimmunology 2:290 stem cell therapy 4:141 clusters of differentiation 2:254 rash 1:191 virus 2:362 complement cascade 2:255–256 rheumatoid arthritis 2:291 immune system and allergies Cushing’s syndrome 3:117 SALT 2:295 2:235–302 cytokines 2:257 semen 3:337 immune system dysfunction 3:205, dependence 4:331 short bowel syndrome 3:88 210 desensitization 2:258 spleen 2:167 immunity 2:273–274; 4:386 diabetes 3:121 splenectomy 2:168 active immunity 2:239 endometriosis 3:276 T-cell lymphocyte 2:296 adenovirus 2:306 fever 2:326 tendonitis 1:359 antibody-mediated immunity 5ASA medications 2:260 testicular torsion 3:347 2:246 food allergies 2:260 thymectomy 2:172 gammaglobulin 2:263 gene therapy 4:127 thymus 2:120–121, 172 innate immunity 2:277–278 ginseng 4:71, 72 toxic epidermal necrolysis 1:205 mononucleosis, infectious 2:345 goldenseal 4:73 toxic shock syndrome 2:357 mumps 2:345 granulocyte 2:138 tuberculosis 2:359 passive immunity 2:289 Graves’ disease 3:131 vaccine 2:298 syphilis 2:356 healing 2:266 immune system 1:255, 350; 2:273 toxoplasmosis 2:358 histamine 2:266–267 abscess 2:306 immunization 2:338; 4:37 immune system 2:236 aging and immune response chickenpox 2:316 immunization 2:338 2:239 diphtheria 2:322 immunoablation 2:274 aging and nutrition/dietary infectious diseases 2:304 immunodeficiency 2:274–275 changes 4:176 influenza 2:338 immunosenescence 2:275 alkyl nitrites 4:321 measles 2:343 immunosuppressive medications allergic dermatitis 2:241 pertussis 2:348 2:275–276 allergy 2:243 rubella 2:351 immunosuppressive therapy antibiotic resistance 4:150 immunoablation 2:254, 274, 276, 2:276 antibody 2:245 294 inflammation 2:277 antivenin 4:152 immunocompromised 1:144, 170; innate immunity 2:277–278 bacteria 2:312 2:274 interferons 2:278 BALT 2:251 adenovirus 2:306 interleukins 2:278 cancer 2:364 babesiosis 2:311 leukemia 2:146 cancer treatment options and candidiasis 2:315 leukocyte 2:119, 148 decisions 2:372 chickenpox 2:316 leukotrienes 2:279 diet and cancer 2:378 CMV 2:320 lichen planus 1:173 echinacea 4:67 coccidioidomycosis 2:318 lichen simplex chronicus 1:174 Epstein-Barr virus 2:323 cryptococcosis 2:319, 320 lymph 2:120 food allergies 2:260 cryptosporidiosis 2:320 lymphokines 2:280–281 gammaglobulin 2:262 drinking water standards 4:20 MAbs 2:283 HIV/AIDS 2:334 encephalitis 2:324 macrophage 2:282 HLAs 2:267–268 environmental hazard exposure mast cell 2:283 HPV 2:336 4:22 measles 2:343 immunization 2:338 hepatitis prevention 4:32 480 Index

histoplasmosis 2:333 coccidioidomycosis 2:318 abscess 2:306 listeriosis 2:341 cystic fibrosis 4:121 active immunity 2:239 meningitis 2:344 Epstein-Barr virus 2:324 aging and immune response necrotizing fasciitis 2:346 graft vs. host disease 2:264 2:239 opportunistic infections 2:347 heart transplantation 2:63 alkyl nitrites 4:320, 321 pneumococcal pneumonia HLAs 2:267 anabolic steroids and steroid 2:349 immunocompromised 2:274 precursors 4:322 pneumonia 2:221 immunodeficiency 2:274 antibiotic resistance 4:150 salmonellosis 2:352 influenza 2:339 antibody 2:245 shigellosis 2:353 lung transplantation 2:213 antibody-mediated immunity toxoplasmosis 2:357, 358 opportunistic infections 2:347 2:246 vaccine 2:298 reticulocyte 2:165 bariatric surgery 4:287 immunodeficiency 2:213, 236–237, SCID 2:294 blood autodonation 4:263 255, 274–275, 294 toxoplasmosis 2:357 body substance isolation 4:357 immunoglobulin 1:255; 2:275 immunotherapy 2:274, 276–277, cancer prevention 4:14 blood 2:127 365, 372 carrier 2:315 gammaglobulin 2:263 impalement 4:363, 364–365, 367, drugs 4:145, 146 immune system 2:236 380 fever 2:326 Kawasaki disease 2:71 impetigo 1:166 HIV/AIDS prevention 4:32 measles 2:343 implantable cardioverter immune response 2:272–273 MHC 2:282 defibrillator (ICD) 1:385; 2:19, immune system 2:273 multiple myeloma 2:159 69 immunity 2:273–274 rabies 2:350 imported drug 4:159 inflammation 2:277 immunoglobulin A (IgA) 1:79; inborn errors of metabolism 4:227 influenza 4:34 2:251, 275; 3:210 incubation period 2:338; 4:36 injecting drugs, risks of 4:340 immunoglobulin E (IgE) indoor air quality 4:34, 34t, 47 laser surgery 4:265 allergic rhinitis 2:242 infantile seborrheic dermatitis. See lymph 2:149 allergy testing 2:244 cradle cap lymph node 2:151 antibody 2:245 infants lymphocytopenia 2:152 gammaglobulin 2:263 aging and changes in microbe 2:344 histamine 2:267 blood/lymph 2:123 monocyte 2:157 immunoglobulin 2:275 aging and changes in pain nosocomial infections 2:347 inflammation 2:277 perception 1:364 opportunistic. See opportunistic leukotrienes 2:279 aging and immune response infections mast cell 2:283 2:239 organ transplantation 4:271 immunoglobulin E (IgE) aging and nutrition/dietary preventive medicine 4:3 hypersensitivity reaction. See type changes 4:176 puncture wound 4:366 I hypersensitivity reaction Apgar score 3:245 wound care 4:280, 281 immunoglobulin G (IgG) 1:79; breastfeeding 3:254 infectious arthritis 1:328, 341–342, 2:255, 268, 269, 275 chlamydia 2:317 352 immunoglobulin M (IgM) 2:254, concussion 1:245 infectious diseases 2:303–363 268, 269, 275 diaper rash 1:152 infectious mononucleosis. See immunosenescence 2:275 Heimlich maneuver 4:373 mononucleosis, infectious immunosuppression 2:63, 214; immunity 2:274 inferior vena cava 2:4, 115 4:272 intussusception 3:64 infertility 3:293–295, 293t–295t; immunosuppressive medications malnutrition 4:185 4:121 2:275–276; 4:270, 271 meconium 3:77 conception 3:264 immunosuppressive therapy 1:151, neonatal jaundice 3:306 ectopic pregnancy 3:272 168, 170; 2:276; 3:75, 150, passive immunity 2:289 endometriosis 3:276 203–205, 208 SIDS 4:48 genital trauma 3:287 adverse drug reaction 4:148 tachypnea 2:232 gestational surrogacy 3:289 aspergillosis 2:185 toxic megacolon 3:93 orchiectomy 3:308 autoimmune disorders 2:249 triceps skinfold 4:307 POF 3:323 bone marrow transplantation infection 1:143, 185, 203, 343–344; reproductive system 3:237 2:133 2:338. See also specific infections retrograde ejaculation 3:336 CMV 2:320 abrasions 4:361 sexual health 3:339 Index 481

STDs 3:340 tendonitis 1:359–360 gastrointestinal system 3:3 tubal ligation 3:347 TGFs 2:297 genetics and molecular medicine urethritis 3:222 toxic shock syndrome 2:357 4:112 varicocele 3:353 inflammation response 1:363; glucagon 3:128 vasectomy 3:354–355 2:136, 163 glucose 3:128 inflammation 2:277 inflammatory bowel disease (IBD) hypoglycemia 3:142 antihistamine medications 3:61–64, 62t, 63t insulin resistance 3:149 2:247 ankylosing spondylitis 1:303 islet cell transplantation 3:149 atelectasis 2:190 antidiarrheal medications 3:13 islets of Langerhans 3:149 atherosclerotic plaque 2:22 colitis 3:25 metabolism 4:225 berylliosis 2:192 colostomy 3:31 pancreas 3:79 bronchitis 2:196 5ASA medications 2:260 recombinant DNA 4:139 bronchus 2:198 ileoanal reservoir 3:60 insulin resistance 2:25, 49; bursa 1:312 nephrolithiasis 3:209 3:148–149 bursitis 1:312 primary sclerosing cholangitis diabetes 3:120 cellulitis 1:143–144 3:84 diabetes prevention 4:19 chondritis 1:318 TNFs 2:297 gestational diabetes 3:288 chondroitin 4:64 influenza 2:338–340 ginseng 4:72 COPD 2:199 echinacea 4:67 hypoglycemia 3:142 c-reactive protein 2:45–46 infectious diseases 2:303 menopause 3:302 cytokines 2:257 lung transplantation 2:213 obesity and health 4:301 endocarditis 2:53–54 NALT 2:288 PCOS 3:320 epicondylitis 1:320–321 pericarditis 2:95 pharmacodynamics 4:168 erythema nodosum 1:156 pneumonia 2:220 polyglandular deficiency garlic 4:69 preventive medicine 4:2 syndrome 3:156 granuloma 2:265 sneeze/cough etiquette 2:354 insulin therapy 3:120, 121, 149 histamine 2:267 vaccine 2:298 integrative medicine 4:78 immune response 2:273 influenza A 2:221, 338; 4:35 integumentary system 1:125–211, immune system 2:236, 238 influenza B 2:221, 338; 4:35 126 immunotherapy 2:276 influenza prevention 4:34–36 breakthrough research and infection 2:338 ingested toxins 4:42, 383–384 treatment advances 1:130 infectious arthritis 1:328 ingrown hair 1:166–167, 188 dermis 1:127–128, 128t interferons 2:278 ingrown nail 1:167 embryonic development 1:125 interleukins 2:278 inhalation burns 4:363, 365, 385 epidermis 1:127, 127t leukotrienes 2:279 inhaled toxins 4:42, 365, 381, fingernails and toenails 1:129 lung abscess 2:208 384–385, 384t, 386 functions of 1:125–129 macrophage 2:282 inheritance pattern 1:222, 225, hair 1:128–129 mast cell 2:283 256, 269, 335 health and disorders 1:129–130, meningitis 2:343–344 inheritance patterns 4:132–133, 130t miliaria 1:176 133t overview 1:125–130 NSAIDs 2:286 inhibin 3:100, 148, 151 structures of 1:125 otitis 1:40 injected toxins 4:385 subcutaneous layer 1:128 pain 1:382 injecting drugs, risks of 4:31, 312, traditions in medical history pericarditis 2:95–96 340–341, 385 1:129 plantar fasciitis 1:349–350 innate immunity 2:274, 277–278 interaction. See drug interaction pleura 2:218 inner ear 1:3–4, 11–12, 16–17, 20, interferons 2:276, 278, 368, 372 polymyositis 1:350 31, 33–35, 60–61, 350 interleukins 2:278; 4:95 prostaglandins 2:290 innovator drug 4:146, 153, 158, cancer treatment options and rheumatoid arthritis 2:291–292 159, 163 decisions 2:372 RICE 1:353 inotropics 2:81, 85t fever 2:326 rotator cuff impingement insanity 3:376 immunotherapy 2:276 syndrome 1:353 insulin 2:8, 72–73, 90, 97, 249; psychoneuroimmunology 2:290 sarcoidosis 2:293–294 3:148 TGFs 2:297 shin splints 4:231 cloning 4:119 TNFs 2:297 soft tissue injuries 4:367 diabetes 3:119 intermittent claudication 2:69, 78, synovitis 1:357 endocrine system 3:100 79, 96 482 Index internal bleeding 4:362, 377 irritable bowel syndrome (IBS) karyotype 4:116, 118, 124, 130, interpersonal relationships 4:248 3:13, 65–66 133, 136 interstitial lung disorders 2:205, ischemic heart disease (IHD) 2:60, Kawasaki disease 2:71, 300t 226 63, 70, 102, 108, 111–112 Kegel exercises 3:87, 199, 224, 278 intestinal adhesions 3:64 ischemic optic neuropathy 1:97–98 keloid 1:170, 194 intestinal lippodystrophy. See ischemic stroke 2:107, 108, 110, keratin 1:127, 129, 170 Whipple’s disease 111 keratinocyte 1:170 intestinal mucosa islet cell transplantation 3:103, integumentary system 1:127, celiac disease 3:21 149–150 129, 130 diverticular disease 3:35 islets of Langerhans 3:149 pemphigus 1:182 gastroenteritis 3:48 diabetes 3:119 psoriasis 1:188 gastrointestinal system 3:4 endocrine system 3:100, 101 scale 1:194 IBD 3:61 GHRH 3:132 sebaceous glands 1:195 malabsorption 3:77 glucagon 3:128 skin 1:195 small bowel transplantation glucose 3:128 squamous cell carcinoma 1:197 3:89 hypoglycemia 3:142 sunburn 1:200–201 small intestine 3:89 insulin 3:148 toxic epidermal necrolysis 1:205 Whipple’s disease 3:94 insulin resistance 3:149 keratitis 1:94, 99, 103 intestinal polyp 1:180; 3:64 islet cell transplantation 3:149 keratoacanthoma 1:170 adenoma 3:107 MEN 3:151 keratoconus 1:83, 99 colonoscopy 3:26 metabolism 4:225 keratocyte 1:141, 143, 145, 170, 175 colorectal cancer 3:28 obesity and health 4:301 keratosis pilaris 1:170–171 FAP 3:43 pancreas 3:79 ketamine 4:328, 338, 342 FOBT 3:44 somatostatin 3:158 kidney 2:49, 50, 137, 359; HNPCC 3:58 itching. See pruritus 3:201–202, 202t rectum 3:87 IVF. See in vitro fertilization aging and urinary system intima 2:20, 44, 45, 64 changes 3:175 intoxication 4:341 J cystinuria 3:183 alcohol 4:315, 316 jaundice 3:66–67, 71, 73, 195; cystitis 3:184 depressants 4:332 4:166 diabetes insipidus 3:122 designer drugs 4:332 jaw 1:57, 294, 359 eating disorders 3:374 ethchlorvynol 4:334 jejunoileal bypass 4:284–286 glomerulonephritis 3:191 flunitrazepam 4:336 jejunum 3:4, 20, 36, 61, 67, 89; glomerulus 3:193 GABA 4:336 4:286 Goodpasture’s syndrome 3:193 hangover 4:338 jock itch. See tinea hepatotoxins 3:57 organic solvents 4:347 joint 1:328, 328t; 2:277, 341, 353; ingested toxins 4:384 substance abuse 4:311 4:64. See also osteoarthritis; nephropathy 3:209–210 intra-aortic balloon pump (IABP) rheumatoid arthritis organ transplantation 4:270 counterpulsation 2:70 adhesive capsulitis 1:298–299 protein loading 4:229 intraductal papilloma 3:295 arthroscopy 1:304 renal failure 3:218 intrahepatic bile ducts. See bile contracture 1:319 renin 3:158 ducts crepitus 1:319 Turner’s syndrome 3:348 intraocular pressure 1:92, 94, 97, dislocations 1:320 uremia 3:221 104, 106, 119 gout 1:323–324 urinary system 3:169, 170–172 intravenous fluid 4:274, 276 infectious arthritis 1:328 vesicoureteral reflux 3:229 intravenous pyelogram (IVP) 3:198 musculoskeletal system 1:294 kidney disease 2:66, 125, 138; intussusception 3:64–65 neurogenic arthropathy 1:340 3:108–109, 138; 4:31, 89 investigational new drug (IND) repetitive motion injuries 1:352 kidney donor 3:199–201 4:159–160 rotator cuff impingement kidney stones 3:189, 196, 197, 208, in vitro fertilization (IVF) 3:238, syndrome 1:353 227 246, 289 sprains and strains 1:355 kidney transplantation 3:202–204; iodine 3:146, 166 joint replacement 1:300, 328–329 4:166 iris 1:97, 120 adrenal glands 3:108 iritis 1:97 K Alport’s syndrome 3:177 iron 2:119, 125, 126, 156; 4:31, Kaposi’s sarcoma 1:168–169, 169t; ESRD 3:187 105, 155 2:95, 158, 370 Fanconi’s syndrome 3:190 Index 483

glomerulosclerosis 3:192 laxatives 3:32, 68–69, 68t, 374 blood disorders 2:121 hemolytic uremic syndrome lazy eye. See amblyopia bone marrow donation 2:132 3:195 LDL-C. See low-density lipoprotein cancer treatment options and hyperoxaluria 3:197 cholesterol decisions 2:372 nephropathy 3:210 lean muscle mass 4:215, 222, 226, carcinogen 2:374 polycystic kidney disease 3:214 233, 288–290, 293, 297, 307 cell structure and function uremia 3:221 learning disorders 1:54, 258–259; 4:115 urinary system 3:174 4:313, 329 chemotherapy 2:377 killer T-cell 2:272, 296 left anterior descending (LAD) CSFs 2:254 Klinefelter’s syndrome 3:291, 294, artery 2:40, 43 immunoglobulin 2:275 296; 4:117 left atrium 2:4, 62, 88 interferons 2:278 knee injuries 1:330–332, 331t, left ventricle 2:4, 32, 40, 112 lymphadenopathy 2:149 332t; 4:211 left ventricular ejection fraction lymphoma 2:155 Baker’s cyst 1:307 (LVEF) 2:45, 61, 72 multiple myeloma 2:159 meniscectomy 1:336 legal blindness 1:67, 122, 122t, pericarditis 2:95 neurogenic arthropathy 1:340 123t stem cell therapy 4:141 Osgood-Schlatter disease 1:341 legend drug 4:161 leukocyte 2:148, 148t patellofemoral syndrome Legionella pneumophila 2:206, 303 aging and changes in 1:348–349 Legionnaires’ disease 1:42t; blood/lymph 2:123 Kupffer cells 2:119, 138, 157, 162 2:206–207, 222, 303 antibody 2:245 kyphosis 1:298, 332, 345 legs 2:69, 96–97, 114–116, 225; antihistamine medications 4:45 2:247 L lens 1:77–79, 82, 89, 100, 108 B-cell lymphocyte 2:251 labyrinth 4:79, 91 lens replacement 1:78, 112 blood and lymph 2:118, labyrinthitis 1:31 lentigines 1:134, 172–173 119–120 lacerations 4:265, 274, 361, 362, lesion 1:173, 173t bone marrow 2:132 365–366, 366, 379–380 acne 1:131 chemokines 2:253 lacrimal (tear) ducts 1:85, 86 actinic keratosis 1:133–134 corticosteroid medications 2:257 lacrimal (tear) glands (Sjögren’s erythema multiforme 1:156 CSFs 2:254 syndrome) 2:294–295 ichthyosis 1:166 cytokines 2:257 lactase 4:180, 185 Kaposi’s sarcoma 1:168 food allergies 2:260 lactation 3:139, 250 keratoacanthoma 1:170 graft vs. host disease 2:263 lactiferous glands 3:250, 253 macule 1:175 granulocyte 2:138 lactose intolerance 4:180, 185 nevus 1:178–179 human ehrlichiosis 2:335, 336 LAD artery. See left anterior petechiae 1:183 immunodeficiency 2:274 descending artery pityriasis rosea 1:186 immunotherapy 2:276 laminectomy 1:333 plaque, skin 1:186 interleukins 2:278 Landsteiner, Karl 2:122, 130 prurigo 1:186–187 leukopenia 2:148 Langerhans cells 1:127; 2:157, 295 psoriasis 1:188, 189 lymph 2:120 Langer’s lines 4:265 purpura 1:190 lymphocyte 2:151 language disorders (aphasia) 1:225 scale 1:194 lymphoma 2:152 laparoscopic surgery 3:14–15, 22, scar 1:194 mast cell 2:283 47, 206; 4:286, 287 seborrheic keratosis 1:195 monocyte 2:157 laryngeal cancer 4:306, 353 staphylococcal scalded skin necrotizing fasciitis 2:346 laryngectomy 1:21, 23, 31–32, 64 syndrome 1:200 PCID 2:289 laryngitis 1:32, 64 thrush 1:58 phagocyte 2:162 laryngocele 1:32 vesicle 1:207 SCID 2:294 larynx 1:13, 21, 31–32, 57, 63–64 wheal 1:209–210 T-cell lymphocyte 2:296 laser skin resurfacing 1:172, 210 xanthoma 1:211 TNFs 2:297 laser surgery 1:71, 108, 111–112, letdown reflex 3:152, 296 leukopenia 2:148, 152 114; 2:111–112, 115; 4:265–266, leukemia 1:150; 2:145–148, 147t leukoplakia 1:32 266, 266t adult survivors of childhood leukotrienes 2:138, 240, 258, 260, laser therapy 1:192, 203 cancer 2:366, 367 279, 290 LASIK (laser-assisted in situ B-cell lymphocyte 2:251 levo-alpha acetylmethadol (LAAM) keratomileusis) eye surgery 1:69, blood and lymph research and 4:342, 354 109, 111, 112 treatment advances 2:122 Lewy body dementia 1:251, 252 484 Index

LH. See luteinizing hormone lifestyle and health 4:37–38 youth high-risk behavior 4:50 libido 3:296–297 aging and endocrine changes life support 1:224–225, 233 amphetamines 4:321 3:111 ligament 1:333; 2:10, 96 andropause 3:245 aging and gastrointestinal ankle injuries 1:301 ginseng 4:71 changes 3:10 dislocations 4:364 hemochromatosis 3:133 aging and nutrition/dietary flat feet 4:222 sexual dysfunction 3:338 changes 4:177 knee injuries 1:330 testicular cancer 3:345 aging and physical ability/fitness musculoskeletal system 1:294 tubal ligation 3:348 4:215 scrotum 3:337 yohimbe 4:107 aging and urinary system sprain or tear 1:332t lichen planus 1:173 changes 3:176 sprains and strains 1:355 lichen simplex chronicus anti-aging approaches 4:58 uterus 3:351 1:173–174 antismoking efforts 4:8 weak ankles 4:237 life expectancy 2:42, 72, 334; 4:2, bariatric surgery 4:288 lignans 2:379t; 4:94 17, 37, 302 breast health 3:255 limbic system 1:242; 4:240 lifestyle and cancer 2:367, cancer prevention 4:14 Lioresal. See baclofen 377–380, 382–383; 4:14 chelation therapy 4:63 lipid-lowering medications lifestyle and cardiovascular health childhood obesity 4:292 2:81–82, 85t 2:72–73; 4:16 constipation 3:32 lipid mediators. See prostaglandins aging and cardiovascular cystinuria 3:183 lipid metabolism 2:10, 16–17, 25, changes 2:10 diabetes 3:122 48–49, 64–66; 4:203 angioplasty 2:13 diet and health 4:182 lipoma 1:333–334 anticoagulation therapy 2:14 dieting 4:293, 294 lipoprotein 2:35, 36, 64, 246; atherosclerosis 2:22 erectile dysfunction 3:280 4:181, 202 blood pressure 2:25 generational health-care listeriosis 2:341 body shape and cardiovascular perspectives 4:247 Lister, Joseph 4:1, 258 health 2:25 genetic predisposition 4:130 lithium 3:147, 377 CABG 2:41, 43 genetics and molecular medicine liver 1:280; 3:69, 69t CAD 2:45 4:112 AFP 3:243 cardiac rehabilitation 2:30–31 gestational diabetes 3:288 aging and changes in cardiomyopathy 2:31, 33 health education 4:26 blood/lymph 2:123 cardiovascular system 2:5, 6 health risk factors 4:27–29 aging and drug metabolism/drug cholesterol blood levels 2:37 Healthy People 2010 4:29–30 response 4:149 CVD 2:34 hot flashes 3:290 alcohol interactions with DVT 2:48 hypnosis 4:77 medications 4:318 heart attack 2:58 IBS 3:66 amebiasis 2:307 heart failure 2:58–59 infertility 3:295 antimitochondrial antibodies hyperlipidemia 2:65 life expectancy 4:37 2:248 hypertension 2:66–67 mind-body interactions 4:90 bile 3:18 intermittent claudication 2:69 naturopathy 4:91 bile ducts 3:18 open heart surgery 2:91 nutritional therapy 4:93 blood and lymph medical Ornish program 2:91–92 obesity 4:300 traditions 2:121 physical exercise and portal hypertension 3:84 carbohydrate loading 4:217 cardiovascular health 2:97 prenatal care 3:326 cardiovascular system 2:6 pulmonary hypertension 2:99 preventive health care and cholestasis 3:23 PVD 2:96–97 immunization 4:42 cholesterol, dietary 4:181 Raynaud’s syndrome 2:101–102 preventive medicine 4:3 cholesterol blood levels 2:36 risk factors for cardiovascular routine medical examination cirrhosis 3:24 disease 2:102 4:45 clotting factors 2:136 smoking and cardiovascular sexually transmitted disease CMV 2:320 disease 2:105 prevention 4:47 CYP450 enzymes 4:154 soy and cardiovascular health variables: overview 4:282–283 delirium tremens 4:330 2:106 variables: smoking and obesity drug interaction 4:155 stroke 2:108 4:282–310 erythrocyte 2:137 triglyceride blood level 2:112 weight loss and weight erythrocytes 2:119 valvular heart disease 2:114 management 4:309, 310 esophageal varices 3:41 Index 485

gallbladder 3:46 liver disease of alcoholism 3:72 Lou Gehrig’s disease. See gastrointestinal system 3:1 liver hemodialysis 3:75 amyotrophic lateral sclerosis glucagon 3:128 liver transplantation 3:75 low-density lipoprotein (LDL) 2:16, graft vs. host disease 2:263 overdose 4:165–166 36, 66; 4:98, 202 heavy-metal poisoning 4:31 portal hypertension 3:84 low-density lipoprotein cholesterol hematopoiesis 2:140 primary biliary cirrhosis 3:84 (LDL-C) hemochromatosis 3:133 primary sclerosing cholangitis apoB100 2:16 hepatic abscess 3:54 3:85 cholesterol blood levels 2:36–37 hepatitis 3:54 short bowel syndrome 3:88 diabetes and cardiovascular hepatomegaly 3:57 liver function tests 3:73, 73–75, disease 2:48–49 hepatotoxins 3:57 74t, 82, 84, 89 diet and cardiovascular health immune system 2:235 liver hemodialysis 3:75 2:50 ingested toxins 4:384 liver spots. See lentigines hyperlipidemia 2:65 insulin 3:148 liver transplantation 3:75–76, 76t medications to treat islets of Langerhans 3:149 biliary atresia 3:19 cardiovascular disease 2:82 jaundice 3:67 cirrhosis 3:25 omega fatty acids and liver cancer 3:69 esophageal varices 3:42 cardiovascular health 2:90 liver failure 3:72 gastrointestinal system 3:6 soy and cardiovascular health malaria 2:342, 343 hepatitis prevention 4:32 2:106 medicinal herbs and botanicals hepatorenal failure 3:195 triglyceride blood level 2:112 4:83 liver disease of alcoholism 3:72 low molecular weight heparin milk thistle 4:89 liver failure 3:73 (LMWH) 2:14, 78 neonatal jaundice 3:306 overdose 4:166 LQTS. See long QT syndrome obesity and cardiovascular portal hypertension 3:84 lumbar puncture 1:241, 259; disease 2:90 primary biliary cirrhosis 3:84 2:323, 341, 344 organ transplantation 4:270 primary sclerosing cholangitis lumbar spine 1:306, 334, 354 peptic ulcer disease 3:82 3:85 lung abscess 2:208, 232 porphyria 4:138 livestock 2:309–311, 338 lung cancer 2:208–212, 209t, 210, portal hypertension 3:83 living donor transplantation 3:75, 211t primary biliary cirrhosis 3:84 187, 200, 206 addiction 4:314 renin 3:158 living organ donation 4:270, 271 adult survivors of childhood rickets 4:199 living with allergies 2:247–248, cancer 2:367 steatohepatitis 3:89 258, 279–280 antismoking efforts 4:8 triglyceride blood level 2:112 living with cardiovascular disease asbestosis 2:184, 185 triglycerides, dietary 4:202 2:5, 73–74, 104 atelectasis 2:191 Wilson’s disease 3:167 living with chronic pulmonary bronchitis 2:196 Zollinger-Ellison syndrome 3:94 conditions 2:185, 190, 201, 203, cancer vaccines 2:373 liver cancer 2:327, 370, 373; 3:55, 205, 207–208 cannabis 4:327 69–71, 70t, 340 living with immune disorders CEA 2:374 liver disease 3:57, 73, 84, 200; 2:280 lifestyle variables: smoking and 4:319, 351 living with pain 1:378 obesity 4:282 liver disease of alcoholism 3:16, 57, LMWH. See low molecular weight pleural effusion 2:218 71–72, 90; 4:89, 317 heparin radon exposure 4:43 liver enzymes 3:57, 73, 74 lobes, of cerebral cortex 1:231, smoking and cancer 2:392 liver failure 1:368; 3:72–73, 72t 231t, 242, 243t smoking and health 4:303, 304 alcohol interactions with lobular capillary hemangioma. See smoking and pulmonary disease medications 4:319 granuloma telangiectaticum 2:230, 231 bioavailability 4:153 lobules 3:69, 83, 250 thoracentesis 2:232 cirrhosis 3:24 location, sense of. See thoracotomy 2:232 dextromethorphan 4:332 proprioception tobacco 4:353 esophageal varices 3:42 locus 4:113, 119, 127 tobacco use other than smoking hemochromatosis 3:133 long bones 1:308, 309, 341 4:306 hepatitis 3:54, 56 long QT syndrome (LQTS) 2:7, 19, lung capacity 2:73, 182 hepatitis prevention 4:32 39, 40, 74–75, 111 lungs 1:168; 2:212–213, 212t–213t hepatorenal failure 3:195 loop diuretics 2:80–81, 81t aerobic capacity 4:213 hepatotoxins 3:57 lordosis 1:298, 334 aerobic exercise 4:214 486 Index

aerobic fitness 2:9 tobacco 4:353 spleen 2:167 aging and cardiovascular trachea 2:233 TGFs 2:297 changes 2:10 tracheostomy 2:234 thymectomy 2:172 aging and pulmonary changes tuberculosis 2:359 thymus 2:172 2:181 tuberculosis prevention 4:49 VALT 2:299 alveolus 2:183 lung transplantation 2:213, lymphocytopenia 2:148, 152 anesthesia 4:262 213–214, 213t; 4:121 lymphoid tissue 2:236, 287–289 anthracosis 2:183 berylliosis 2:193 lymphokines 2:280–281 ARDS 2:181 COPD 2:201 lymphoma 1:150; 2:152–155, 153t, asbestosis 2:184 oxygen-carbon dioxide 154t; 4:141 asphyxia 2:186 exchange 2:216 adult survivors of childhood atelectasis 2:190 pulmonary fibrosis 2:226 cancer 2:367 auscultation 2:191 smoking and pulmonary disease B-cell lymphocyte 2:251 berylliosis 2:192 2:230 cancer vaccines 2:373 breathing 2:193 thoracotomy 2:233 carcinogen 2:374 bronchus 2:197 lutein 1:102; 4:79, 79, 79t, 107 chemotherapy 2:377 byssinosis 2:198 luteinizing hormone (LH) 3:100, leukemia 2:148 cardiopulmonary bypass 2:33 111, 119, 127, 129, 148, 151, 282 lung transplantation 2:214 chest percussion and postural LVEF. See left ventricular ejection lymphadenopathy 2:149 drainage 2:199 fraction lymphocyte 2:152 coccidioidomycosis 2:318 lycopene 2:379t; 4:79, 79–80, 80t MALT 2:284 cyanosis 2:46 Lyme disease 2:341–342, 342t multiple myeloma 2:159 drowning 4:368 lymph 2:120, 123–124, 149, 170, myelodysplasia syndrome 2:160 dyspnea 2:203 384, 391. See also blood and lymph tissue endurance 4:220 lymph antigen 2:246 hantavirus pulmonary syndrome lymphadenitis 2:120, 149, 151, 155 BALT 2:251–252 2:331 lymphadenopathy 2:71, 120, 149, blood stem cells 2:129 hemoptysis 2:204 151, 333, 351 GALT 2:265 histoplasmosis 2:333 lymphangioma 2:149–150 immune system 2:235 inhaled toxins 4:384 lymphatic capillaries 2:120, 155 lymphocyte 2:151 interstitial lung disorders 2:205 lymphatic system 2:134, 152, 245, MALT 2:284 lung cancer 2:208 343 SALT 2:295 lung transplantation 2:213 lymphedema 2:134, 150, 151, 155 VALT 2:299 measles 2:343 lymph node 2:150–151 lymph vessels 2:155 overdose 4:166 lymph 2:120, 149 aging and changes in oxygen-carbon dioxide lymphadenitis 2:149 blood/lymph 2:124 exchange 2:216 lymphadenopathy 2:149 cisterna chyli 2:134 oxygen therapy 2:217 lymphedema 2:150 lymph 2:149 pleura 2:218 lymph vessels 2:155 lymphadenitis 2:149 pleural effusion 2:218 monocyte 2:157 lymphangioma 2:149 pleurisy 2:218 sentinel lymph node dissection lymphedema 2:150 pneumococcal pneumonia 2:349 2:391 lymph node 2:151 pneumonia 2:220 spleen 2:167 right lymphatic duct 2:165 pneumonitis 2:222 T-cell lymphocyte 2:296 thoracic duct 2:170 pneumothorax 2:223 thoracic duct 2:170 lysergic acid diethylamide (LSD) pulmonary arteries 2:98 lymphocyte 2:151–152 4:170, 328, 337 pulmonary edema 2:223 clusters of differentiation 2:254 pulmonary embolism 2:224, 225 graft vs. host disease 2:263 M pulmonary fibrosis 2:226 granulocyte 2:139 MAbs. See monoclonal antibodies pulmonary hypertension 2:98 immune system 2:235, 236 macrophage 2:282 pulmonary veins 2:99 immunotherapy 2:276 aging and immune response respiratory failure 2:227–228 leukocyte 2:119 2:239 silicosis 2:229–230 lymph 2:120 antigen 2:246 smoking and pulmonary disease lymphocytopenia 2:152 BALT 2:251 2:230–231 NK cell 2:286 cell-mediated immunity 2:253 sputum 2:231 SALT 2:295 chemokines 2:253 Index 487

erythrocytes 2:119 mammogram 3:250, 254, 255, 285, prostate cancer 3:330 human ehrlichiosis 2:335 295, 298, 315 prostate health 3:331 immune system 2:236 mandible 1:294, 359 TCM 4:102 leukocyte 2:120 mania 3:366, 370, 375, 377 meditation 1:375; 2:92, 94, 205, lymph 2:120 Marfan syndrome 1:235, 295, 208; 3:372, 373; 4:88 lymphokines 2:281 335–336; 2:11, 37, 59, 63; 4:110 alternative and complementary monokines 2:283 Marie-Strümpel disease. See approaches to conventional phagocytosis 2:162 ankylosing spondylitis medicine 4:52 SALT 2:295 marijuana 4:312, 326, 342, 348 anger and anger management tuberculosis 2:359 massage therapy 1:366; 4:65, 82, 4:241 macula 1:70–71, 113 93, 96 integrative medicine 4:78 macular degeneration. See age- mastalgia 3:289, 298 labyrinth 4:79 related macular degeneration mast cell 2:283 Native American healing 4:91 macule 1:174, 175, 186 allergic asthma 2:240 prayer and spirituality 4:95 mad cow disease. See bovine allergic rhinitis 2:243 tai chi 4:101 spongiform encephalopathy antihistamine medications visualization 4:104 magnet therapy 1:365; 4:81, 81t 2:247 yoga 4:106 major histocompatability complex corticosteroid medications 2:256 medulla 3:107, 108 (MHC) 2:193, 253, 267, 282, desensitization 2:258 megakaryocyte 2:119, 163 282, 282, 282 food allergies 2:260, 261 melanin 1:127, 135, 170, 175, 196, malabsorption 3:77 histamine 2:266 200 antidiarrheal medications 3:13 hypersensitivity reaction 2:268 melanocyte 1:175–176 bariatric surgery 4:286 immune system 2:236 aging and integumentary bioavailability 4:153 leukotrienes 2:279 changes 1:135 celiac disease 3:21 SALT 2:295 chloasma 1:145 diarrhea 3:34 mastectomy 3:251, 252, 298–299 integumentary system 1:127, malnutrition 4:186 mastitis 3:254, 299–300, 300t 129 nutritional deficiency 4:194 mastoiditis 1:6, 33 nevus 1:178 peritonitis 3:83 masturbation 3:300, 342 skin 1:195 rapid gastric emptying 3:86 measles 1:30; 2:253, 303, 304, 343, sunburn 1:200 short bowel syndrome 3:88 350 vitiligo 1:207 weight loss and weight mechanical ventilation 2:214–215; melanoma. See malignant management 4:310 4:166 melanoma Whipple’s disease 3:94 meconium 3:77; 4:120 melasma. See chloasma malaria 1:42t; 2:275, 342–343, medical emergencies. See melatonin 1:65; 3:101, 151, 154, 343t, 350 emergencies, medical 382, 384; 4:88–89, 89t, 104 Malassezia sp. 1:148, 205 Medicare coverage for permanent membranous labyrinth 1:4, 33 maldynia 1:363, 364, 378–379, renal failure 3:187, 203, 205 memory and memory impairment 379t, 380 medications to treat cardiovascular 1:260–262, 261t, 270, 272–273; male breast enlargement. See disease 2:67, 76–84, 77t–86t 4:71, 262, 317 gynecomastia medicinal herbs and botanicals memory B-cells 2:246, 251 male infertility factor 3:293, 296 4:82–88, 85t–88t memory T-cells 2:253, 296 malignant melanoma 1:141, adverse drug reaction 4:149 MEN. See multiple endocrine 178–179, 197–198, 198t Ayurveda 4:59 neoplasia malignant tumor. See tumor, bioavailability 4:153 menarche 3:126, 242, 269, 300, cancerous black cohosh 4:61 335 malnutrition 1:119; 3:21, 77, 88; drug interaction 4:154 Mendel, Gregor Johann 4:111, 132 4:185–186 fibrocystic breast disease 3:285 Ménière’s disease 1:33–35; 3:13, 94 addiction 4:314 hot flashes 3:290 meninges 1:33, 230, 234, 241, aging and nutrition/dietary integrative medicine 4:78 262–263 changes 4:177 menopause 3:302 meningitis 1:6, 33, 108; 2:256, 318, minerals and health 4:186 morning sickness 3:306 342, 343–344, 349; 4:340 starvation 4:202 naturopathy 4:91 meniscectomy 1:336 substance abuse 4:312 nutritional supplements 4:196 meniscus 1:330, 336 MALT. See mucosa-associated overdose 4:166 menopause 1:343–345, 374; 2:9, lymphoid tissue PMS 3:325 10, 381; 3:300–303, 302t 488 Index

abdominal adiposity 4:284 menstruation 1:131, 132, 374; addiction 4:314, 315 aging and endocrine changes 3:304–305 club drugs 4:328 3:111 abdominal distention 3:8 depressants 4:332 aging and nutrition/dietary dong quai 4:66 ethchlorvynol 4:334 changes 4:176 dysmenorrhea 3:269 illicit drug use 4:340 aging and physical ability/fitness eating disorders 3:374 stimulants 4:350 4:215 endometrial hyperplasia 3:275 methemoglobinemia 2:156–157; aging and urinary system feverfew 4:68 4:320 changes 3:175 ginseng 4:72 methotrexate 2:258, 259, 270 antidepressant medications hematuria 3:194 methylenedioxymethamphetamine 3:361, 362 hysterectomy 3:292 (MDMA) 4:328, 338, 343, 343t black cohosh 4:61 menarche 3:300 methylmercury 4:30, 31 breast 3:250 menopause 3:300 MHC. See major histocompatability conditioning 4:218 menstrual cycle 3:303 complex cystocele 3:185 ovulation 3:314 microbe 2:344 dysmenorrhea 3:270 progesterone 3:156 microinfarction 1:86; 2:84 endometrial cancer 3:274 puberty 3:335 micronutrients 4:190, 193, 204 estrogens 3:126, 127 uterus 3:351 micturition. See urination fertility 3:282 mercury 4:17, 30–31 middle ear 1:15, 20, 23, 35, 41 fibroadenoma 3:284 mescaline 4:337–338, 343 middle pain. See mittelschmerz fibrocystic breast disease 3:286 mesoderm 3:233, 272–273 migraine headache 1:365, 366, hot flashes 3:290 metabolic disorders 4:226–227, 373–374, 376t, 377; 4:67 medicinal herbs and botanicals 227t miliaria 1:176 4:83 metabolic equivalent (MET) 4:225, milk thistle 3:25, 57; 4:83, 89–90, perimenopause 3:318 228 90t, 338 phytoestrogens 4:94 metabolic syndrome X. See insulin mind-body interactions 2:290, 387; POF 3:323 resistance 4:90, 90t rectocele 3:87 metabolism 1:364; 2:7–9, 24, 33, acupuncture 4:57 reproductive system 3:236–237 326; 4:225–227 alternative and complementary resistance exercise 4:229 aging and nutrition/dietary approaches to conventional sexual dysfunction 3:338 changes 4:176 medicine 4:52 sexuality 4:252 alcohol 4:316 art therapy 4:59 strength 4:233 alcohol interactions with biofeedback 4:61 urinary incontinence 3:224 medications 4:318 craniosacral massage 4:65 uterine fibroids 3:350 cell structure and function 4:116 hypnosis 4:78 uterus 3:351 childhood obesity 4:291 meditation 4:88 menstrual cycle 1:132; 3:303–304; drowning 4:368 Native American healing 4:91 4:66 drugs 4:147 visualization 4:104 aging and reproductive/sexual efficacy 4:158 mineralocorticosteroid 3:111, 135 changes 3:242 frostbite 4:375 minerals and health 1:313–315; amenorrhea 3:243 hangover 4:338 2:50, 118–119; 4:186–189, breast 3:250 heat and cold injuries 4:374 188t–189t breast health 3:254 nutrients 4:190 minimal change disease 3:205–206 DUB 3:268 obesity 4:299 minimally invasive cardiac surgery endometriosis 3:276 peak level 4:168 2:86, 394 GnRH 3:129 pharmacodynamics 4:168 minimally invasive surgery 1:304; menarche 3:300 pharmacokinetics 4:168 4:258, 260, 266–267, 268, menstruation 3:304 weight loss and weight 284–285 mittelschmerz 3:305 management 4:309 mini-stroke. See transient ischemic ova 3:309 metastasis 1:170, 197, 235, 237, attack ovulation 3:314 309, 310; 2:120, 149, 151, 152, mitochondria 4:116, 134, 139, 232 PMS 3:325 384, 390, 391; 3:90, 250, 274, mitochondrial disorders 4:129, pregnancy 3:321 310, 328, 344; 4:74 134 puberty 3:335 methadone 4:315, 342, 342, 354 mitochondrial DNA (mtDNA) reproductive system 3:237 methamphetamine 4:342–343, 4:129, 134 vagina 3:352 343t mittelschmerz 3:305 Index 489 modes of transmission. See motor neuron disease 1:265, 297. contracture 1:319 transmission modes See also amyotrophic lateral cramp 1:319 Mohs’ micrographic surgery 1:176 sclerosis dystonia 1:320 mold 2:271, 279, 327; 4:34 motor vehicle accidents 4:2, 5, 40, fibromyalgia 1:321–322 molecularly targeted therapies 312, 316, 378–379 hernia 1:325–326 2:368, 384, 384, 384, 384, 384t, mouth 1:35 Langer’s lines 4:265 397 bronchoscopy 2:197 lean muscle mass 4:297 molecular medicine 4:4, 28, 111 buprenorphine 4:325 lipoma 1:333 monoamine oxidase (MAO) 3:361; candidiasis 2:315 musculoskeletal system 4:97, 107 canker sore 1:14 1:293–294 monoclonal antibodies (MAbs) cold sore 1:17–18 myasthenia gravis 1:339 2:283, 283t; 3:252 digestive enzymes 3:35 myopathy 1:339–340 cancer treatment options and gastrointestinal system 3:1, 3 myotonia 1:340 decisions 2:372 halitosis 1:26 polymyositis 1:350 DMARDs 2:258 herpes simplex 2:332 rhabdomyoma 1:353 graft vs. host disease 2:264 HPV 2:336 spasm 1:356 hypersensitivity reaction 2:270 leukoplakia 1:32 spastic cerebral palsy 1:238–239 immune system 2:238 myoclonus 1:266 sprains and strains 1:355 immunotherapy 2:277 normal flora 2:346 strength 4:232 oncogenes 2:384 oral hygiene 1:39 tendon 1:359 TNFs 2:297 salivary glands 1:49 tension headache 1:373 tumor suppressor genes 2:397 teeth 1:358 torticollis 1:360 monocyte 2:157 temporomandibular disorders triceps skinfold 4:307 granulocyte 2:139 1:359 trigger-point injection 1:385 human ehrlichiosis 2:335 thrush 1:57–58 weak ankles 4:237 immune response 2:272 tobacco 4:353 muscle cramp 4:50, 217, 374, 375, leukocyte 2:119–120 tobacco use other than smoking 381 lymph 2:120 4:306 muscle mass 4:77, 215, 321, 336 lymphocyte 2:152 mucocutaneous lymph node muscle relaxant medications 1:75, macrophage 2:282 syndrome. See Kawasaki disease 337, 337t; 4:324 monokines 2:283 mucosa 2:287–288, 319 muscle spasm. See spasm phagocytosis 2:162 mucosa-associated lymphoid tissue muscle strength 4:211, 228, 229 monokines 2:283 (MALT) 2:235, 236, 239, 242, muscle tone 3:93, 245 mononuclear phagocyte system 275, 284, 289, 296, 324 muscular dystrophy 1:295, 2:162, 167, 282, 283–284 mucous membranes 1:49, 182; 337–339, 338t; 4:135, 139, 140, mononucleosis, infectious 2:275, 2:283, 294–295, 306, 349 163 303, 323, 344–345 mucus 1:47, 51; 2:199, 202, 231, musculoskeletal system 1:290–360, monosaccharide 3:4, 128; 4:191 233, 287 291, 292 monosomy 4:117, 128 multiple chemical sensitivity biomechanics of movement monovision 1:83, 109 syndrome 2:190, 223, 284–285 1:294 morbid obesity 4:284, 302 multiple-drug-resistant infections bone 1:307–309 morning sickness 3:305–306, 322; 4:147, 160 breakthrough research and 4:70 multiple endocrine neoplasia treatment advances morphine 1:363, 377 (MEN) 3:94, 151–152, 156 1:295–296 dependence 4:330 multiple myeloma 2:138, 148, 152, chiropractic 4:63 drugs 4:145 157–160, 158t, 372, 384 functions of 1:293 fentanyl 4:334 multiple sclerosis 1:263–265, 264t, health and disorders of heroin 4:338 269 1:294–295, 295t methadone 4:342 multiple trauma 4:49, 367, 377, joint 1:328 opiates 4:347 378, 379, 379, 380 joints 1:294 substance abuse 4:311 mumps 2:345 ligament 1:333 mosaic autosomal trisomy 4:114, muscle 1:336–337 muscle 1:336–337 122, 136 aging and musculoskeletal muscles 1:293–294 mosaicism 4:134–135 changes 1:299–300 obesity and health 4:301 mosquito bites 2:322, 324, 342 bursa 1:311–312 overview 1:290–296 motor nerves 1:246, 247t, 252 bursitis 1:312 resistance exercise 4:230 490 Index

skeleton 1:293, 355 Mycobacterium tuberculosis 2:269, drugs 4:145 structures of 1:290–293 305, 359, 360; 4:49 fentanyl 4:334 teeth 1:294, 358 mydriasis 1:100, 107 hallucinogens 4:338 tendons, ligaments, and fasciae myelin 1:255, 263, 270, 317 heroin 4:338 1:294 myelodysplasia syndrome 2:160 opiates 4:347 traditions in medical history myelofibrosis 2:160–161, 164 prescription drug abuse 4:349 1:295 myeloma 2:275, 283 substance abuse 4:311 yoga 4:106 myocardial cells 2:74–75, 81, 82, tolerance 4:354 mutation 4:135 88, 111 narrow therapeutic index (NTI) achondroplasia 1:298 myocardial infarction 2:86–87 2:14–15, 76–78, 81, 83, 375; adenocarcinoma 2:366 angina pectoris 2:12 4:161–162, 162t albinism 1:135–136 apoB100 2:16–17 bioavailability 4:153 Alzheimer’s disease 1:221–222 cardiac enzymes 2:29 bioequivalence 4:153 birth defects 4:9 cardiomyopathy 2:32 dosage 4:154 BRCA-1/BRCA-2 2:369 heart attack 2:56 formulary 4:158 cancer 2:364 heart sounds 2:60 generic drug 4:159 cerebral palsy 1:238 LVEF 2:72 peak level 4:168 CJD 1:248 sudden cardiac death 2:108 therapeutic level 4:172 CMT disease 1:317 thrombolytic therapy 2:110, 111 trough level 4:173 color deficiency 1:80 myocardial perfusion imaging 2:87 nasal mucosa 2:243, 319; 4:328 congenital heart disease 2:38 myocarditis 2:31, 87–88, 322 nasal polyp 1:36 cystic fibrosis 4:120 myocardium 2:88, 88t nasal septum 1:49–50 ethical issues in genetics and angina pectoris 2:11, 12 nasal vestibulitis 1:36 molecular medicine 4:125 aorta 2:16 nasogastric aspiration and lavage genetic carrier 4:128 cardiac enzymes 2:29 3:77 genetic disorder 4:128 heart 2:4 National Institutes of Health (NIH) genetics and molecular medicine medications to treat 4:132, 212 4:110 cardiovascular disease 2:79 Native American healing 4:52, 61, genetic testing 4:130 myocardial infarction 2:86 73, 79, 82–83, 91, 95 Goodpasture’s syndrome 3:193 myocardial perfusion imaging natural immunity. See innate hemochromatosis 3:133 2:87 immunity HNPCC 3:57 TMLR 2:112 natural killer (NK) cell 2:151, 236, Huntington’s disease 1:256 myoclonus 1:265–266, 266t 253, 268, 272, 276, 278, 286 LQTS 2:74–75 myometrium 3:241, 351 naturopathy 4:52, 64, 76, 78, Marfan syndrome 1:335–336 myopathy 1:339–340, 350; 4:134 91–92 MEN 3:152 myopia 1:73, 82, 100–101, 111, nausea 3:77–78 musculoskeletal system 1:296 113, 114 nearsightedness. See myopia myotonic muscular dystrophy myotonia 1:340 neck 1:360, 365, 373; 4:44 1:337–338 myotonic muscular dystrophy necrosis 1:323; 3:20, 83, 347; nephritis 3:207 1:337–338, 338t 4:114, 382 nervous system 1:218 myringitis 1:35 necrotizing fasciitis 2:346, 357 neural tube defects 4:39 myringotomy 1:33, 35, 35, 40, 41, Neisseria gonorrhoeae 2:329, 330 oncogenes 2:384 59 neonatal jaundice 1:238; 3:19, 306 pemphigus 1:183 myxoma 2:88 nephrectomy 3:109, 200, 206–207, polycystic kidney disease 3:214 216 progeria 4:138 N nephritis 3:207–208, 224, 225, 230 psoriasis 1:188 nabothian cyst 3:306 nephroblastoma 3:215, 231 Tay-Sachs disease 4:142 nails 1:177–178, 177t, 179, 180 nephrolithiasis 3:208–209 thalassemia 2:170 NALT. See nose-associated lymphoid ESWL 3:189 tremor disorders 1:289 tissue horseshoe kidney 3:195, 196 tumor suppressor genes 2:397 naltrexone 4:320, 325, 344, 354 hydronephrosis 3:196 vitiligo 1:208 naphthoquinone. See vitamin K hypercalciuria 3:196 Wilms’s tumor 3:232 narcolepsy 1:267; 4:321, 342 hyperoxaluria 3:197 Wilson’s disease 3:167 narcotics 1:363, 366, 367, 384; urinary system 3:173 myasthenia gravis 1:339; 4:344–345, 345t. See also opiates urolithiasis 3:227 2:120–121, 172 dependence 4:330 vesicoureteral reflux 3:230 Index 491 nephron 3:209 seizure disorders 1:281–282 neuron 1:270 aging and urinary system sialorrhea 1:50 neurotransmitter 1:271 changes 3:175 SIDS 4:48 pain 1:382 Fanconi’s syndrome 3:189–190 spinal cord 1:283 pain and pain management glomerulonephritis 3:191 spinal cord injury 1:283–284 1:362 glomerulosclerosis 3:192 structures of 1:212 substance abuse 4:313 glomerulus 3:193 traditions in medical history tobacco 4:353 kidneys 3:201 1:218 neurosis 3:377 minimal change disease 3:205 vertigo 1:60–61 neurotoxicity 4:337, 381, 382 nephropathy 3:210 neural blockade (nerve block) neurotransmitter 1:271–272, 271t nephrotic syndrome 3:211 1:380 acute pain 1:363 nephrotoxins 3:211–212 neuralgia 1:268–269 aging and drug metabolism/drug renal cancer 3:215 neural tube 1:212, 217 response 4:149 renal failure 3:218 neural tube defects 1:217, 220, alcohol 4:316 RTA 3:219 282–283; 4:12, 39, 123 Alzheimer’s disease 1:221, 223 urinary system 3:169, 171, 173 neuritis 1:269, 269; 2:322, 345 amphetamines 4:321 nephropathy 3:209–211 neurofibromatosis 1:7, 139, 269 antianxiety medications 3:359 nephrotic syndrome 3:205, 211 neurogenic arthropathy 1:340, antidepressant medications nephrotoxins 3:210, 211–212, 218 340t 3:361, 362 nerve 1:267 neurogenic bladder 3:187, 196, 212 antipsychotic medications 3:363 nerve damage 1:53, 306 neurogenic pain 1:366, 380–381, barbiturates 4:323 nerve endings 4:95, 216 381t botulinum therapy 1:141 nerve impulses 1:260, 361. See also neurological damage 4:376, 378, brain 1:232 neurotransmitter 383, 386 cannabis 4:326 nerve roots 2:316, 328, 332 neurologic examination 1:253–254, delirium 1:250 nervous breakdown 3:377 259, 270 delirium tremens 4:330 nervous system 1:212–289, 213, neurolysis 1:380 depressants 4:331 214, 267–268; 2:63, 273, 355 neuromuscular disorders 1:55, dopamine 3:124 aging and changes in pain 317–318 ECT 3:375 perception 1:364 neuron 1:270; 3:362, 375 endocrine gland 3:125 aging and neurologic changes aging and neurologic changes endocrine system 3:99 1:220 1:220, 221 epinephrine 3:125 analgesic medications 1:367 alcohol 4:316 erection 3:278 brain 1:230–233 ALS 1:223 hallucinogens 4:337 breakthrough research and barbiturates 4:323 hangover 4:338 treatment advances 1:218–219 brain 1:230, 232 hypnotics 4:339 cerebral palsy 1:238 depressants 4:331 integumentary system 1:127 cerebrospinal fluid 1:241 hallucinogens 4:337 myasthenia gravis 1:339 communication within maldynia 1:378 nervous system 1:217 1:216–217 muscle 1:336 neuron 1:270 cranial nerves 1:246–247 nerve 1:267 neuroreceptor 1:271 FAS 4:335 nervous system 1:215–217 nicotine 4:345 functions of 1:212 nociceptor 1:381 norepinephrine 3:152 health and disorders of pain and pain management pain 1:382 1:217–218, 218t 1:361 pharmacodynamics 4:168 integumentary system 1:128 neuropathy 1:270–271, 271t, 340; restless legs syndrome 1:279 meninges 1:262–263 2:342, 356, 376; 4:301 SAD 3:382 neurofibromatosis 1:269 neuroreceptor 1:271; 3:361, 384 SAMe 4:97 neurotransmitter 1:271–272 aging and neurologic changes side effect 4:171 organization and structure 1:221 tobacco 4:353 1:212, 215–216, 216t alcohol interactions with Tourette’s syndrome 1:287 overview 1:212–219 medications 4:318 withdrawal syndrome 4:354 paralysis 1:274–275 analgesic medications 1:367 neutropenia 2:148, 152, 160, 161, peripheral nervous system depressants 4:331 376 1:276–277 narcotics 4:344 neutrophil 2:120, 138, 141, 161, reflex 1:279 nervous system 1:217 162, 278, 279 492 Index nevus 1:139, 141, 178–179, 197 ECT 3:375 nutrition 2:201, 207 nicotine 2:72, 93, 105, 230; endocrine system 3:99 aging and gastrointestinal 4:345–346, 345t epinephrine 3:126 changes 3:10 drugs 4:145 metabolism 4:225 breastfeeding 3:254 nicotine replacement 4:297 nicotine 4:345–346 fiber and gastrointestinal health smoking and health 4:303 pheochromocytoma 3:154 3:45 smoking cessation 4:304 tobacco 4:353 gastrectomy 3:48 substance abuse 4:311 yohimbe 4:107 gastrointestinal system 3:1 tobacco 4:353 normal flora 2:346–347; 4:150 IBD 3:64 tobacco use other than smoking antibiotic medications 2:308 ileum 3:61 4:306 bacteria 2:311 malabsorption 3:77 nicotine replacement 4:297–298, botulism 2:312 pancreatitis 3:81 304, 315, 345, 346, 354 candidiasis 2:314–315 sexual health 3:339 night blindness 1:102, 114 E. coli infection 2:324 short bowel syndrome 3:88 NIH. See US National Institutes of fungus 2:327 substance abuse treatment Health GALT 2:265 4:351 nitrates 2:83, 85t pneumococcal pneumonia training 4:233 NK cell. See natural killer cell 2:349 triceps skinfold 4:307 nociceptor 1:381 nose 1:4, 37–38; 2:197, 346; 4:339 upper arm circumference 4:307 acupuncture 1:365 blowing of 1:12–13 nutritional deficiency 1:309; 3:21, aging and changes in pain blowing the nose 1:12–13 77; 4:104–105, 177, 180, 186, perception 1:364 broken nose 1:13 194, 194t neurogenic pain 1:380–381 cluster headache 1:374 nutritional needs 4:93, 176, pain and pain management epistaxis 1:22 194–196, 195t, 198, 295, 309 1:361, 362 foreign objects in 1:24 nutritional supplements 1:366; phantom pain 1:382 functions of 1:4 3:35, 92; 4:196–197 pruritus 1:187 nasal polyp 1:36 antioxidant 4:177 tension headache 1:373 postnasal drip 1:45 enteral nutrition 4:182 nocturia 3:212, 212t, 224 rhinoplasty 1:47 malnutrition 4:186 nocturnal emission 3:306 rhinorrhea 1:47 metabolism 4:226 nodule 1:63, 131, 156, 161, 164, septal deviation 1:49 nutritional therapy 4:93 179 septal perforation 1:49–50 performance-enhancing noise exposure and hearing 1:30, sinuses 1:51 substances 4:348 36–37, 45, 48 sneeze 1:54 starvation 4:202 noncancerous tumor. See tumor, nose-associated lymphoid tissue nutritional therapy 4:92–93, 92t, noncancerous (NALT) 2:284, 287–288 100, 177 noncoding DNA 4:109, 116, 143 nosocomial infections 2:215, 222, nutrition and diet 4:174–175, non-Hodgkin’s lymphoma 2:152, 347; 4:41, 147, 151, 260, 281 174–209 153 NSAIDs. See nonsteroidal anti- nystagmus 1:12, 62, 102, 102t nonimpact exercise 4:230, 231 inflammatory drugs nonself antigen 2:282, 296 NTI. See narrow therapeutic index O nonself cells 2:235, 236, 246, 247, nucleic acid 2:361, 362; 4:111, 187 obesity 1:39, 301; 4:299–300, 300t 267, 283 nucleotide 4:109, 127, 135 abdominal distention 3:8 nonseminoma 3:343, 345 nursing. See breastfeeding aging and nutrition/dietary nonsteroidal anti-inflammatory nutrient density 4:185, 190, 300, changes 4:176 drugs (NSAIDs) 2:286–287, 286t 309 amphetamines 4:321 nonstriated muscle. See smooth nutrients 2:49, 280, 378, 382; BMI 4:289 muscle 4:190–193, 191t, 192t CAD 2:45 norepinephrine 3:152 bariatric surgery 4:286 CVD 2:34 adrenal glands 3:107, 108 dieting 4:293 food cravings 4:295 aldosterone 3:112 genetic predisposition 4:130 lifestyle variables: smoking and anger and anger management metabolism 4:225 obesity 4:283 4:240–241 nutrient density 4:190 malnutrition 4:185 antidepressant medications nutritional needs 4:194 nutritional therapy 4:92 3:361 nutrition and diet 4:175 pulmonary embolism 2:225 dopamine 3:124 sports drinks and foods 4:231 renal cancer 3:216 Index 493

sleep disorders 3:384 oculomotor nerve 1:246, 247t eye 1:89 tai chi 4:101 off-label use 1:153; 4:149, 163 eyes 1:65 upper arm circumference 4:307 olanzapine 3:367, 377 glaucoma 1:92 uterine prolapse 3:350 olfactory nerve 1:37, 52, 53, 246, intraocular pressure 1:97 obesity and cardiovascular disease 247t ischemic optic neuropathy 2:89–90, 89t oliguria 3:213 1:97–98 atherosclerosis 2:22 omega fatty acids and multiple sclerosis 1:263 cardiovascular disease cardiovascular health 2:50, 90 retina 1:113 prevention 4:16 oncogenes 2:384–385, 384t–385t, retrobulbar optic neuritis cardiovascular system 2:6 397 1:115–116 hyperlipidemia 2:65 onychocryptosis. See ingrown nail optic nerve atrophy 1:94, 105–106, hypertension 2:66 onychomycosis 1:179 105t lifestyle and cardiovascular oophorectomy 3:292, 307 optic nerve hypoplasia 1:106 health 2:73 open-angle glaucoma 1:92, 93t oral cancers 4:306, 353 risk factors for cardiovascular open fracture 1:322; 4:364, 366 oral contraception 1:132, 374; disease 2:102 open heart surgery 2:33–34, 44, 2:48, 65, 105, 308, 374, 381 obesity and health 4:301–302, 301t 90–91, 287; 4:334 oral hygiene 1:25, 26, 39, 44; aging and nutrition/dietary open surgery 2:168, 394; 3:48, 291, 4:24–25 changes 4:176, 177 307; 4:260, 266, 268, 284 Orange Book, The 4:159, 163, 172 childhood obesity 4:291, 292 operation 4:268–270, 268t–270t. orbital cellulitis 1:88, 106, 119 diabetes 3:120 See also surgery; specific operations, orchiectomy 3:307–308 endocrine system 3:102 e.g.: amputation orchiopexy 3:267, 308 exercise and health 4:221 ophthalmic examination orchitis 3:277, 308 health risk factors 4:28, 29 1:103–104 organ donation 4:272–273 lifestyle and cancer 2:382 dark adaptation test 1:85–86 organ harvest 1:81, 233, 248; 4:272 lifestyle and health 4:38 electroretinography 1:87 organic brain syndrome 1:272–273, obligate intracellular parasite. See fluorescein staining 1:91 272t virus ophthalmoscopy 1:104–105 organic solvents 4:347–348, 348t obsessive-compulsive disorder optical coherence tomography organ of Corti 1:3, 17 (OCD) 3:376, 378, 381, 386 (OCT) 1:105 organ transplantation 4:270–273, obstructive sleep apnea 1:39, 59; refraction test 1:111 270t. See also specific transplantation 2:90, 184; 3:187, 384; 4:283 slit lamp examination operations, e.g.: liver occupational health and safety 1:117–118 transplantation 4:39–40, 39t. See also US Snellen chart 1:118 cell-mediated immunity 2:253 Occupational Safety and Health tonometry 1:119 cloning 4:119 Administration vision health 1:122 cystic fibrosis and the lungs carpal tunnel syndrome ophthalmoscopy 1:104–105 2:202 1:315–316 opiate receptors 4:313, 325, 332, graft vs. host disease 2:263 contact dermatitis 1:150 342, 344, 345 HLAs 2:267, 268 ergonomics 4:23–24 opiates 1:362, 366, 368; 4:347, immunosuppressive medications eye strain 1:90 347t. See also narcotics 2:276 HIV/AIDS prevention 4:33 heroin 4:338 immunosuppressive therapy noise exposure and hearing methadone 4:342 2:276 1:36–37 naltrexone 4:344 lifestyle and health 4:38 repetitive motion injuries narcotics 4:344 orgasm 3:272, 300, 306, 308–309, 1:352–353 substance abuse 4:311 338, 354 routine medical examination withdrawal syndrome 4:354 Ornish program 2:91–92; 4:78, 90 4:45 opium 1:361; 4:145, 311, 344, 347 orphan drug 4:163–164 tuberculosis prevention 4:49 opportunistic infections 2:347, 347t OSHA. See US Occupational Safety workplace stress 4:256 oppositional defiant disorder 3:378 and Health Administration occupational therapy 1:223, 243, optical coherence tomography ossification 1:293, 299, 308 341 (OCT) 1:105 osteoarthritis 1:341–342; 2:30, 291 OCD. See obsessive-compulsive optic disk 1:105, 107, 113 aging and musculoskeletal disorder optic nerve 1:105, 105t; 3:151, 155. changes 1:300 ocular herpes simplex 1:103 See also optic disk cartilage 1:316 ocular herpes zoster 1:103 cranial nerves 1:246, 247t cervical spondylosis 1:316–317 494 Index

chondroitin 4:64 ototoxicity 1:42t, 43 alcohol interactions with flexibility 4:224 outdated drug 4:164 medications 4:319 glucosamine 4:72 ova (eggs) 3:233, 246, 281, 309, caffeine 4:326 gout 1:323–324 313, 337, 356; 4:127, 134, 144 dextromethorphan 4:332 joint replacement 1:328 ovarian cancer 2:364, 369, 372, drug interaction 4:154 musculoskeletal system 1:295 373, 381; 3:309–312, 311t, 312t, drugs 4:146 obesity and health 4:301 313 generic drug 4:158 OTC drug 4:167 ovarian cyst 3:312–313 heroin 4:338 SAMe 4:97 ovaries 3:313–314, 314t Orange Book, The 4:163 spinal stenosis 1:356 aging and endocrine changes overdose 4:164 temporomandibular disorders 3:111 weight loss and weight 1:359 amenorrhea 3:243 management 4:309 osteoblast 1:293, 307, 308 androgens 3:113 ovulation 3:314 osteocyte 1:293, 307, 308 endocrine system 3:100 aging and reproductive/sexual osteogenesis imperfecta 1:342–343 endometriosis 3:276 changes 3:243 osteoid 1:309, 343 estrogens 3:126 amenorrhea 3:243 osteomalacia 1:315, 343; 4:176, 200 FSH 3:127 chorionic gonadotropin 3:115 osteomyelitis 1:343–344, 345 menstrual cycle 3:304 conception 3:264 osteopathic manipulative treatment oophorectomy 3:307 fertility 3:282 (OMT) 4:64, 93, 93 ovarian cancer 3:309 infertility 3:293 osteopathy 4:52, 93, 93 ovarian cyst 3:312 inhibin 3:148 osteopenia 1:310, 344 PCOS 3:320 mittelschmerz 3:305 osteopetrosis 1:344–345 POF 3:323 ova 3:309 osteophyte. See bone spur progesterone 3:156 ovaries 3:313 osteoporosis 1:345–347, 346t; relaxin 3:158 sexual intercourse 3:339 2:173, 257; 3:115, 139, 143, 153, reproductive system 3:233 oxidation 4:131, 177 219, 243 testosterone 3:160 oxybutynin (Ditropan) 3:188, 224, aging and nutrition/dietary tubal ligation 3:347 225 changes 4:176 overactive bladder 3:212, 225 oxycodone 1:363; 4:311, 330 ankle injuries 1:302 overdose 1:368, 384; 4:164–166, oxygen bone density 1:310 165t aerobic capacity 4:213 calcium and bone health 1:313 aging and drug metabolism/drug aging and changes in hGH supplement 4:77 response 4:149 blood/lymph 2:123 osteopenia 1:344 buprenorphine 4:325 blood 2:118 resistance exercise 4:229 designer drugs 4:332 blood doping 4:324 scoliosis 1:354 dose 4:154 blood vessels 2:5 otitis 1:3, 8, 40, 41, 58 drugs 4:147 cardiac capacity 2:27 otitis externa (swimmer’s ear) 1:21, ethchlorvynol 4:334 cardiopulmonary bypass 2:33 40 fentanyl 4:334 cardiovascular system 2:6 otitis media 1:40; 2:294, 343, 349; glutethimide 4:336 drowning 4:368 4:150 half-life 4:159 erythrocytes 2:119 achondroplasia 1:298 heroin 4:339 heart 2:4, 56 eustachian tube 1:23 ingested toxins 4:384 heart attack 2:57 mastoiditis 1:33 injected toxins 4:385 lymph 2:120 myringitis 1:35 methamphetamine 4:342 MET 4:225 myringotomy 1:35 minerals and health 4:187 myocardial infarction 2:86 ruptured eardrum 1:48 narcotics 4:345 myocardium 2:88 sinusitis 1:52 OTC drug 4:167 physical exercise and traditions in medical history PCA 4:274 cardiovascular health 2:97 1:5–6 poison prevention 4:42 smoking and cardiovascular tympanic membrane 1:59 overeating 4:178, 295, 299 disease 2:105 otoconia 1:11, 12 over-the-counter (OTC) drug smoking and health 4:304 otoplasty 1:14, 41 3:362, 363; 4:166–167 stroke 2:107 otorrhea 1:41 accidental injuries 4:5 substance abuse 4:313 otosclerosis 1:9, 29, 41 adverse drug reaction tachypnea 2:232 otoscopy 1:41, 43 4:148–149 TMLR 2:112 Index 495 oxygenated blood 2:4–5, 7, 226 heart transplantation 2:63 pandemics 4:2, 35 oxygenation sick sinus syndrome 2:104 panic disorder 3:376, 378, 379 aging and cardiovascular TENS 1:385 Papaver somniferum 1:361; 4:311, changes 2:10 Paget’s disease of the bone 1:348; 344, 347 CAD 2:44 3:139, 153 papillae 1:4, 26 cardiac cycle 2:29 Paget’s disease of the breast 3:315 papilledema 1:107, 115 cardiopulmonary bypass 2:33 pain 1:382. See also specific forms of papillitis 1:107, 269 cyanosis 2:46 pain, e.g.: acute pain papilloma 1:180 heart attack 2:57 pain, living with 1:378 Pap test 3:256, 258, 259, 264, 315, pulmonary embolism 2:225 pain and pain management 316t; 4:14 oxygen-carbon dioxide exchange 1:361–389. See also specific pain papule 1:180, 181, 186, 194 2:216 management medications and paracentesis 3:16, 322 aging and pulmonary changes techniques, e.g.: analgesic paracrine activity 2:257, 290 2:182 medications paralysis 1:274–275; 2:312, 332; alveolus 2:183 acupuncture 4:56 3:182, 369 asphyxia 2:186 anesthesia 4:261, 262 Bell’s palsy 1:228–229 berylliosis 2:192 breakthrough research and disability and exercise 4:220 capillary beds 2:27 treatment advances 1:362 Guillain-Barré syndrome 1:255 erythrocyte 2:137 buprenorphine 4:325 head and spinal cord injuries erythrocytes 2:119 dependence 4:331 4:378 hemoglobin 2:142 fentanyl 4:334 poliomyelitis 1:277, 278 lifestyle and cardiovascular hallucinogens 4:338 spina bifida 1:282 health 2:72 heroin 4:338 spinal cord injury 1:283 lungs 2:212 ketamine 4:342 vocal cord paralysis 1:63 mechanical ventilation 2:214 massage therapy 4:82 paraneoplastic pemphigus 1:182, methemoglobinemia 2:157 mechanisms of 1:361 183 oxygen therapy 2:217 narcotics 4:344 paranoia 3:379, 383; 4:319, 348 pulmonary edema 2:224 OTC drug 4:167 paraphimosis 3:315–316 respiratory cycle 2:227 overview 1:361–362 parasite 1:180–182, 194; 2:348, sickle cell disease 2:165 PCA 4:274 348t, 350, 363 oxygen saturation 2:216–217 placebo 4:169 parasitic illness. See specific illnesses, breathing exercises 2:194 postoperative procedures 4:275, e.g.: amebiasis hypoxia 2:205 276 parathormone. See parathyroid mechanical ventilation 2:215 substance abuse 4:311 hormone oxygen-carbon dioxide surgery 4:258 parathyroid glands 3:100, 138, 143, exchange 2:216 traditions in medical history 151, 153, 153 oxygen therapy 2:217 1:361–362 parathyroid hormone 3:153–154; smoking and pulmonary disease pain management in cancer 4:187 2:230 2:386–387 bone 1:307–308 oxygen therapy 2:217, 217t pallidotomy 1:274 calcitonin 3:115 anaphylaxis 2:244 palpitations 2:40, 44, 51, 93–94, endocrine system 3:100 heart attack 2:57 94, 94t, 342; 4:326, 330 hyperparathyroidism 3:138 oxygen-carbon dioxide pancreas 3:79–80, 80t hypoparathyroidism 3:143 exchange 2:216 cystic fibrosis 4:120 osteoporosis 1:346 positive airway pressure 2:223 gastrointestinal system 3:1 parathyroid glands 3:153 pulmonary edema 2:224 hemochromatosis 3:133 urinary system 3:172 pulmonary hypertension 2:99 insulin 3:148 parenteral nutrition 3:77, 88; respiratory failure 2:227, 228 islet cell transplantation 3:149 4:198, 202 oxytocin 3:99, 145, 152, 250 islets of Langerhans 3:149 parenting 4:243, 249 metabolism 4:225 paresthesia 1:269, 275, 318; 4:332 P pancreatic cancer 3:80 Parkinson’s disease 1:275–276; pacemaker 2:93 pancreatitis 3:80 3:99, 124, 376 arrhythmia 2:18 pancreatic cancer 2:370, 374; 3:80, aging and nutrition/dietary AV node 2:23 81; 4:306 changes 4:176 bundle branch block 2:26 pancreatic duct 3:38, 79 aphasia 1:225 CRT 2:31 pancreatitis 3:80–81 benign essential tumor vs. 1:288 496 Index

cloning 4:119 pneumonia 2:221 epinephrine 3:125 deep brain stimulation 1:250 prion 2:349–350 FSH 3:127 dyskinesia 1:252 protozoa 2:350 GH 3:131 ectropion 1:87 puncture wound 4:367 GHRH 3:131 integumentary system 1:127 radiation and biochemical glucagon 3:128 memory and memory injuries 4:386 GnRH 3:129 impairment 1:262 responder safety and personal hormone 3:134, 135 midbrain 1:232 protection 4:358 hypothalamus 3:144 nervous system 1:217–219 transmission modes 2:358 inhibin 3:148 neurotransmitter 1:272 traumatic amputation 4:380 insulin 3:148 pallidotomy 1:274 vaccine 2:298 LH 3:151 proprioception 1:350–351 virus 2:361–362 melatonin 3:151 seborrheic dermatitis 1:151 patient controlled analgesia (PCA) norepinephrine 3:152 smell and taste disturbances 1:367, 384; 4:274, 276 nutrients 4:192 1:53 PBSC. See peripheral blood stem oxytocin 3:152 swallowing disorders 1:56 cells pineal gland 3:154 thalamotomy 1:286 PCA. See patient controlled prolactin 3:157 paronychia 1:180, 181t. See also analgesia relaxin 3:158 whitlow PDA. See patent ductus arteriosus renin 3:158 paroxysmal atrial tachycardia (PAT) PDE inhibitors. See somatostatin 3:158 2:77, 94, 94, 94, 94, 101 phosphodiesterase inhibitors T4 3:166 paroxysmal supraventricular peak level 4:168, 172, 173 thymosin 3:160 tachycardia (PSVT). See pediculosis 1:180–182 TRH 3:166 paroxysmal atrial tachycardia Pediculus sp. 1:181, 182 TSH 3:164 partial combined immunodeficiency peer pressure 4:250, 315, 348 T3 3:166 (PCID) 2:289 pellagra 4:198–199, 199t, 205 percutaneous liver biopsy 3:25, 82 passive immunity 2:274, 289, 294 pelvic examination 3:259, 316–317 performance-enhancing substances Pasteur, Louis 4:1, 258 pelvic inflammatory disease (PID) 4:348 PAT. See paroxysmal atrial 2:317, 330; 3:222, 317, 317t, 347 pericarditis 2:95–96, 110 tachycardia pemphigus 1:182–183 pericardium 2:4, 91, 95–96, 96, Patau’s syndrome 1:350; 4:114, penicillin 2:308, 327, 330, 349, 110 117, 136, 136t 356; 4:79, 80 perimenopause 3:301, 318 patellofemoral syndrome penis 3:317–318, 318t periodontal disease 1:25, 44; 4:176 1:348–349 balanitis 3:248 peripheral blood stem cells (PBSC) patent ductus arteriosus (PDA) chordee 3:262 2:122, 129, 132, 133, 159 2:38, 40, 64 circumcision 3:263 peripheral nerves 1:276, 364, 365 pathogen 2:348 ejaculation 3:272 peripheral nervous system 1:215, antibody-mediated immunity erectile dysfunction 3:278 246–247, 276–277, 284, 361 2:246 erection 3:278 peripheral neurotransmitters bacteria 2:311–312 gonnorhea 2:330 1:255, 270–271, 279, 284, 317, BALT 2:251 HPV 2:336 350, 367 body substance isolation 4:358 paraphimosis 3:315 peripheral vascular disease (PVD) electrocution 4:372 Peyronie’s disease 3:318 1:143, 275; 2:96–97 emergency and first aid 4:356 phimosis 3:319 angioplasty 2:13 fungus 2:327 priapism 3:327 atherosclerotic plaque 2:22 gunshot wounds 4:377 urinary system 3:173 diabetes and cardiovascular head and spinal cord injuries peptic ulcer disease 1:42t; 2:20, disease 2:49 4:378 287; 3:53, 81–82, 94; 4:74 ginkgo biloba 4:71 immune system 2:236 peptide healing 2:266 immunization 2:338 ACTH 3:110 hyperlipidemia 2:64–65 incubation period 2:338 ADH 3:113 intermittent claudication 2:69 infection 2:338 appetite 4:178 medications to treat lymph node 2:151 calcitonin 3:115 cardiovascular disease 2:78 motor vehicle accidents 4:378 chorionic gonadotropin 3:115 obesity and cardiovascular multiple trauma 4:379 CRH 3:115 disease 2:90 phagocytosis 2:162 dopamine 3:124 obesity and health 4:301 Index 497 peristalsis 3:3, 4, 9, 45, 52, 82, 83, phosphate 4:186, 187 oxytocin 3:152 221 phosphodiesterase (PDE) inhibitors prolactin 3:157 peritoneal cavity 3:16, 82 3:238, 279 SAD 3:382 peritonitis 3:15, 82–83, 86, 93; photophobia 1:95, 100, 107–108, sleep disorders 3:384 4:287 136; 4:338 TSH 3:164 peritonsillar abscess 1:44 photosensitivity 1:183–184, 193 pityriasis rosea 1:186 permanent teeth 1:294, 358 phototherapeutic keratectomy placebo 4:68, 169 persistent vegetative state 1:244, (PTK) 1:108, 108t placenta 2:9–10, 131; 3:319–320, 277 phototherapy 1:184 319t personal health history 4:28, physical abuse 4:242, 245 childbirth 3:262 40–41, 44 physical activity recommendations CVS 3:262 personal hygiene 4:41 4:38, 215, 222, 228–229 estrogens 3:126 acne 1:132–133 physical exercise and cardiovascular gestational diabetes 3:289 addiction 4:314 health 2:73, 97, 106 LH 3:151 community sanitation 4:18 physical fitness. See fitness umbilical cord 3:349 enteral nutrition 4:183 physical inactivity 4:15, 28, 210, plantar fasciitis 1:349–350 hand washing 4:26 211, 291, 301 plantar warts 2:336, 337 preventive medicine 4:3 physical therapy 1:349 plaque, skin 1:173–174, 186, 189 sneeze/cough etiquette 2:354 phytochemicals 4:177, 193 plasma 2:162–163 wound care 4:281 phytoestrogens 4:83, 94–95, 94t, albumin 2:124 pertussis 1:6; 2:348–349; 4:17 95t, 99 blood 2:118 pessary 3:185, 350 PID. See pelvic inflammatory disease bone marrow 2:132 petechiae 1:183; 2:137, 142 piercings 1:14, 39, 184–185 gammaglobulin 2:262, 263 Peyer’s patches 2:265, 289 pilonidal disease 1:185–186 immune response 2:273 Peyronie’s disease 3:318–319, 338 pineal gland 1:65, 229; 3:100, 151, immune system 2:236 phagocyte 2:162, 255, 283–284; 154–155; 4:88 inflammation 2:277 4:114 pinguecula 1:108 leukocyte 2:148 phagocytosis 2:162 pituitary gland 1:175, 229; plasma cells 2:236, 239, 245, 246, cancer treatment options and 3:155–156 251. See also B-cell lymphocyte decisions 2:370 acromegaly 3:104 plasmapheresis 1:205; 2:129, 142 complement cascade 2:255 ACTH 3:110 plasmid transfer 4:150–151 hemolysis 2:143 ADH 3:113 Plasmodium sp. 2:342, 343 immune system 2:235 adrenal insufficiency 3:109 plastic surgery 1:41, 47, 75; 3:256, immunoglobulin 2:275 aging and endocrine changes 299; 4:274, 274–275, 275t, 287 leukocyte 2:148 3:111 platelet 2:119, 132, 137, 141, 148, lymph node 2:151 anabolic steroids and steroid 163, 170, 171 spleen 2:167 precursors 4:322 platelet aggregation 2:163; 4:69 phantom pain 1:382–383 breast 3:250 anticoagulation therapy 2:14 pharmacodynamics 4:168 CRH 3:116 aspirin therapy 2:20 pharmacogenomics 4:112, 147 Cushing’s syndrome 3:117 coagulation 2:136 pharmacokinetics 4:168–169 diabetes insipidus 3:122 hemophilia 2:143 pharmacopeia 4:169 endocrine system 3:98–99 medications to treat pharyngitis 1:5, 22, 45, 45 FSH 3:127 cardiovascular disease pharynx 1:45, 57 GH 3:131 2:78–79 phenazopyridine (Pyridium) 3:184, GHRH 3:131 NSAIDs 2:287 226 GnRH 3:129 platelet 2:119 phencyclidine (PCP) 4:338, 348, hGH supplement 4:76 prostaglandins 2:289–290 348, 348t hyperprolactinemia 3:139 von Willebrand’s disease 2:174 phenotype 4:136 hyperthyroidism 3:139 platinum compounds (for phenylketonuria (PKU) 4:130, hypopituitarism 3:143 chemotherapy) 2:376, 376t 136–138, 137t, 226, 227t hypothalamus 3:144 pleura 2:218 pheochromocytoma 3:109, 151, hypothyroidism 3:146 pleural cavity 2:218, 219, 232 152, 154 inhibin 3:148 pleural effusion 2:190, 218, 218, phimosis 3:248, 262, 319, 319 LH 3:151 218, 218, 219 phlebotomy 2:122, 128, 162, 164 MEN 3:151 pleural rub 2:195, 219 phobia 3:376, 379, 379–380, 380t menstrual cycle 3:303 pleural space 2:218, 223 498 Index pleurisy 2:183, 218, 218–219, 223 porphyria 4:138 estrogens 3:126 PMN (polymorphonuclear) cells. See portal hypertension 3:41, 83–84 family planning 3:281 granulocyte positive airway pressure 2:223 FAS 4:334, 335 PMS. See premenstrual syndrome postanesthesia care unit (PACU) fertility 3:282 pneumococcal pneumonia 2:338, 4:260, 275, 276 fetus 3:283 349, 349t postnasal drip 1:45, 51, 374 fibroadenoma 3:284 pneumoconiosis 2:219–220, 220t, postoperative procedures food cravings 4:295 223 4:275–276 genetic screening 4:130 pneumonectomy 2:232, 233 postpartum depression 3:262, 372, genital herpes 2:328–329 pneumonia 2:219, 220–222; 4:2 380 genitalia 3:287 anthrax 2:310 post-traumatic stress disorder gestational diabetes 3:288 ARDS 2:181 (PTSD) 3:358, 359, 376, gestational surrogacy 3:289 aspergillosis 2:185 380–381; 4:251, 315 ginseng 4:72 chlamydia 2:317 potassium 3:137, 142; 4:186, 187 HIV/AIDS prevention 4:33 colds 2:319 potassium channel blocker 2:18t, hydronephrosis 3:196 complement cascade 2:256 76, 82, 82t, 85t infertility 3:293 influenza 2:338 poultry 2:314, 333 inhibin 3:148 Legionnaires’ disease 2:206 PPI medications. See proton pump letdown reflex 3:296 lung transplantation 2:213 inhibitor medications listeriosis 2:341 measles 2:343 prayer and spirituality 4:52, 79, 95, magnet therapy 4:81 mechanical ventilation 2:215 253 medications to treat PCID 2:289 precancerous conditions 1:32, cardiovascular disease 2:77, pneumonitis 2:223 133–134, 180; 3:258, 275 78 SARS 2:353 preeclampsia 3:271, 289, 321, 325 menstrual cycle 3:304 splenectomy 2:168 pregnancy 3:321–323, 323t menstruation 3:304 pneumonitis 2:197, 222–223 abdominal distention 3:8 migraine headache 1:374 pneumothorax 2:190, 197, 223, aging and endocrine changes morning sickness 3:305 233 3:111 nervous system 1:217 POF. See premature ovarian failure aging and urinary system nutritional needs 4:194 poisoning 4:5, 381 changes 3:175 ova 3:309 poison prevention 4:41–42, 41t, aromatherapy 4:58 ovulation 3:314 382, 384–386 ART 3:245 perimenopause 3:318 poliomyelitis 1:277–278; 2:237, autosomal trisomy 4:114 PKU 4:137 253, 298; 4:17 Bell’s palsy 1:229 placenta 3:319 pollen 2:271, 279 birth defects 4:9 POF 3:324 polycystic kidney disease 3:214, 216 black cohosh 4:61 postpartum depression 3:380 polycystic ovary syndrome (PCOS) bladder 3:178 preeclampsia 3:321 3:320–321 bladder exstrophy 3:182 prenatal care 3:326 polycythemia vera 2:164, 171, 205 breast health 3:254 progesterone 3:156 polydactyly 1:350 cardiomyopathy 2:32 reproductive system 3:236 polyglandular deficiency syndrome cerebral palsy 1:238 rubella 2:351 3:156 childbirth 3:261 sexual assault 4:251 Addison’s disease 3:107 chloasma 1:145 sexual health 3:339 adrenal insufficiency 3:110 chorionic gonadotropin 3:115 sexual intercourse 3:339 Cushing’s syndrome 3:118 chromosomal disorders 4:118 sexuality 4:252 GH 3:131 CMV 2:320 SIDS 4:48 hypocalcemia 3:141 conception 3:264 sperm 3:342 hypopituitarism 3:144 congenital heart disease 2:40 stillbirth 3:342 islets of Langerhans 3:149 contraception 3:264 stretch marks 1:200 MEN 3:152 CVS 3:262 substance abuse 4:313 polymorphonuclear (PMN) cells diabetes 3:120 talipes equinovarus 1:358 2:138, 235. See also granulocyte eclampsia 3:271 toxoplasmosis 2:357, 358 polymyositis 1:350 ectopic pregnancy 3:271 umbilical cord 3:349 polyp 1:36, 133 embryo 3:272 urinary urgency 3:225 polysaccharides 4:71, 191 environmental hazard exposure urolithiasis 3:227 poptosis. See exophthalmos 4:22 uterus 3:351 Index 499

VBAC 3:355 GnRH 3:129 vesicoureteral reflux 3:229 vitamins and health 4:206 hormone 3:135 prostate health 3:331; 4:98 yoga 4:106 LH 3:151 prostate-specific antigen (PSA) preleukemia. See myelodysplasia ovaries 3:313 3:249, 328, 330, 331, 333, 333t syndrome uterus 3:351 prostatitis 3:334 premature birth 1:115, 118; 3:238, prohormones 3:113, 126 prosthetic eye 1:69, 88, 109–110 245, 324–325 prolactin 3:124, 139, 157, 250 prosthetic limb 1:351 premature ovarian failure (POF) Propionibacterium acne 1:131, 132 protein 3:3, 4; 4:99, 192–193, 201, 3:290, 323–324 proprioception 1:294, 340, 226 premature ventricular contraction 350–351 protein loading 4:229 (PVC) 2:51, 97–98, 100 prostaglandins 1:363, 366, 367, proteinuria. See albuminuria premenstrual syndrome (PMS) 373, 382; 2:289–290; 3:280, 337; proton pump inhibitor (PPI) 3:270, 325–326, 372; 4:67, 94 4:67 medications 3:59, 85 prenatal care 3:326–327, 327t allergic asthma 2:240 protozoa 2:329, 348, 350 birth defects 4:12 antihistamine medications prurigo 1:186–187 cerebral palsy 1:241 2:247 pruritus 1:187–188, 187t cesarean section 3:260 aspirin therapy 2:20 PSA. See prostate-specific antigen childbirth 3:262 congenital heart disease 2:40 pseudofolliculitis barbae 1:167, 188 cleft palate/cleft palate and lip desensitization 2:258 Pseudomonas sp. 1:159, 180, 181t 1:16 fever 2:326 psoralen plus ultraviolet A (PUVA) CVS 3:263 5ASA medications 2:260 phototherapy 1:184, 187, 207 episiotomy 3:278 food allergies 2:260 psoriasis 1:188–190, 189t, 190t fetus 3:284 histamine 2:267 psychiatric disorders and learning disorders 1:258 immune response 2:273 psychologic conditions morning sickness 3:306 inflammation 2:277 3:357–386 pregnancy 3:323 NSAIDs 2:286, 287 psychogenic pain 1:383 scoliosis 1:355 platelet aggregation 2:163 psychoneuroimmunology 2:290 SIDS 4:48 prostate cancer 2:365, 372, 373, psychosis 3:362, 367, 381; 4:319, spina bifida 1:282–283 381; 3:327–330, 329t 332, 337, 339, 348 stillbirth 3:342 aging and reproductive/sexual psychotherapy 3:381; 4:255, 314, preoperative procedures 4:276 changes 3:243 320, 331, 332, 351 prepuce. See foreskin bladder cancer 3:182 psychotic disorder 3:371, 382 presbycusis 1:8–9, 29, 45–46, 58 BPH 3:248 pterygium 1:110 presbyopia 1:83, 108–109, 112 DRE 3:35 ptosis 1:110 prescription drug abuse 4:349, 354 endocrine system 3:103 PTSD. See post-traumatic stress pressure sore. See decubitus ulcer lycopene 4:79, 80 disorder preventive health care and medicinal herbs and botanicals puberty 1:131, 134, 164; immunization 4:17, 42, 93, 292 4:83 3:334–335 preventive medicine 4:1–50 orchiectomy 3:307 adolescence 4:240 priapism 3:327 prostatectomy 3:331 aging and endocrine changes primary biliary cirrhosis 3:84 PSA 3:333 3:110 primary sclerosing cholangitis prostatectomy 3:249, 272, 328, breast 3:249 3:84–85 331–333 childhood obesity 4:291 prion 1:248, 249; 2:349–350; 4:4 prostate gland 2:290, 366; endocrine system 3:100 problem solving and conflict 3:330–331, 331t; 4:98 hypogonadism 3:291 resolution 4:241, 250 aging and urinary system Klinefelter’s syndrome 3:296 proctitis 3:11, 85 changes 3:175 ova 3:309 prodrome 2:332, 350 bladder 3:178 reproductive system 3:233, 236 progeria 4:138–139 BPH 3:248 secondary sexual characteristics progesterone 3:156–157 DRE 3:35 3:337 adrenal glands 3:107, 108 prostate cancer 3:327 sexuality 4:252 aging and endocrine changes prostate health 3:331 sperm 3:340 3:111 prostatitis 3:334 trichotillomania 3:386 chorionic gonadotropin 3:115 PSA 3:333 public health 2:305, 332, 343, 360, DUB 3:268 semen 3:337 363 endocrine system 3:100 urinary incontinence 3:224 community sanitation 4:17–18 500 Index

drinking water standards amputation 1:300–301 sarcoma 2:391 4:19–21 anti-aging approaches 4:58 radioactive iodine 3:130, 140 environmental hazard exposure chromosomal disorders 4:118 radiofrequency ablation 2:18, 19, 4:22 chronic fatigue syndrome 23, 94, 101, 117 food safety 4:24 1:369–370 radioisotope 2:238, 388, 388t Healthy People 2010 4:29–30 coping with cancer 2:377 radon exposure 2:212, 374, 382, preventive medicine 4:2, 3 deep brain stimulation 1:250 383; 4:43–44 radiation and biochemical Down syndrome 4:123 rales (crackles) 2:195, 224 injuries 4:386 exercise and health 4:221 rapid gastric emptying 3:48, 86 pubococcygeal muscle 3:178, 199, health insurance 4:26–27 rash 1:191, 191t; 4:148 224, 226 joint replacement 1:329 allergic dermatitis 2:241 puerperal fever. See childbirth fever lifestyle and health 4:38 impetigo 1:166 pulmonary arteries 2:98 living with allergies 2:279–280 lichen planus 1:173 aging and cardiovascular living with cardiovascular lichen simplex chronicus changes 2:10 disease 2:73–74 1:173–174 aorta 2:16 living with chronic pulmonary Lyme disease 2:341–342 congenital heart disease 2:39 conditions 2:208 measles 2:343 heart 2:4 living with pain 1:378 photosensitivity 1:183–184 heart transplantation 2:62 maldynia 1:379 pityriasis rosea 1:186 lungs 2:212 obesity and health 4:302 Rocky Mountain spotted fever pulmonary embolism 2:224, occupational therapy 1:341 2:350 225 organic brain syndrome 1:273 rubella 2:351 pulmonary hypertension pain management in cancer SALT 2:295 2:98–99 2:386–387 scabies 1:194 pulmonary edema 2:182, 218, Patau’s syndrome 4:136 scarlet fever 2:352 223–224 persistent vegetative state 1:277 Raynaud’s syndrome 2:101–102, pulmonary embolism (PE) 2:30, physical therapy 1:349 101t; 4:346, 376 78, 110, 136, 224–226; 4:211 prosthetic limb 1:351 razor rash. See pseudofolliculitis pulmonary fibrosis 2:184, 194, smell and taste disturbances 1:52 barbae 195, 207, 219, 226 vision impairment 1:123 rebound headache 1:374–375, 376t pulmonary hypertension 2:98–99, quetiapine 3:367, 377 rebound tenderness 3:86 98t, 182, 201, 213, 224, 228 recombinant DNA 2:254, 278, 283; pulmonary system 2:175–234, 176 R 4:111–112, 119, 139 pulmonary veins 2:4–5, 10, 39, 99, RAA. See renin-angiotensin- reconstructive surgery. See plastic 115 aldosterone system surgery pulp (of tooth) 1:294, 358 rabies 2:350 rectal fistula 3:86–87 pulse 2:4, 20, 29, 60, 99–100, 99t; radiation and biochemical injuries rectal prolapse 3:87 4:145, 369, 376 4:363, 386 rectocele 3:87 pumping the stomach. See radiation therapy 1:169, 237, 309, rectum 1:367; 3:87, 87t nasogastric aspiration and lavage 310; 2:388–390, 388t; 3:91, 147, colorectal cancer 3:28 puncture wound 4:265, 363, 365, 206–207, 232, 274, 345 DRE 3:35 366–367 adult survivors of childhood enema 3:40 Purkinje fibers 2:4, 23, 25, 54 cancer 2:366, 367 FAP 3:43 purpura 1:190, 190t bone marrow transplantation fecal impaction 3:43 pustule 1:158, 190 2:133 fecal incontinence 3:44 PUVA. See psoralen plus ultraviolet cancer 2:365 gastrointestinal bleeding 3:51 A phototherapy cancer treatment options and gastrointestinal system 3:4 PVC. See premature ventricular decisions 2:370, 372 Hirschsprung’s disease 3:58 contraction carcinogen 2:374 HNPCC 3:58 PVD. See peripheral vascular disease immunoablation 2:274 ileostomy 3:60 Pyridium. See phenazopyridine immunodeficiency 2:274 intestinal polyp 3:64 leukemia 2:147 proctitis 3:85 Q lifestyle and cancer 2:382 rectal fistula 3:86 quality of life 4:43 lung cancer 2:211 rectocele 3:87 aging and physical ability/fitness pain management in cancer uterine fibroids 3:349 4:215 2:386, 387 recurrence 2:390 Index 501 red blood cells (RBCs). See hemolytic uremic syndrome resistance exercise 1:310, 332, 344, erythrocyte 3:194 345; 4:229–230, 230t reflex 1:279 hydronephrosis 3:196 aging and physical ability/fitness Achilles tendon 1:297 hyperkalemia 3:138 4:214 concussion 1:245 hyperoxaluria 3:197 conditioning 4:218 cough 1:18–19 hypokalemia 3:143 cross training 4:219 gag reflex 1:25 kidney transplantation 3:202 endurance 4:220 goose bumps 1:160–161 Medicare coverage for metabolism 4:226 pain 1:382 permanent renal failure 3:205 physical activity pruritus 1:187 nephritis 3:207 recommendations 4:228 sciatica 1:354 nephrotoxins 3:212 strength 4:232, 233 sneeze 1:54 oliguria 3:213 upper arm circumference reflexology 4:82, 93, 95–96 overdose 4:165–166 4:307 refraction test 1:111, 118 uremia 3:221 walking for fitness 4:235 refractive errors 1:67, 99, 111, 111 urinary system 3:171–172 respiration rate 2:194, 214, 227, refractive surgery 1:96, 101, renal medulla 3:169, 201 232; 4:48, 235 111–113 renal pelvis 3:172–173, 196 respiratory cycle 2:193, 212, 214, regional anesthesia 4:260, 261 renal tubular acidosis (RTA) 3:209, 227, 232 Reiki 4:79, 82, 96, 96 219–220 respiratory failure 2:227–228 Reiter’s syndrome 1:352 renal tubules 3:189, 209 alcohol 4:317 relaxation techniques 1:375, 377 renin 3:108, 111, 158, 169, 171, ARDS 2:181 relaxin 3:158 192, 201, 202 COPD 2:201 remission 2:390 renin-angiotensin-aldosterone diphtheria 2:322 renal cancer 3:108, 195, 206, 215, (RAA) system 3:99, 108, 111, hantavirus pulmonary syndrome 215t 158, 171 2:331 renal corpuscle 3:169, 209 repetitive motion injuries mechanical ventilation 2:214 renal cortex 3:169, 201 1:352–353 oxygen saturation 2:216 renal cyst 3:216 bone spur 1:311 pulmonary edema 2:224 renal dialysis 3:216–218; 4:166. See bursitis 1:312 pulmonary fibrosis 2:226 also hemodialysis carpal tunnel syndrome rescue breathing 4:369 ESRD 3:187 1:315–316 thoracotomy 2:233 Fanconi’s syndrome 3:190 ergonomics 4:23–24 responder safety and personal glomerulonephritis 3:191 fitness: exercise and health protection 4:358 glomerulosclerosis 3:192 4:211 restenosis 2:13, 45 hemolytic uremic syndrome knee injuries 1:330 resting metabolic rate (RMR) 3:194 occupational health and safety 4:193, 226 hepatorenal failure 3:195 4:40 restless legs syndrome 1:279 kidney transplantation 3:203 plantar fasciitis 1:349–350 reticulocyte 2:119, 165 nephropathy 3:211 rotator cuff impingement retina 1:113, 113t polycystic kidney disease syndrome 1:353 albinism 1:135 3:214 tendonitis 1:359–360 ARMD 1:70–71 uremia 3:221 replication error 4:117, 122–124, electroretinography 1:87 urinary system 3:171 136, 139 eye 1:89 renal failure 1:368; 2:125, 138, reproductive system 1:236–237; flashes 1:91 324; 3:218–219, 218t, 219t 2:346, 347; 3:233–356, 234, 235 laser surgery 4:265 adrenal glands 3:108–109 rescue breathing 4:369 lycopene 4:79, 80 aging and urinary system cold water drowning 4:368 optical coherence tomography changes 3:175 CPR 4:371 (OCT) 1:105 Alport’s syndrome 3:177 electrocution 4:372 retinitis pigmentosa 1:114 anabolic steroids and steroid Heimlich maneuver 4:373 retinopathy 1:114–115 precursors 4:322 ingested toxins 4:384 scotoma 1:117 bioavailability 4:153 inhaled toxins 4:385 Tay-Sachs disease 4:142 dextromethorphan 4:332 injected toxins 4:385 zeaxanthin 4:107 diabetes insipidus 3:123 motor vehicle accidents retinal detachment 1:79, 91, ESRD 3:187 4:378–379 113–114, 124 Goodpasture’s syndrome 3:193 shock 4:367 retinitis pigmentosa 1:114 502 Index retinoblastoma 1:114, 118 Rocky Mountain spotted fever suicidal ideation and suicide retinopathy 1:71, 87, 114, 2:350–351 3:385 114–115; 2:66, 259, 368; 4:79 rods 1:91, 113, 114 sciatica 1:354 retrobulbar optic neuritis Rome, ancient 4:1, 17–18 sclera 1:65, 79, 88, 117, 123 1:115–116, 263, 269 rosacea 1:74, 79, 192–193, 192t scleritis 1:117, 117t retrograde ejaculation 3:182, 272, rotator cuff impingement syndrome SCN. See suprachiasmatic nucleus 335–336, 345 1:275, 353 scoliosis 1:354–355 retrovirus 2:305, 362 route of administration 4:169–170, scotoma 1:117 reverse transcriptase 2:334, 362 169t, 344 scrotum 3:267, 283, 290, 337, 343, Reye’s syndrome 1:59, 279–280; routine medical examination 346 2:316 2:52–53, 58, 378, 380, 383; 4:42, scurvy 4:174, 201–202, 202t, 206 rhabdomyoma 1:353 44–45, 218 seasonal affective disorder (SAD) rheumatic heart disease 2:54, 103, RTA. See renal tubular acidosis 3:382 113, 114, 353–355 rubella 1:30, 238; 2:40, 245, 351 sebaceous glands 1:125, 131, 133, rheumatoid arthritis 1:117, 328, rubeola. See measles 146–148, 194–195 354, 357, 370–371; 2:291–292, ruptured eardrum 1:41, 47–48, 59 seborrheic dermatitis 1:147–148, 292t 151 adverse drug reaction 4:148 S seborrheic keratosis 1:195 aging and physical ability/fitness Safe Drinking Water Act (SDWA) sebum 1:125, 128, 131, 162, 164, 4:215 4:19, 20 194–195 antiphospholipid antibodies St. John’s wort (hypericum) 1:183; secondary adrenal insufficiency 2:249 3:372; 4:83, 99, 99t 3:106, 291 DMARDs 2:258 salicylic acid 1:361; 4:82 secondary sexual characteristics immune system 2:238 saliva 1:49, 50; 2:295, 332, 344 3:236, 242, 249, 296, 334, 337, immunoglobulin 2:275 salivary glands 1:4, 49, 50; 337t, 348 immunosuppressive medications 2:294–295, 345 sedation 1:384; 4:276, 323, 331 2:276 salmonellosis 2:352 sedentary lifestyle. See physical immunosuppressive therapy SAMe 4:97–98, 98t, 99 inactivity 2:276 SA node. See sinoatrial node seizure disorders 1:218, 265, inflammation 2:277 sarcoidosis 2:193, 198, 293–294, 281–282, 281t; 3:187, 271, 360, Sjögren’s syndrome 2:294 293t, 319 384 TNFs 2:297 sarcoma 2:391, 391, 391t seizures 4:332, 334, 337, 375 Rh factor 2:129, 130, 246; 4:12 satiety 4:201, 299 selective estrogen receptor rhinoplasty 1:47 saturated fats 4:181, 191 modulators (SERMs) 1:346; 3:252 rhinorrhea 1:5, 41, 45, 47 saw palmetto 4:83, 98, 98t selective serotonin reuptake rhizotomy 1:241, 268, 280 scabies 1:194 inhibitors (SSRIs) 1:217, 381; rhytidoplasty 1:191–192, 210 scale 1:194 4:172 ribosomes 4:110, 116, 127 scalp (dandruff) 1:147–148 antianxiety medications 3:359 RICE (rest, ice, compression, and scar 1:194; 4:366 antidepressant medications elevation) 1:301, 353, 355, 356, scarlet fever 2:352–353 3:361 359, 363, 372 scarring 2:199, 214, 219, 226; autism 3:365 rickets 1:315; 4:199–200 4:265, 268, 280, 361 body dysmorphic disorder 3:368 Rickettsia rickettsii 2:350, 351 scar tissue 2:230, 266, 291 depression 3:372 right atrium 2:104, 225 SCC. See squamous cell carcinoma eating disorders 3:374 right lymphatic duct 2:134, 149, scheduled drug 4:170, 170t GAD 3:376 155, 165, 170 schizophrenia 3:382–383 OCD 3:378 ringworm. See tinea antipsychotic medications 3:362 psychiatric disorders and risk factors for cardiovascular delusion 3:371 psychologic conditions 3:358 disease 2:36, 49, 64, 102–103, hallucinogens 4:337 SAD 3:382 102t. See also obesity and paranoia 3:379 trichotillomania 3:386 cardiovascular disease; smoking performance-enhancing selenium 4:105, 177 and cardiovascular disease substances 4:348 self antigens 2:237, 246, 282, 296 apoB100 2:16–17 psychiatric disorders and self cells 2:235–237, 246, 267, 364 risperidone 3:367, 377 psychologic conditions 3:358 semen 3:272, 330, 331, 337–338, RNA (ribonucleic acid) 2:334, 338, psychosis 3:381 338t, 339 361, 362; 4:110, 139 substance abuse 4:313 seminal vesicles 3:337, 343 Index 503 seminoma 3:343, 345 alkyl nitrites 4:320 sildenafil (Viagra) 1:80, 119; 3:279; Semmelweis, Philipp 4:1, 258 balanitis 3:248 4:106–107 senescence 4:113, 140 chlamydia 2:317 silicosis 2:183, 185, 198, 199, 205, sensorineural hearing loss 1:28, 29, genital herpes 2:327–329 219, 229–230, 230t 58 gonorrhea 2:329–330 silymarin 4:89, 338 sensory nerves 1:246, 247t hepatitis prevention 4:31 sinoatrial (SA) node 2:4, 23, 25, sentinel lymph node dissection HIV/AIDS 2:333 26, 28, 94, 104, 104–105 2:150, 151, 155, 391 HIV/AIDS prevention 4:32 sinuses 1:33, 36, 37, 51 septal defect 2:38, 63 HPV 2:336–337 sinus headache 1:374, 376t septal deviation 1:49 infertility 3:294 sinusitis 1:18, 51–52, 53, 107; septal perforation 1:49–50 injecting drugs, risks of 4:340 2:201, 294 septicemia 1:155; 2:349, 353 pelvic examination 3:317 site and situation assessment 4:359 serotonin 1:217; 3:361, 375, 382; reproductive system 3:237 sitz bath 3:88 4:97, 337 semen 3:337 Sjögren’s syndrome 1:50; serotonin reuptake inhibitors 4:99, sexual assault 4:251 2:294–295 241. See also selective serotonin sexual health 3:339 skeletal dysplasia 1:298, 334, 355 reuptake inhibitors (SSRIs) syphilis 2:355–356 skeletal muscle 1:293–294, 336, serotonin syndrome 3:362, 372; trichomoniasis 2:358 356 4:97, 99 tubal ligation 3:348 skeleton 1:293, 299, 308, 313, 336, Sertoli cells 3:341, 343 urethritis 3:222 355 severe acute respiratory syndrome sexual maturity 3:100, 110 skin 1:195, 196t (SARS) 2:181, 353; 4:2 sexual orientation 4:252 allergic dermatitis 2:241–242 severe combined immunodeficiency shigellosis 2:353 angioedema 2:245 (SCID) 2:294 shingles. See herpes zoster bariatric surgery 4:287 sex chromosome 4:140 shin splints 4:231 cellulitis 1:143–144 sexual abuse 4:242, 245 shock 3:81, 106, 124, 152, 271; chamomile 4:62 sexual activity and cardiovascular 4:367, 367t chemical peel 1:144–145 disease 2:104 bleeding control 4:362 contact toxins 4:382 sexual assault 3:287, 338, 372, 380; blunt trauma 4:377 cyanosis 2:46 4:251–252, 336 burns 4:363 dehydration 4:374 sexual dysfunction 3:287, 297, dehydration 4:375 Fitzpatrick skin type 1:158 338–339, 361, 371 electrocution 4:372 graft vs. host disease 2:263 sexual health 3:278, 287, 297, 318, gunshot wounds 4:378 heat exhaustion 4:375 339 inhalation burns 4:365 keloid 1:170 sexual intercourse 3:339 multiple trauma 4:379 keratinocyte 1:170 cesarean section 3:261 open fracture 4:366 keratosis pilaris 1:170–171 chlamydia 2:317 traumatic amputation 4:380 laser skin resurfacing 1:172 clitoris 3:264 short bowel syndrome 3:88, 88, 93 lentigines 1:172–173 erectile dysfunction 3:278 shoulder 1:298–299, 353 lichen planus 1:173 erection 3:278 sialadenitis 1:50 miliaria 1:176 genital herpes 2:328 sialolithiasis 1:50 nails 1:176 genitalia 3:287 sialorrhea 1:49, 50, 55 nevus 1:178–179 gonnorhea 2:330 sick building syndrome 4:12–13, nodule 1:179 orgasm 3:309 34, 40, 47 normal flora 2:346 penis 3:317 sickle cell disease 2:121, 125, 157, open fracture 4:366 sperm 3:342 165, 165–167, 170; 4:110, 115, papule 1:180 vagina 3:352 135 pediculosis 1:180–182 vaginitis 3:353 sick sinus syndrome 2:104 pemphigus 1:182–183 sexuality 4:252 side effect 4:171 petechiae 1:183 sexually transmitted disease (STD) SIDS. See sudden infant death photosensitivity 1:183–184 prevention 2:330, 335, 337; syndrome phototherapy 1:184 3:267, 277, 281, 317, 353; sigmoid colon 3:4, 28, 35, 51, 58, piercings 1:184–185 4:46–47, 46t 87, 93 pilonidal disease 1:185–186 sexually transmitted diseases (STDs) sign language 1:51 plaque 1:186 1:352; 3:339–340, 341t; 4:46–47, signs and symptoms of cancer platelet 2:119 46t 2:148, 155, 391–392 prurigo 1:186–187 504 Index

pruritus 1:187–188 sleep disorders 1:39, 267, 279; lifestyle and cancer 2:382–383 pseudofolliculitis barbae 1:188 3:155, 212, 383–384; 4:89, 104, lung cancer 2:208, 211, 212 psoriasis 1:188–190 336 preventive medicine 4:3 purpura 1:190 slit lamp examination 1:104, renal cancer 3:216 pustule 1:190 117–118 smoking and cardiovascular disease radiation therapy 2:388 small bowel transplantation 2:19, 22, 49, 72, 105, 212; 4:16 rash 1:191 3:88–89 smoking and health 4:303–304, scabies 1:194 small-cell lung cancer (SCLC) 304t scale 1:194 2:208, 384 addiction 4:314 scar 1:194 small intestine 3:89, 89t antismoking efforts 4:8 sebaceous glands 1:194–195 alcohol 4:316 calcium and bone health 1:313 seborrheic keratosis 1:195 amebiasis 2:307 cystitis 3:183 stretch marks 1:200 bariatric surgery 4:286 DLE 1:152, 153 sun protection 1:201–202 cecum 3:21 environmental cigarette smoke sweat glands 1:202 celiac disease 3:21 4:22–23 tattoos 1:203 cholera 2:317 erectile dysfunction 3:279 tinea 1:204 colon 3:26 health risk factors 4:28 tinea versicolor 1:204–205 cyclosporiasis 2:320 ketamine 4:342 toxic epidermal necrolysis 1:205 CYP450 enzymes 4:154 lifestyle and health 4:38 triceps skinfold 4:307 diarrhea 3:34 narcotics 4:345 vesicle 1:207 digestive enzymes 3:35 nicotine 4:345 vitiligo 1:207–208 drug interaction 4:155 nicotine replacement 4:297 wart 1:209 duodenum 3:36 performance-enhancing wheal 1:209–210 fiber and gastrointestinal health substances 4:348 whitlow 1:210 3:45 preventive medicine 4:3 wrinkles 1:210–211 5ASA medications 2:260 semen 3:337–338 xanthoma 1:211 gastroenteritis 3:48 substance abuse 4:313 skin-associated lymphoid tissue gastrointestinal system 3:4 vocal cords 1:64 (SALT) 2:284, 295 giardiasis 2:329 Smoking and Health: Report of the skin cancer 1:196–198, 198t IBD 3:61 Advisory Committee to the Surgeon aging and integumentary ileoanal reservoir 3:60 General of the Public Health Service changes 1:135 ileostomy 3:60 2:105, 230; 4:3, 8, 282 birthmark 1:139, 141 ileum 3:60 smoking and pulmonary disease Fitzpatrick skin type 1:158 jejunum 3:67 2:230–231 integumentary system 1:130 malabsorption 3:77 asbestosis 2:185 keratoacanthoma 1:170 overdose 4:166 atelectasis 2:191 lentigines 1:172 Peyer’s patches 2:289 bronchitis 2:196, 197 melanocyte 1:176 rapid gastric emptying 3:86 COPD 2:199, 201 Mohs’ micrographic surgery short bowel syndrome 3:88 living with chronic pulmonary 1:176 small bowel transplantation conditions 2:207 sun protection 1:201, 202 3:88 pleurisy 2:219 warning signs 1:127 stomach 3:90 pneumoconiosis 2:219 wrinkles 1:210 typhoid fever 2:360 smoking cessation 2:72, 105, 200; skin grafts 1:198–199, 205, Whipple’s disease 3:94 3:361, 362; 4:8, 297–298, 304, 207–208; 4:141 smallpox 2:237, 298, 304, 304–305, 305t, 346 skin irritation 4:215–217 353–354; 4:17, 386 smooth muscle 1:336; 2:77, 233; skin replacement 1:130, 198–199 smell and taste disturbances 3:42, 362; 4:320 skin self-examination 1:172, 178, 1:52–54 snacking 4:294, 295 195, 198, 199–200, 200t smokeless tobacco 4:306–307, 345 sneeze 1:13, 54 skin tag. See acrochordon smoking and cancer 2:392 sneeze/cough etiquette 2:354 skin test 2:359, 360 antismoking efforts 4:8 Snellen chart 1:104, 111, 118, 121; SLE. See systemic lupus bladder cancer 3:179 4:44 erythematosus cancer prevention 4:14 snuff 4:345, 353 sleep aids 4:324, 327, 331, 334, cancer risk factors 2:370 sobriety 4:350 336 carcinogen 2:374 sodium 2:47, 80, 81; 3:138, 143, sleep apnea 2:223, 234 CEA 2:374 171 Index 505 sodium channel blocker 2:18t, 76, laminectomy 1:333 sports drinks and foods 4:231–232, 82, 82t, 86t meninges 1:262–263 375 soft tissue injuries 4:367, 367t, 377. nervous system 1:212, 215, 216 sprains and strains 1:301–302, 304, See also repetitive motion injuries pain and pain management 333, 353, 355–356; 4:237, 367 soilborne illness 2:318–319, 333 1:361 sputum 2:195, 196, 206, 208, 219, solar keratosis. See actinic keratosis spina bifida 1:282–283 231, 233; 4:357 somatic cell 4:115, 118, 127, 133, spinal nerves 1:284 squamous cell. See keratinocyte 140 spinal stenosis 1:356 squamous cell carcinoma (SCC) somatic motor nerves 1:246, 247t stinger 4:232 actinic keratosis 1:133 somatic nervous system 1:216, 277 spinal cord injury 1:217–218, cancer 2:365 somatization disorder 3:384–385, 283–284; 3:223, 360; 4:50, 368, characteristics 1:198t 385t 369 epidermolysis bullosa 1:155 somatostatin 3:35, 79, 100, 128, spinal nerves 1:284 esophageal cancer 3:40 132, 149, 158–159 dermatome 1:252 integumentary system 1:130 sore throat 1:45, 57 herniated nucleus pulposus keratinocyte 1:170 soy 4:83, 94, 95, 98–99, 98t, 99t, 1:326 keratoacanthoma 1:170 177, 185 laminectomy 1:333 lung cancer 2:208 soy and cardiovascular health neural blockade 1:380 Mohs’ micrographic surgery 2:106, 106t peripheral nerves 1:276 1:176 Spanish flu 4:2, 35 peripheral nervous system 1:276 skin cancer 1:197 spasm 1:286, 319, 320, 356, 365; rhizotomy 1:280 SSRIs. See selective serotonin 2:101, 204; 4:381 sciatica 1:354 reuptake inhibitors speech disorders 1:54–55, 63, spinal cord 1:283 staging and grading of cancer 225–226 spinal stenosis 1:356 2:392–393, 392t, 393t sperm 3:340–342; 4:115 spinal stenosis 1:356–357 breast cancer 3:253 ART 3:246 spinal tap. See lumbar puncture cervical cancer 3:257–258, 257t endocrine system 3:100 spine 1:302–303, 306–307, 332, CIN 3:258 fertility 3:283 334, 354–355, 365 colorectal cancer 3:29 orgasm 3:309 spiritual beliefs and health care endometrial cancer 3:273–274 relaxin 3:158 4:79, 82, 88, 91, 238, 252–253 leukemia 2:148 reproductive system 3:233 spleen 2:167, 167; 3:18, 19, 67 lung cancer 2:210 secondary sexual characteristics aging and changes in lymphoma 2:155 3:337 blood/lymph 2:123–124 ovarian cancer 3:310–311 semen 3:337 bone marrow 2:132 prostate cancer 3:328 sexual intercourse 3:339 erythrocyte 2:137 sentinel lymph node dissection tubal ligation 3:347 erythrocytes 2:119 2:391 urethra 3:222 hematopoiesis 2:140 stomach cancer 3:91 vas deferens 3:354 immune system 2:235 thoracentesis 2:232 zygote 3:356 leukocyte 2:148 staphylococcal scalded skin spermatic cord 3:337, 343, 345, MAbs 2:283 syndrome 1:200 346 platelet 2:119, 163 Staphylococcus 1:143, 180, 181t, 200; spermatocele 3:342, 346 splenectomy 2:168 2:221, 357; 4:147, 150 spermatogenesis 3:127, 148, 160, splenomegaly 2:168 starvation 4:185, 202, 309 293, 337, 340–341, 343 T-cell lymphocyte 2:296 statins 2:57, 82, 82t; 4:16 spermatozoon 4:127, 138, 144 splenectomy 2:168, 168, 168t STDs. See sexually transmitted sperm donation 3:342 babesiosis 2:311 diseases spiders 4:381–382 immune disorders 2:272 steatohepatitis 3:89–90; 4:149 spider veins. See telangiectasis spleen 2:167 steatorrhea 3:90 spina bifida 1:217, 282–283; 4:39, splenomegaly 2:168 Stein-Leventhal syndrome. See 120 thalassemia 2:169 polycystic ovary syndrome spinal accessory nerve 1:246, 247t thrombocythemia 2:170 (PCOS) spinal cord 1:283 thymectomy 2:172 stem cell 1:130, 219; 2:122, 130; anesthesia 4:261 splenomegaly 2:143, 160, 164, 168, 4:115, 140–141 cerebrospinal fluid 1:241 168t, 345 stem cell therapy 4:141 herniated nucleus pulposus spontaneous abortion 3:240, 263, stem cell transplantation 2:159, 1:326 282, 350 276, 372 506 Index stenosis 2:113, 114 weight loss and weight stress fracture 1:322; 4:231 stent 2:13, 45, 106 management 4:310 stress incontinence 3:175, 224 stereotactic halo 1:250, 274, 286 Zollinger-Ellison syndrome 3:94 stress response hormonal cascade sterility 3:222, 348 stomach cancer 2:284, 370, 374; 3:159 sternum 1:309; 2:4, 62, 91, 233 3:48, 53, 90–92, 91t, 94 ACTH 3:110 steroid 1:78; 3:113, 126, 134, 135, stomach pumping. See nasogastric Addison’s disease 3:107 156, 160; 4:154 aspiration and lavage anger and anger management sterols 4:177, 181 strabismus 1:72, 118, 136 4:241 stethoscope 2:106, 191, 194 strength 4:232–233 cortisol 3:116 Stevens-Johnson syndrome. See anti-aging approaches 4:58 CRH 3:116 toxic epidermal necrolysis conditioning 4:217 epinephrine 3:125 stillbirth 2:341, 355; 3:283, 342 cross training 4:219 hypothalamus 3:145 stimulants 4:350–351, 351t disability and exercise 4:220 melatonin 3:151 diet aids 4:293 endurance 4:220 metabolism 4:225 ginseng 4:71, 72 fitness level 4:222 nicotine 4:345 MDMA 4:343 GABA 4:336 norepinephrine 3:152 nicotine 4:345 resistance exercise 4:229 pituitary gland 3:155 performance-enhancing tai chi 4:101 progesterone 3:156 substances 4:348 training 4:233 stress and stress management prescription drug abuse 4:349 weekend warrior 4:237 4:253 sports drinks and foods 4:231 strep throat 1:32, 155; 2:103, 114, stress test 2:31, 74, 106 substance abuse 4:312 338, 354–355, 355t stretch marks 1:200 tobacco 4:353 streptococcal bacteria 1:59, 166; striated muscle. See skeletal muscle withdrawal syndrome 4:354 2:103, 352, 354 stroke 2:107–108; 3:182, 358, 361, stinger 4:232, 381 Streptococcus 1:143, 180, 181t 379 stoma 3:31, 60, 223 streptokinase 2:83, 110 aging and neurologic changes stomach 2:134, 265, 267; 3:90, streptomycin 2:305, 359 1:221 90t stress and stress management aneurysm 2:11 adverse drug reaction 4:148 4:253–254 angioplasty 2:13 aging and nutrition/dietary Addison’s disease 3:107 anticoagulation therapy 2:13 changes 4:176 adrenal glands 3:107 aphasia 1:225 alcohol 4:316 adrenal insufficiency 3:110 apraxia 1:226 bariatric surgery 4:286–288 biofeedback 4:60 aspirin therapy 2:20 bezoar 3:18 chamomile 4:62 atherosclerosis 2:21 borborygmus 3:20 cortisol 3:116 atrial fibrillation 2:22 digestive enzymes 3:35 craniosacral massage 4:65 Bell’s palsy 1:228 duodenum 3:36 endocrine system 3:99 blood doping 4:324 esophageal atresia 3:40 euthyroid sick syndrome 3:127 brain 1:233 esophagitis 3:42 headache 1:377 brain hemorrhage 1:234 esophagus 3:42 healing 2:266 cardiac catheterization 2:28 fiber and gastrointestinal health human relations 4:238 cardiac rehabilitation 2:30 3:45 hyperventilation 2:205 carotid stenosis 2:35 gallbladder 3:46 hypnosis 4:78 coagulation 2:136 gastrectomy 3:48 massage therapy 1:366 cognitive function and gastritis 3:48 meditation 4:88 dysfunction 1:244 gastrointestinal bleeding 3:51 nervous breakdown 3:377 conditioning 4:218 gastrointestinal system 3:3 psychoneuroimmunology endarterectomy 2:53 gastroparesis 3:52 2:290 heredity and heart disease 2:64 GERD 3:50 rheumatoid arthritis 2:291 hypertension 2:66 Helicobacter pylori 3:53 SLE 2:296 living with cardiovascular hiatal hernia 3:58 somatization disorder 3:384 disease 2:73 H2 antagonist medications 3:59 stress response hormonal medications to treat peptic ulcer disease 3:81 cascade 3:159 cardiovascular disease 2:83 PPI medications 3:85 temporomandibular disorders nervous system 1:218 rapid gastric emptying 3:86 1:359 papilledema 1:107 vomiting 3:93 workplace stress 4:256 progeria 4:139 Index 507

smoking and cardiovascular Surgeon General’s Report (1964). systole 2:34, 41, 54, 70, 217 disease 2:105 See Smoking and Health: Report of systolic measure 2:24, 66 smoking and pulmonary disease the Advisory Committee to the 2:230 Surgeon General of the Public Health T TIA 2:111 Service tachycardia 2:17, 55, 223; 4:367, stupor 1:284–285 surgery 4:257–281. See also specific 374 subcutaneous injection 1:367; forms of surgery tachypnea 2:181, 191, 199, 223, 4:385 surgery benefit and risk assessment 232; 4:330, 367 subcutaneous layer 1:128, 195 4:277–279, 277t, 278t. See also tai chi 4:88, 101, 106, 224 sublingual (drug) 4:169, 325 specific forms of surgery, e.g.: open talipes equinovarus 1:358 substance abuse 3:367, 369, 378, heart surgery tamoxifen 3:252, 276 381, 385; 4:311–354, 312t, 354 surgery for cancer 2:370, 386, 391, tamponade, cardiac 2:95, 110 substance abuse prevention 393–394 tardive dyskinesia 1:252; 4:148 4:47–48 swallowing disorders 1:25, 32, taste 1:4, 8 substance abuse treatment 4:315, 55–56, 60; 2:222, 234; 3:9, 42; tattoos 1:203 325, 344, 350, 351–352 4:6, 183, 198, 373 taxanes 2:376, 376t substantia nigra 1:127, 178, 232 sweat glands 1:128, 164–165, 195, Tay-Sachs disease 4:128, 142–143 sudden cardiac death 2:108 202 TBI. See traumatic brain injury CAD 2:43 sweating 4:184, 374, 375 TCAs. See tricyclic antidepressants cardiac arrest 4:372 swimmer’s ear (otitis externa) 1:21, T-cell lymphocyte 1:339; 2:296; cardiomyopathy 2:32 40 3:100, 160, 205 congenital heart disease 2:39 sympathetic nervous system 1:216, aging and changes in heredity and heart disease 2:63 371 blood/lymph 2:123 LQTS 2:74 symptom assessment and care aging and immune response sarcoidosis 2:293 triage 4:359–360 2:239 stimulants 4:351 synaptic vesicles 3:125, 152 antibody-mediated immunity torsade de pointes 2:111 syncope 2:108–109 2:246 Wolff-Parkinson-White blood pressure 2:24 antigen 2:246 syndrome 2:117 hypotension 2:67–68 BALT 2:251 sudden infant death syndrome palpitations 2:93 berylliosis 2:192 (SIDS) 2:121, 184; 4:48 PAT 2:94 cell-mediated immunity 2:253 suicidal ideation and suicide 3:371, sick sinus syndrome 2:104 clusters of differentiation 2:254 383, 385–386 TIA 2:111 graft vs. host disease 2:264, 265 sunburn 1:200–201 Wolff-Parkinson-White HIV/AIDS 2:334, 335 burns 4:364 syndrome 2:116 hypersensitivity reaction 2:268, dong quai 4:66 syndactyly 1:357 269 Fitzpatrick skin type 1:158 syndrome X. See insulin resistance immune system 2:235–237 keratitis 1:99 synovial capsule 1:307, 328 immunotherapy 2:276 photosensitivity 1:183–184 synovial membrane 1:312, 357 interferons 2:278 skin cancer 1:196, 198 synovitis 1:357 lymph node 2:151 sun protection 1:201–202 syphilis 1:186; 2:130, 355–356; lymphocyte 2:151 vitiligo 1:207 4:46 lymphokines 2:281 sunlight 1:128, 175 systemic lupus erythematosus (SLE) lymphoma 2:152 sun protection 1:134–136, 172, 2:295–296, 296t; 3:207; 4:148 MALT 2:284 196, 198, 201–202, 315 antiphospholipid antibodies MHC 2:282 Sun’s Soup 4:99–100 2:249 NALT 2:287 superior vena cava 2:4, 115 complement cascade 2:256 thymectomy 2:172 support groups 1:223; 4:254, 292, DLE 1:152–153 thymus 2:120–121, 172 305, 314, 320 immunoglobulin 2:275 tea 4:145, 326. See also green tea suppressor T-cells 2:253, 254, 296 immunosuppressive medications tear ducts. See lacrimal ducts suprachiasmatic nucleus (SCN) 2:276 tear glands (Sjögren’s syndrome) 3:145, 151, 155 immunosuppressive therapy 2:294–295 Surgeon General’s Report. See 2:276 tears 1:65, 85–87 Smoking and Health: Report of the sialadenitis 1:50 teeth 1:358 Advisory Committee to the Surgeon Sjögren’s syndrome 2:294 addiction 4:314 General of the Public Health Service thymus 2:120–121, 172 dental caries 1:20 508 Index

fluoridation 4:24–25 adrenal glands 3:107, 108 thrombolytic medications 2:57, functions of the mouth 1:4 aging and endocrine changes 82–83, 83t, 86t musculoskeletal system 1:294 3:111 thrombolytic therapy 2:107, 108, oral hygiene 1:39 aging and reproductive/sexual 110–111, 110t, 225 periodontal disease 1:44 changes 3:243 thrombosis. See blood clots scurvy 4:201 anabolic steroids and steroid thrush 1:57–58; 2:309, 314 tobacco use other than smoking precursors 4:321, 322 thymectomy 2:121, 152, 172 4:306 androgens 3:113 thymosin 3:100, 160 toothache 1:57 andropause 3:244 thymus 1:339; 2:120–121, 123, telangiectasis 1:203 breast 3:249 148, 172, 172, 296; 3:100, 145, telomere 4:140, 143 DHEA 3:119 160 temporal lobe 1:231t, 242, 260 endocrine system 3:100, 103 thyroid cancer 3:115, 151, 152, temporomandibular disorders hirsutism 3:134 160–162, 164 1:359 inhibin 3:148 thyroidectomy 3:141, 143, 146 tendon 1:294, 320–321, 336, 353, LH 3:151 thyroid gland 3:162–163, 163t; 355, 359, 359–360 libido 3:296 4:225 tendonitis 1:297, 320–321, 352, puberty 3:335 calcitonin 3:115 353, 359–360 reproductive system 3:236 endocrine system 3:99, 100 TENS. See transcutaneous electrical saw palmetto 4:98 euthyroid sick syndrome 3:127 nerve stimulation sperm 3:342 goiter 3:128 tension headache 1:373, 376t testicles 3:343 Graves’ disease 3:129 teratogenic medications 4:9, 12 tetracycline 1:183; 2:318, 330, 350 hyperthyroidism 3:139 teratogens 4:118, 120 tetralogy of Fallot 2:34, 39 hypothalamus 3:145 terminal pain 1:384; 4:347 thalamotomy 1:241, 286 hypothyroidism 3:145 testes thalamus 1:232, 286, 361 parathyroid glands 3:153 aging and endocrine changes thalassemia 2:121, 125, 169–170 T4 3:166 3:111 therapeutic equivalence 4:158, 172 thyroid cancer 3:160 androgens 3:113 therapeutic level 1:367; 4:172, 172 thyroiditis 3:163, 164 cryptorchidism 3:267 therapeutic window 4:172 thyroid storm 3:165 endocrine system 3:100 thiazide diuretics 2:81, 81t T3 3:166 estrogens 3:126 thimerosal 4:17, 31 thyroid hormone FSH 3:127 thoracentesis 2:232 bipolar disorder 3:367 inhibin 3:148 thoracic cavity 2:212, 214, 218, hyperthyroidism 3:139 LH 3:151 223 hypothyroidism 3:145 progesterone 3:156 thoracic duct 2:149, 155, 165, 170, thyroid gland 3:162 reproductive system 3:233 218 thyroiditis 3:163 testosterone 3:160 thoracotomy 2:213, 232–233 thyroid nodules 3:164 testicles 3:343, 343t three-day measles. See rubella thyroid storm 3:165 cryptorchidism 3:267 throat 1:57; 3:3, 42 thyroiditis 3:129, 163–164, 163t, epididymitis 3:277 bronchoscopy 2:197 165, 166 hydrocele 3:291 eustachian tube 1:23 thyroid nodule 3:164 orchiectomy 3:307 HPV 2:336 thyroid-stimulating hormone (TSH) orchiopexy 3:308 measles 2:343 3:111, 130, 139, 164–165 orchitis 3:308 obstructive sleep apnea 1:39 thyroid storm 3:165 scrotum 3:337 peritonsillar abscess 1:44 Graves’ disease 3:131 sperm 3:340 pertussis 2:349 hyperthyroidism 3:140, 141 testicular self-examination postnasal drip 1:45 T4 3:166 3:346 rheumatic heart disease 2:103 thyroid cancer 3:162 varicocele 3:353 strep throat 2:354–355 thyroiditis 3:164 testicular cancer 3:103, 267, swallowing disorders 1:55–56 T3 3:166 343–346, 344t, 345t, 346; 4:322 trachea 2:233 thyrotoxicosis. See hyperthyroidism testicular self-examination (TSE) throat culture 2:354, 355 thyrotropin-releasing hormone 3:255, 342, 344, 346 thrombocythemia 2:136, 152, 161, (TRH) 3:111, 139, 145, 146, 157, testicular torsion 3:346–347 164, 170–171, 170t 166 testosterone 1:131, 310; 2:372, thrombocytopenia 2:148, 161, 164, thyroxine (T4) 3:99, 130, 139, 146, 381; 3:160 171, 171–172, 171t 162, 166; 4:225 Index 509 tibia 1:301, 330, 341; 4:231 traditional Chinese medicine (TCM) tricyclic antidepressants (TCAs) tic 1:75, 286, 287, 320 3:1; 4:101–103 1:268; 3:361, 378 tick bites 2:311, 322, 324, 335, drugs 4:145 trigeminal nerve 1:54, 246, 247t 336, 341, 342, 350 ginger 4:70 triglyceride blood level 1:211; 2:36, tinea 1:179, 204, 204t ginseng 4:72 64, 65, 82, 112, 112t tinea versicolor 1:204–205 integrative medicine 4:78 triglycerides, dietary 4:192, tinnitus 1:29, 34, 42t, 43, 47, 58; labyrinth 4:79 202–203 4:261 medicinal herbs and botanicals triiodothyronine (T3) 3:99, 130, tissue expansion 1:163, 205 4:84 139, 146, 162, 166 TMP-SMZ. See trimethoprim- naturopathy 4:92 trimethoprim-sulfamethoxazole sulfamethoxazole Sun’s Soup 4:100 (TMP-SMZ) 2:320, 349, 353, 360 TNM system 2:392–393, 393t tai chi 4:101 triptans 1:374, 377 tobacco 4:8, 14, 314, 345, 353. See training 4:233–234 trisomy 4:117, 128 also smoking transcutaneous electrical nerve trochlear nerve 1:246, 247t tobacco use other than smoking stimulation (TENS) 1:381, trophozoite 2:307, 329 4:306–307, 307t. See also 384–385; 4:57, 81 tropia. See strabismus smokeless tobacco transdermal patch 1:366, 378; trough level 4:168, 172, 172–173 toenails 1:129, 167 4:169–170, 334 TSE. See testicular self-examination toes 1:145–146, 350, 357 trans fats 4:181, 192 TSH. See thyroid-stimulating tolerance 4:353–354 transforming growth factors (TGFs) hormone tolterodine (Detrol) 3:188, 224, 2:296–297 tubal ligation 3:281, 347–348 225 transient ischemic attack (TIA) tuberculosis 2:229, 230, 304, 305, tongue 1:25, 26, 57 2:22, 111 359–360, 359t; 4:2, 46, 49, 340 tonometry 1:93, 97, 104, 119 translocation 4:118, 128, 143 tuberculosis prevention 4:49, 358 tonsillitis 1:6, 58–59 transmission modes 2:315, 358; tubule 3:169, 171, 172 tonsils 1:44, 57–59 4:26, 341 tumor, cancerous. See also toothache 1:20, 57 transmyocardial laser adenocarcinoma topiramate 3:367, 377 revascularization (TMLR) 2:12, adenoma-to-carcinoma torsade de pointes 2:74, 82, 111 111–112 transition 2:366 torticollis 1:360 transplant-related Kaposi’s sarcoma angiogenesis inhibitor drugs totipotent cells 4:115, 140 1:168, 169 2:368 Tourette’s syndrome 1:287 transposition of the great arteries bladder cancer 3:179 toxic epidermal necrolysis 1:205 (TGA) 2:6, 39 blastoma 2:368–369 toxic megacolon 3:58, 93 trauma prevention 4:48–49 brain tumor 1:235–237 toxic optic neuropathy 1:119–120, traumatic amputation 4:361, 380 cancer 2:364 119t traumatic brain injury (TBI) cancer of the penis 3:256 toxic shock syndrome 1:47; 2:357 1:287–288; 3:379 carcinoma 2:374–375 Toxoplasma gondii 2:357, 358 apraxia 1:226 cervical cancer 3:256 toxoplasmosis 1:238; 2:322, blunt trauma 4:377 endometrial cancer 3:273 357–358 cognitive function and lung cancer 2:208 trace minerals 4:184, 186, 187 dysfunction 1:244 neurofibromatosis 1:269 trachea 1:5, 182; 2:233–234 concussion 1:244–245 ovarian cancer 3:309 alveolus 2:183 dementia 1:251 prostate cancer 3:327 auscultation 2:191 head and spinal cord injuries radiation therapy 2:388 breathing 2:193 4:378 retinoblastoma 1:114 breath sounds 2:194 papilledema 1:107 thyroid nodules 3:164 bronchoscopy 2:197 paralysis 1:275 tumor, noncancerous (benign) bronchus 2:197 water safety 4:50 acoustic neuroma 1:7 drowning 4:368 trauma to the eye 4:379–380 adenocarcinoma 2:366 inhalation burns 4:365 tremor disorders 1:227, 250, 252, adenoma 3:107 lungs 2:212 265–266, 274–276, 288–289 adenoma-to-carcinoma oxygen therapy 2:217 TRH. See thyrotropin-releasing transition 2:366 pleura 2:218 hormone angioma 1:138 positive airway pressure 2:223 triceps skinfold 4:307 blastoma 2:369 tracheostomy 2:234 trichomoniasis 2:358 brain tumor 1:235–237 tracheostomy 2:217, 234 trichotillomania 3:386, 386t dermatofibroma 1:152 510 Index

fibroadenoma 3:284 typhoid fever 2:360 urethritis 1:352; 3:222–223, 277, fibroelastoma 2:55 tyramines 1:377; 4:107 290 granuloma telangiectaticum tyrosine 3:146, 166 urinary diversion 3:223–224 1:161 urinary frequency 3:175, 178, 179, intraductal papilloma 3:295 U 224, 227 lipoma 1:333–334 ultraviolet A (UVA) light 1:200; urinary incontinence 3:182, 199, myxoma 2:88 4:199, 200 212, 224 neurofibromatosis 1:269 ultraviolet B (UVB) light 1:200, urinary retention 3:185, 224–225, papilloma 1:180 201 227, 230 rhabdomyoma 1:353 ultraviolet light 1:175, 196, 315; urinary system 3:169–232, 170 seborrheic keratosis 1:195 2:365, 382; 4:265 urinary tract infection (UTI) tumor markers 2:395 umbilical cord 3:349 3:225–226, 226t; 4:73 uterine fibroids 3:349 unconsciousness 1:245, 277, bladder catheterization 3:182 tumor cells 2:286, 297 284–285, 289 cystitis 3:183 tumor markers 2:373, 395–397, anesthesia 4:262 cystocele 3:185 395t–396t; 3:345, 346 dehydration 4:374 cystoscopy 3:185 tumor necrosis factors (TNFs) frostbite 4:376 nephritis 3:207 2:237, 259, 260, 297, 326 head and spinal cord injuries nephrolithiasis 3:208 tumor suppressor genes 2:397, 4:378 polycystic kidney disease 3:214 397t Heimlich maneuver 4:373 retrograde ejaculation 3:336 Turner’s syndrome 3:291, 324, 348; injected toxins 4:385 urinary diversion 3:224 4:117, 119 ketamine 4:342 urinary retention 3:224 tympanic membrane 1:3, 11, 15, surgery 4:257 urinary urgency 3:225 20, 35, 59, 59. See also ruptured symptom assessment and care vesicoureteral reflux 3:230 eardrum triage 4:359 urinary urgency 3:175, 179, 225, tympanoplasty 1:11, 48, 59 syncope 2:108–109 227 type IV (delayed) hypersensitivity understanding pain 1:386 urination 3:226–227, 227t reaction (allergic reaction) 2:241, unilateral orchiectomy 3:307, 308 aging and urinary system 269, 269t uniparental disomy 4:117, 129 changes 3:175 type 1 complex regional pain United Network for Organ Sharing bladder 3:178 syndrome 1:371, 372 (UNOS) 3:201, 203; 4:270 BPH 3:248 type 1 diabetes 2:238, 249; UNOS. See United Network for chlamydia 2:317 3:119–120, 149; 4:19 Organ Sharing cystocele 3:185 type I hypersensitivity reaction upper arm circumference 4:297, diabetes insipidus 3:123 (allergic reaction) 307, 307t dysuria 3:186 allergic asthma 2:240 upper respiratory tract 1:19; 4:34 Fanconi’s syndrome 3:190 allergic conjunctivitis 2:240–241 uremia 3:221 gonorrhea 2:330 allergic rhinitis 2:242 ureter 3:173, 178, 189, 196, 206, nervous system 1:216 anaphylaxis 2:244–245 221, 229 penis 3:317 atopy 2:249 urethra 3:221–222 trichomoniasis 2:358 desensitization 2:258 aging and urinary system urinary diversion 3:223 gammaglobulin 2:262 changes 3:175 urinary system 3:172 histamine 2:267 cystoscopy 3:185 urine 3:227 hypersensitivity reaction 2:268, cystourethrogram 3:185 albuminuria 3:176 269t ESWL 3:189 alcohol 4:316 immunosuppressive therapy hypospadias 3:197 amniotic fluid 3:244 2:276 rectal fistula 3:86 bladder 3:178 type III hypersensitivity reaction urinary system 3:172, 173 bladder catheterization 3:182 2:269, 269t, 295–296 urination 3:226 body substance isolation 4:357 type 2 complex regional pain UTI 3:225 cannabis 4:327 syndrome 1:371, 372 vesicoureteral reflux 3:229 cystinuria 3:183 type 2 diabetes 2:6, 49, 73, 102, urethral meatus 3:221, 226 cystourethrogram 3:185 257; 3:119, 120, 149, 288; 4:3, urethral obstruction 3:187, 225 diabetes insipidus 3:122, 123 19, 28, 221, 301 urethral sphincter muscle 3:173, dysuria 3:186 type II hypersensitivity reaction 221, 226 endocrine system 3:103 2:268–269, 269t urethral stricture 3:222 enuresis 3:187 Index 511

kidneys 3:201 homeopathy 4:75 immunization 2:338 ureter 3:221 imported drug 4:159 immunotherapy 2:277 urethra 3:221 IND 4:159–160 infectious diseases 2:304, 305 urinary system 3:172 innovator drug 4:159 preventive medicine 4:1 vesicoureteral reflux 3:229 keratoconus 1:99 VACTERL 2:37–38, 40; 3:352 urine tests 4:314, 322, 350 magnet therapy 4:81 VADs. See ventricular assist devices urolithiasis 3:173, 184, 189, 196, medicinal herbs and botanicals vagina 3:352–353, 353t 197, 227–228, 229 4:84 Bartholin’s cyst 3:248 urticaria 1:183, 205–206; 2:241, meninges 1:263 genital herpes 2:328 269, 295; 4:148 myopia 1:101 gonnorhea 2:330 US Centers for Disease Control and nutritional supplements 4:196 HPV 2:336, 337 Prevention (CDC) 2:219, 299; off label use 4:163 pelvic examination 3:316 3:245, 246 Orange Book, The 4:163 rectal fistula 3:86 alternative and complementary OTC drug 4:167 rectocele 3:87 approaches to conventional outdated drug 4:164 semen 3:337 medicine 4:52 Parkinson’s disease 1:276 uterine prolapse 3:350 antibiotic resistance 4:151 pharmacopeia 4:169 vaginal birth 3:261, 355 antismoking efforts 4:8 soy 4:98 vaginal birth after cesarean. See childhood obesity 4:291 therapeutic equivalence 4:172 VBAC fitness: exercise and health yohimbe 4:107 vaginitis 2:311, 315, 347, 358; 4:212 US National Institutes of Health 3:248, 353 food safety 4:24 (NIH) 1:141, 365; 4:56, 300 vagus nerve 1:53, 246; 3:52, 94 HIV/AIDS prevention 4:33 US Occupational Safety and Health valerian 4:62, 89, 99, 104, 104t influenza 4:36 Administration (OSHA) 1:30, 37; valley fever. See coccidioidomycosis sexually transmitted disease 2:183, 192, 207, 229, 230; 4:24 valproic acid (valporate) 3:367, prevention 4:47 US Surgeon General 4:210, 282, 377, 386 US Congress 4:83, 270 283, 335–336 VALT. See vascular-associated US Department of Agriculture uterine fibroids 3:277, 338, 349–350 lymphoid tissue (USDA) 4:24, 186, 194–196 uterine prolapse 3:338, 350–351 valvular heart disease 2:51, 54, 55, US Environmental Protection uterus 3:351, 351t 59, 60, 103, 113–114, 113t Agency (EPA) D&C 3:268 variable pain response 1:388 berylliosis 2:192 DUB 3:268 variation 4:143–144 building-related illness 4:12–13 endometrial hyperplasia 3:275 varicella disease. See chickenpox drinking water standards 4:19 endometriosis 3:276 varicella zoster 1:103, 269; 2:221, heavy-metal poisoning 4:30 hysteroscopy 3:292 315, 316, 332 indoor air quality 4:34 pregnancy 3:322 varicocele 3:346, 353–354 lung cancer 2:212 progesterone 3:156 varicose veins 2:48, 114–115, 115, omega fatty acids and semen 3:337 225 cardiovascular health 2:90 sperm 3:342 vascular-associated lymphoid tissue radon exposure 4:43 tubal ligation 3:347 (VALT) 2:284, 299 sick building syndrome 4:47 uterine fibroids 3:349 vasculitis 1:117; 2:200t, 249t, US Food and Drug Administration uterine prolapse 3:350 299–302, 300t–301t (FDA) 2:159, 288, 368, 373; UTI. See urinary tract infection vas deferens 3:222, 277, 343, 346, 3:264 uveitis 1:97, 120 354, 354 adverse drug reaction 4:149 uvula 1:5, 16 vasectomy 3:281, 337, 354, Alzheimer’s disease 1:222 354–355 antibiotic resistance 4:151 V vasoconstrictors 2:83, 86t, 101, bioequivalence 4:153 vaccination 1:277; 4:17, 35, 42 230; 4:345, 353 birth defects 4:9 vaccine 2:298–299, 298t–299t vasodilators 2:83–84, 84t, 86t, 99 botulinum therapy 1:141 active immunity 2:239 VBAC (vaginal birth after cesarean) drinking water standards antibody 2:245 3:261, 262, 355 4:19–21 cancer vaccines 2:373 vein 2:115; 4:362 drugs 4:146 childhood diseases 4:17 AVM 2:19–20 food safety 4:24 heavy-metal poisoning 4:31 blood vessels 2:4–5 generic drug 4:158 HIV/AIDS prevention 4:32 cardiovascular system 2:6 HIV/AIDS prevention 4:33 immune system 2:237 circulation 2:5 512 Index

DVT 2:47–48 viral disease. See specific diseases, e.g.: minerals and health 4:186–187 platelet 2:163 encephalitis osteomalacia 1:343 pulmonary veins 2:99 viral infection. See specific infections osteoporosis 1:345–346 varicose veins 2:114–115 virion 2:334, 361 rickets 4:199, 200 vena cava 2:115 virus 2:237, 298, 305, 309, urinary system 3:172 venogram 2:115–116 361–362, 361t–362t; 4:139, 386. vitamins and health 4:204, 207 venous insufficiency 2:115 See also specific viruses, e.g.: vitamin E 4:105, 177, 204, 207 velopharyngeal insufficiency 1:60 herpesvirus vitamin K 2:14, 76, 78, 136, 173, vena cava 2:4, 33, 115, 115, 115, visceral motor nerves 1:246, 247t 173t, 311; 4:204, 207, 209 115 vision health 1:121–122, 122t; 4:79 vitamins and health 1:315, 343; venogram 2:115–116 vision impairment 1:122–123, 122t 3:143, 285; 4:204–209, 208t, venous insufficiency 2:48, 114, 115 albinism 1:135 209t ventricles amblyopia 1:72–73 cardiovascular disease AV node 2:23 ARMD 1:70–71 prevention 4:16 bundle branch 2:25 bilberry 4:60 drug interaction 4:154 bundle of His 2:26 braille 1:75–76 nutritional supplements 4:196 cardiomyopathy 2:31 color deficiency 1:80 vitamin and mineral therapy heart 2:4 corrective lenses 1:82–84 4:104 pulmonary arteries 2:98 diplopia 1:86 vitiligo 1:127, 176, 207–208 VADs 2:116 Down syndrome 4:123 vitrectomy 1:123–124 ventricular fibrillation 2:116 entropion 1:87 vitreous detachment 1:67, 124 Wolff-Parkinson-White exophthalmos 1:88 vitreous humor 1:67, 91, 113, syndrome 2:116–117 eyes 1:67 123–124 ventricular assist devices (VADs) intraocular pressure 1:97 VLDL cholesterol. See very low- 2:7, 33, 58, 116 ischemic optic neuropathy 1:98 density lipoprotein cholesterol ventricular fibrillation 2:17, 47, 69, keratoconus 1:99 vocal cord cyst 1:62 74, 116; 4:376 myopia 1:101 vocal cord nodule 1:63 ventricular septum 2:25, 32 nystagmus 1:102 vocal cord paralysis 1:63 venules 1:127; 2:5, 27 optic nerve hypoplasia 1:106 vocal cord polyp 1:63 vermiform appendix. See appendix refractive errors 1:111 vocal cords 1:5, 13, 54, 63–64, vertebrae 1:302–303, 316–317, retinitis pigmentosa 1:114 288–289 326–327, 333 scleritis 1:117 voice therapy 1:13, 63, 64 vertigo 1:60–61; 4:338 trauma to the eye 4:380 vomiting 1:374; 2:326, 352, 376; barotrauma 1:11 visual acuity 1:121 3:13, 33, 52, 93–94, 305; 4:41, BPPV 1:11, 12 visual acuity 1:80, 104, 121 169–170 cholesteatoma 1:15 visual field 1:102, 104, 121, 121t von Willebrand’s disease 2:144, labyrinthitis 1:31 visualization 3:373, 385; 4:52, 78, 173–174, 174 Ménière’s disease 1:34 79, 88, 104 vulva 1:32; 3:188, 316 ototoxicity 1:43 vitamin A 1:102; 2:50, 343; 4:105, vulvodynia 3:355–356 vestibular neruonitis 1:61, 62 177, 204–205 very low-density lipoprotein vitamin and mineral therapy 4:79, W (VLDL) cholesterol 2:36, 49, 65, 92, 104–105, 177 waist circumference 4:284, 289, 66, 82; 4:202 vitamin B 1:16, 142; 4:105, 179, 290, 308, 308t vesicle 1:207, 210 180, 187, 204 waist to hip ratio 4:284, 289, vesicoureteral reflux 3:182, 186, vitamin B complex 4:180, 205 308–309, 308t 195, 196, 207, 229–230, 229t vitamin B3 4:198, 205 walking for fitness 2:194, 226; vestibular dysfunction 1:20, 31, vitamin B12 1:119, 269, 275; 2:64, 4:211, 217, 224, 228, 233, 235, 60–62 125, 126; 4:176, 206 236t vestibular neuronitis 1:61–62 vitamin C 2:50, 379t; 4:105, 177, warfarin (Coumadin) 2:14, 15t, 69, vestibulocochlear nerve 1:17, 246, 194, 196, 201, 204, 206 76, 78, 173; 4:153 247t vitamin D warmup 1:302, 332, 356; Viagra. See sildenafil aging and nutrition/dietary 4:235–237, 236t, 237 villi 3:4, 89 changes 4:176 warm water drowning 4:50, 369, vinca alkaloids 2:376, 376t calcium and bone health 1:315 369–370 violence 1:283; 4:238, 241, 251, hypocalcemia 3:141 wart 1:180, 209 255 integumentary system 1:128 watchful waiting 3:107, 127, 285 Index 513 waterborne illnesses 2:362–363, white blood cells (WBCs). See X 363t; 4:2 leukocyte xanthelasma 1:124, 211 amebiasis 2:306–307 white matter 1:216, 283 xanthoma 1:211 cholera 2:317–318 whitlow 1:210 X-rays 1:13, 295 cryptosporidiosis 2:320 WHO. See World Health cyclosporiasis 2:320 Organization Y E. coli infection 2:324–325 whooping cough (pertussis) yeast infection 1:57–58, 152; giardiasis 2:329 2:348–349 2:185, 308–309, 314–315, 347 infectious diseases 2:303 Wilms’s tumor 3:215, 231–232, yoga 4:106 listeriosis 2:341 231t; 4:135 alternative and complementary parasite 2:348 Wilson’s disease 3:134, 167–168, approaches to conventional salmonellosis 2:352 168t; 4:31 medicine 4:52 SARS 2:353 withdrawal reflex 1:381, 382 anger and anger management shigellosis 2:353 withdrawal syndrome 4:354 4:241 typhoid fever 2:360 addiction 4:315 conditioning 4:218 water safety 4:49–50 alcoholism 4:320 cross training 4:219 Watson, James 4:111, 122, 132 benzodiazepines 4:324 depression 3:372 weak ankles 1:302; 4:237 dependence 4:330 endurance 4:220 weight and pain 1:389 depressants 4:331 flexibility 4:224 weekend warrior 4:237 methadone 4:342 headache 1:375 weight loss and weight stimulants 4:350–351 hyperventilation 2:205 management 1:265; 2:30, 96; Wolff-Parkinson-White syndrome IBS 3:66 4:309–310, 310t 2:39, 101, 116–117 knee injuries 1:332 abdominal adiposity 4:284 women’s health living with chronic pulmonary bariatric surgery 4:284, 287, aging and cardiovascular conditions 2:208 288 changes 2:10 meditation 4:88 BMI 4:290 cancer risk factors 2:370 yohimbe/yohimbine 4:84, body fat percentage 4:288–289 episcleritis 1:88 106–107, 107t childhood obesity 4:291–292 fibromyalgia 1:321, 322 youth high-risk behavior 4:50, conditioning 4:218 HPV 2:336 50t diet aids 4:293 migraine headache 1:374 dieting 4:293, 294 osteoporosis 1:346 Z eating habits 4:295 pain and pain management zeaxanthin 1:102; 4:79, 107–108, “fat burners” 4:295 1:362 107t fitness: exercise and health rheumatoid arthritis 2:291 zinc 4:177, 187 4:210 Sjögren’s syndrome 2:295 ziprasidone 3:367, 377 flat feet 4:224 SLE 2:295, 296 Zollinger-Ellison syndrome lifestyle variables: smoking and smoking and cardiovascular 3:94–95, 152 obesity 4:283 disease 2:105 zona fasciculata 3:108, 109 obesity 4:299, 300 trichomoniasis 2:358 zona glomerulosa 3:108, 109 obesity and health 4:301, 302 workplace stress 4:40, 255–256 zygote 3:356; 4:144 physical activity World Health Organization (WHO) chromosomal disorders 4:117 recommendations 4:228 1:344; 2:237, 304, 353–354; chromosome 4:118–119 satiety 4:201 3:288 cloning 4:119 waist circumference 4:308 wound care 1:141; 4:280–281 ectopic pregnancy 3:271, 272 walking for fitness 4:235 wrinkles 1:134–135, 141, 158, 191, embryo 3:272 wheal 1:205–206, 209–210 210–211 gamete 4:127 Whipple’s disease 3:89, 94 wryneck. See torticollis replication error 4:139