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Medical Sciences E-Book

Medical Sciences E-Book

Jeannette Naish | Denise Syndercombe Court | Jeannette Naish | Denise Syndercombe Court

(2014)

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Book Details

Abstract

An integrated approach to teaching basic sciences and clinical medicine has meant that medical students have been driven to a range of basic science textbooks to find relevant information. Medical Sciences is designed to do the integration for you. In just one book, the diverse branches of medical science are synthesised into the appropriate systems of the human body, making this an invaluable aid to approaching the basics of medicine within in a clinical context.

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An integrated approach to teaching basic sciences and clinical medicine has meant that medical students have been driven to a range of basic science textbooks to find relevant information. Medical Sciences does the integration for you. In just one book, the diverse branches of medical science are synthesised into the appropriate systems of the human body, making this an invaluable aid to approaching the basics of medicine within in a clinical context.

    • Eleven new contributors.
    • Completely new chapters on Biochemistry and cell biology, Genetics, The nervous system, Bones, muscle and skin, Endocrine and reproductive systems, The cardiovascular system, The renal system and Diet and nutrition.
    • Completely revised and updated throughout with over 35 new illustrations .
    • Expanded embryology sections with several new illustrations.

Table of Contents

Section Title Page Action Price
Front Cover Cover
Medical Sciences iii
Dedication ii
Copyright iv
Contents v
Contributors vii
Preface ix
Acknowledgements xi
Chapter 1: Introduction and homeostasis 1
CHAPTER 2 BIOCHEMISTRY AND CELL BIOLOGY 1
CHAPTER 3 ENERGY METABOLISM 1
CHAPTER 4 PHARMACOLOGY 1
CHAPTER 5 HUMAN GENETICS 2
CHAPTER 6 PATHOLOGY AND IMMUNOLOGY 2
CHAPTER 7 EPIDEMIOLOGY 2
SYSTEMS OF THE BODY 2
CHAPTER 16 DIET AND NUTRITION 3
HOMEOSTASIS 3
HOMEOSTATIC REGULATION MECHANISMS 3
Negative feedback 4
Homeostatic control of glucose metabolism 4
Thermoregulation 4
Human body temperature ( Clinical box 1.1) 5
Heat loss mechanisms 5
Heat gain mechanisms 5
Thermoneutral zones 6
Positive feedback ( Clinical box 1.2) 6
Feedforward ( Information box 1.1) 6
WATER AND ELECTROLYTES: HOMEOSTATIC CONTROL OF BODY FLUIDS 7
Fluid compartments 7
Movement of fluids between compartments 8
Properties of forces that drive fluid movement between compartments 8
Osmolarity 8
Tonicity ( Clinical box 1.3) 8
Effect of solutes on body fluids 8
Homeostatic control of fluid balance 9
Hormonal control of fluid balance ( Clinical box 1.4) 9
Behavioural control of fluid balance ( Clinical box 1.5) 9
Thirst 9
ACID–BASE BALANCE: HOMEOSTATIC CONTROL OF HYDROGEN IONS ( Clinical box 1.8) 10
Partial pressure of hydrogen ions 10
Physiological range of pH 11
Effect of pH on physiological processes 11
Sources of acid and alkali 11
Buffer systems 11
Bicarbonate/carbon dioxide 11
Protein buffers 12
Haemoglobin buffer system 12
Phosphate buffer system 12
Control of acid–base balance 12
Respiratory control of pH ( Clinical box 1.9) 12
Renal control of pH ( Clinical box 1.10) 13
Renal H + excretion 13
Renal bicarbonate reabsorption 13
Chapter 2: Biochemistry and cell biology 15
PRINCIPLES OF MOLECULAR INTERACTIONS 16
ATOMS 16
IONS 16
ACIDS AND BASES 16
CHEMICAL BONDS 16
Ionic bonds 16
Covalent bonds 17
Polar covalent bonds 17
Hydrogen bonds 17
Non-polar molecular interactions 17
ORGANIC COMPOUNDS 17
Spatial arrangement of organic molecules 18
CHEMICAL REACTIONS 18
Electrophiles and nucleophiles 18
Oxidation–reduction (redox) reactions 18
THE ENERGY CYCLE IN BIOLOGY 18
Potential energy of chemical bonds 18
Energy flow in chemical reactions 19
Activation energy 19
Metabolic energy generation 19
Anabolic and catabolic pathways 19
CHEMICAL ELEMENTS THAT FORM THE HUMAN BODY 20
WATER CONTENT AND THE MAIN FLUID COMPARTMENTS 20
ORGANIC BIOMOLECULES 20
CARBOHYDRATES 21
MONOSACCHARIDES, DISACCHARIDES AND POLYSACCHARIDES 21
Monosaccharides 21
The five-carbon sugars (pentoses) 21
The six-carbon sugars (hexoses) 21
Amino sugars and sugar-derived acids 21
Disaccharides 21
Polysaccharides 21
COMPLEX CARBOHYDRATES 23
LIPIDS ( Clinical box 2.2) 23
FATTY ACIDS 23
Triacylglycerols 23
Dietary fats 24
Essential fatty acids 24
Eicosanoids 24
CHOLESTEROL AND OTHER STEROIDS 24
Bile acids 25
Vitamin D 25
Steroid hormones 25
COMPLEX LIPIDS 26
Phospholipids 26
Sphingolipids 26
PURINES AND PYRIMIDINES 26
Synthesis and degradation of nucleotides 27
Nucleotide recycling: the salvage pathways 28
NUCLEIC ACIDS 28
DEOXYRIBONUCLEIC ACID 28
The primary structure of the nucleic acids 29
Secondary structure of DNA 29
The double helix 29
Complementarity of the DNA strands 30
Tertiary structure of DNA: chromatin and the nucleosomes 30
Mitochondrial DNA 30
DNA replication 31
DNA proofing and repair 31
Damage to DNA 31
RIBONUCLEIC ACIDS 31
Secondary structure of RNA 31
AMINO ACIDS 32
Structure of the amino acids 32
Dissociation of amino acids 32
Classification of amino acids 32
PROTEINS 33
The peptide bond 34
STRUCTURE OF PROTEINS 34
Primary structure 34
Secondary structure 34
Tertiary structure 34
Protein denaturation 34
Quaternary structure 34
Cooperativity between protein subunits 34
PROTEIN SYNTHESIS AND PROCESSING 36
Ribosomes 36
Transcription 36
Post-transcriptional modification of mRNA: splicing 36
Translation 37
Elongation of the polypeptide chain 37
Post-translational modification of proteins 38
Cellular protein targeting 38
Protein processing in the endoplasmic reticulum 38
Protein processing in the Golgi apparatus 39
Protein secretion 39
FUNCTIONS OF PROTEINS 39
STRUCTURAL PROTEINS 39
Collagens and proteins present in the extracellular matrix 39
Muscle 40
Cytoskeletal proteins 40
Immunoglobulins 40
Transport (binding) proteins 40
CATALYTIC PROTEINS: ENZYMES 40
Enzyme kinetics 40
Enzyme inhibition 42
Regulation of enzyme activity 42
Enzyme cofactors 42
Cell membranes 43
Proteins in cell membranes 44
CYTOPLASM 44
CYTOSKELETON 44
NUCLEUS 45
ENDOPLASMIC RETICULUM 45
GOLGI APPARATUS (GOLGI COMPLEX) 45
MITOCHONDRIA 45
LYSOSOMES 45
PROTEASOMES 46
PEROXISOMES 46
CELL JUNCTIONS 46
Tight junctions 46
Adhering junctions 46
Gap junctions 46
CELL ADHESION AND RECOGNITION 46
SIGNAL TRANSDUCTION IN CELLS 46
Hormones 47
Neurotransmitters 47
RECEPTORS 47
Cell surface (membrane) receptors 47
Signal transduction cascades 47
Intracellular receptors 48
MEMBRANE TRANSPORT 48
PASSIVE DIFFUSION 48
CARRIER MEDIATED TRANSPORT 48
Facilitated diffusion 48
Ion channels 49
Active transport 49
Na + /K + -ATPase 49
Other ATPases 49
Secondary active transport 49
COORDINATED ACTION OF TRANSPORTERS 50
ENDOCYTOSIS 50
EXOCYTOSIS 51
TRANSCYTOSIS 51
RECEPTOR-MEDIATED ENDOCYTOSIS 51
TRANSPORT OF SUBSTANCES IN THE BLOOD 51
ORGANS AND TISSUES 51
EPITHELIAL TISSUES 51
CONNECTIVE TISSUE 53
Fibrocollagenous tissues 53
Extracellular matrix 53
Cartilage, teeth and bone 53
Fat (adipose) tissue 54
Blood 54
MUSCLE 54
NERVOUS TISSUE 55
INTEGRATED LEARNING: THE SYSTEMIC APPROACH 56
Chapter 3: Energy metabolism 57
INTRODUCTION TO METABOLISM 57
ENERGY IS RELEASED BY CATABOLISM AND CONSUMED BY ANABOLISM 57
TRICARBOXYLIC ACID CYCLE 59
Control of the TCA cycle 59
ELECTRON TRANSPORT CHAIN AND OXIDATIVE PHOSPHORYLATION 59
Electron transport chain 59
Oxidative phosphorylation 60
Coupling of the electron transport chain and oxidative phosphorylation 60
Electron transport chain inhibition 61
Energy output 61
REGULATION OF FUEL METABOLISM 61
Binding of allosteric effectors to an enzyme to alter its affinity for substrate 61
Reversible activation and deactivation by covalent modification 62
Regulation of gene expression and transcription in response to changing metabolic demands 62
Action of hormones 62
When nutrients are plentiful 62
Metabolic adaptation to changes in energy requirement 62
FURTHER CONSIDERATIONS IN FUEL METABOLISM 62
Different tissues metabolise different energy substrates 63
How fuel is stored and transported between tissues 63
CARBOHYDRATE METABOLISM 63
REGULATION OF BLOOD GLUCOSE (GLYCAEMIA) 63
SOURCES OF BLOOD GLUCOSE 63
FOUR KEY PATHWAYS MAINTAIN AND UTILISE BLOOD GLUCOSE 64
GLUCOSE TRANSPORT 64
GLUT1 64
GLUT2 64
GLUT3 64
GLUT4 64
GLYCOLYSIS – THE ANAEROBIC CATABOLISM OF GLUCOSE 65
Importance of the anaerobic nature of glycolysis 65
For red blood cells 65
When a tissue’s oxygen supply is cut off 65
Energy-using reactions in glycolysis – glucose phosphorylation 66
Hexokinase 66
Glucokinase 67
One of the intermediate metabolites of glycolysis is G6P and at this point the pentose phosphate pathway branches off 67
Phosphofructokinase-1 (PFK-1) 67
PFK-1 activity is highly sensitive to the energy status of the cell 67
Regulation of PFK-1 68
Regulation by energy status and allosteric effectors 68
Fructose-2,6-bisphosphate 68
In the liver 68
In muscle 68
Citrate and pH 68
Energy-producing stage of glycolysis – production of pyruvate and lactate 69
Reactions yielding ATP 69
Pyruvate kinase 70
Fate of pyruvate 70
In mitochondria-containing cells 70
Fed state 70
Fasted state 70
In cells that lack mitochondria, when oxygen is limited, and in starvation 70
Lactate dehydrogenase 70
OXIDATIVE GLUCOSE METABOLISM – AEROBIC GLYCOLYSIS 71
Pyruvate dehydrogenase complex 71
Regulation of PDC activity 71
GLYCOGEN – THE STORAGE FORM OF GLUCOSE 72
In the liver 72
In skeletal muscle 72
SYNTHESIS OF GLYCOGEN 72
Glycogenin, the glycogen primer 73
Glycogen synthase (GS) 73
Structure of glycogen 73
Control of glycogen synthesis 73
Allosteric activation of glycogen synthesis 74
Covalent mechanisms regulating glycogen synthesis 74
Glycogen synthesis in the liver 74
Direct versus indirect pathway of hepatic glycogen synthesis 74
Glycogen synthesis in skeletal muscle 74
GLYCOGENOLYSIS – THE BREAKDOWN OF GLYCOGEN 75
Glycogenolysis in liver 75
Glycogenolysis in muscle 75
REGULATION OF GLYCOGENOLYSIS 75
Regulation of hepatic glycogenolysis 76
Hormone regulation of hepatic glycogenolysis 76
MECHANISM OF GLUCAGON REGULATION OF GLYCOGENOLYSIS – HORMONE SIGNALLING 76
SYMPATHETIC STIMULATION 76
Enzyme regulation of hepatic glycogenolysis 76
REGULATION OF HEPATIC GLYCOGEN PHOSPHORYLASE 77
Regulation of phosphorylase kinase by covalent modification – phosphorylation 77
Amplification of the signalling cascade 77
Ca 2 + as a second messenger 77
Regulation of muscle and brain glycogenolysis 77
Genetic defects in glycogenolysis 78
GLUCONEOGENESIS – GLUCOSE SYNTHESIS 78
Precursors of gluconeogenesis 78
Gluconeogenesis from lactate 78
Gluconeogenesis from protein 79
Gluconeogenesis from glycerol 80
Peroxisome proliferator-activated receptors in energy homeostasis 80
Energy for gluconeogenesis 80
Cori and glucose–alanine cycles 81
Gluconeogenesis from sugars 81
Regulation of gluconeogenesis 81
AMINO ACID METABOLISM 83
METABOLIC CLASSES OF AMINO ACIDS ( Clinical box 3.13) 83
ABSORPTION OF AMINO ACIDS 83
NITROGEN IN AMINO ACID METABOLISM 84
Transamination 84
Amino acid release by skeletal muscle in the post-absorptive state 84
Deamination 85
Glutamine in acid–base homeostasis 85
Ammonia 86
Urea cycle ( Clinical box 3.16) 86
Regulation of the urea cycle 86
Nitrogen balance 87
AMINO ACIDS IN GLUCONEOGENESIS 87
ESSENTIAL AMINO ACIDS (See also Clinical box 3.17) 87
AMINO ACIDS AND SIGNALLING MOLECULES 88
Amino acids as neurotransmitters ( Clinical boxes 3.17 and 3.18) 88
Amino acids as precursors of neurotransmitters and hormones 88
LIPID METABOLISM ( Clinical box 3.19) 88
SOURCES OF FATTY ACIDS 88
Dietary fatty acids 89
Endogenously synthesised fatty acids 89
STORAGE OF LIPIDS 90
FATTY ACIDS 90
Protein-bound fatty acids 90
TRIACYLGLYCEROLS (TRIGLYCERIDES) 91
Regulation of triacylglycerol breakdown 91
LIPOPROTEINS 91
Apolipoproteins 92
Lipoprotein classes and functions 92
Chylomicrons 92
Very-low-density lipoprotein 92
Intermediate-density lipoprotein 92
Low-density lipoprotein 92
High-density lipoprotein 92
Lipoprotein receptors 93
Scavenger receptors 93
Lipoprotein metabolism 93
Reverse cholesterol transport 93
Lipoprotein fuel transport and overflow pathways 93
FATTY ACID OXIDATION 93
Fatty acid activation and transport into mitochondria 93
Carnitine shuttle 94
Carnitine shuttle in the regulation of fatty acid oxidation 94
β-Oxidation of fatty acids in mitochondria 94
Oxidation of acetyl-CoA in the TCA cycle 94
Inhibition of the β -oxidation spiral by excess CoA 95
Ketogenesis in the liver 95
Oxidation of acetyl-CoA in the ketogenic pathway 95
Role of ketone bodies in fuel homeostasis 96
Ketone body utilisation 96
LIPOGENESIS – FATTY ACID SYNTHESIS 96
Stage 1: ACC – the committed step of lipogenesis 96
Regulation of ACC activity 98
Acetyl-CoA contains an allosteric site for the binding of citrate or palmitoyl-CoA 98
ACC control by hormone-dependent covalent modification 98
The rate of ACC synthesis is highly regulated 98
Stage 2: fatty acid synthase (FAS) 98
Chain elongation 98
Desaturation 98
Regulation of fatty acid synthase and rate of lipogenesis 98
Malate shuttle – production of acetyl-CoA for lipogenesis 98
FINE-TUNING OF FATTY ACID SYNTHESIS, OXIDATION AND KETOGENESIS 99
REGULATION OF FAT METABOLISM 100
In the fasting (post-absorptive) state 100
In the fed (absorptive) state 100
Chapter 4: Pharmacology 101
INTRODUCTION 101
DIGOXIN – AN EXAMPLE IN CLINICAL PHARMACOLOGY 102
Pharmacodynamics – how digoxin works 102
Pharmacokinetics – how the body handles digoxin 102
Unwanted effects 102
Factors that contribute to digoxin toxicity 102
ABSORPTION – TRANSFER OF DRUGS ACROSS CELL MEMBRANES 103
PASSIVE DIFFUSION THROUGH LIPID MEMBRANES 103
Lipid solubility 103
Ionised and non-ionised forms of a drug 104
Degree of ionisation of a drug 104
Passive diffusion across cell membranes 104
Ion trapping 104
Effects of acidosis or alkalosis on absorption and distribution 104
CARRIER-MEDIATED TRANSPORT 104
Transporters (carrier proteins) 105
Ion channel proteins 106
ENDOCYTOSIS AND EXOCYTOSIS 106
DIFFUSION THROUGH AQUEOUS AND INTERCELLULAR PORES 106
Gap junctions 106
DRUG DISTRIBUTION 106
BLOOD FLOW 106
CAPILLARY PERMEABILITY AND GAP JUNCTIONS 106
Drug distribution to special organs 107
Central nervous system 107
Foetus 107
ACCUMULATION OF DRUG IN FAT AND REDISTRIBUTION IN OTHER TISSUES 107
BINDING OF DRUGS TO PROTEINS 107
Competitive protein binding 108
Hypoproteinaemia 108
Sequestration of drugs in tissues 108
DISTRIBUTION OF DRUGS IN THE BODY 108
Extent of drug distribution into aqueous compartments 109
Apparent volume of distribution 109
DRUG METABOLISM 109
PHASE I METABOLIC REACTIONS (PRE-CONJUGATION REACTIONS) 110
Oxidation 110
Microsomal oxidation reactions 110
Cytochrome P450 system 110
Non-microsomal oxidative reactions 110
Reduction 111
Hydrolysis – hydroxylation 111
PHASE II METABOLIC REACTIONS (CONJUGATION REACTIONS) 112
Conjugation by glucuronidation 112
Other conjugation reactions 112
Drug detoxification 112
FACTORS AFFECTING DRUG METABOLISM 112
Genetic factors 112
Environmental contaminants and drugs 112
Enzyme induction 113
Enzyme inhibition 113
Enzyme inhibition by metabolites 113
CONVERSION OF INACTIVE PRO-DRUG TO ACTIVE METABOLITE 113
EXCRETION OF DRUGS AND METABOLITES 113
RENAL SYSTEM 113
Glomerular filtration 114
Tubular secretion 114
Tubular reabsorption 114
Diuretic drugs 115
Diuretics acting on the loop of Henle 115
Chapter 5: Human genetics 155
INTRODUCTION 155
HISTORICAL BACKGROUND 155
BASIS OF MODERN GENETICS 156
THE HUMAN GENOME 157
DNA AND CHROMOSOMES 157
Chromosome karyotypes ( Fig. 5.2) 157
Mitochondrial DNA 157
Cell division 158
The cell cycle 159
Interphase 159
Mitosis ( Fig. 5.4) 160
Meiosis 161
Chromosome abnormalities 163
Abnormalities in number 163
Abnormalities in structure 163
DNA AND GENES 166
Homeobox (HOX) genes 166
Non-coding DNA (see Ch. 2) 166
Transcription ( Fig. 5.12) 166
Regulation of transcription 167
Translation 167
DNA DAMAGE 168
DNA damage from environmental factors 168
Spontaneous damage (DNA replication mistakes) 168
Repair mechanisms 168
Direct reversal of base damage 168
Breakage repair 168
Single-strand breaks 168
Double-strand breaks (DSBs) 169
GENES AND DEVELOPMENT 169
MEDIATORS OF DEVELOPMENT 169
Signalling molecules 169
Fibroblast growth factor and fibroblast growth factor receptor 169
Sonic hedgehog 170
Wingless (Wnt) 170
Transforming growth factor β 170
DNA transcription factors 170
SOX family genes 170
Extracellular matrix proteins 170
PATTERNING 170
Anterior/posterior axis formation 170
Left/right axis formation 170
Dorsal/ventral axis development 170
ORGANOGENESIS 171
Neuronal development 171
The asymmetrical heart 171
Organ formation 171
Limb development 171
HUMAN GENETIC VARIATION 172
POLYMORPHISMS 172
Mutation or polymorphism? 172
Types of mutational events leading to polymorphisms 172
Single nucleotide polymorphisms 172
Deletions and insertions ( Clinical box 5.6) 172
Gene duplications 173
Consequences of genetic mutation 173
Founder effects 173
Genghis Khan and the founder effect 173
Bottlenecks 174
Population drift 174
Genotypes, phenotypes and genetic penetrance 176
MODES OF INHERITANCE 177
MENDELIAN DISORDERS 177
Autosomal dominant inheritance ( Figs 5.22 and 5.23) 177
Autosomal recessive inheritance ( Figs 5.24 and 5.25) 178
Consanguinity and recessive disorders 178
Coefficient of relationship 178
Rare disorders and consanguinity 179
X-linked inheritance 179
Lyonisation 179
Dominant X-linked inheritance ( Figs 5.26 and 5.27) 179
Recessive X-linked inheritance ( Figs 5.28 and 5.29) 180
Haemophilia – the royal disease 181
Other modes of inheritance 181
Genomic imprinting 181
Mitochondrial disorders 182
Mosaicism 182
Inborn errors of metabolism (see Ch. 3) 182
POLYGENIC OR COMPLEX DISEASE 183
CONTINUOUS EFFECTS MODELS 184
THRESHOLD EFFECTS MODELS 184
CHARACTERISTICS OF MULTIFACTORIAL DISEASES 184
Heritability 185
Genetic epidemiology 185
Twin studies 185
Biases in twin studies 186
Adoption studies 186
Association studies 186
TOOLS TO INVESTIGATE POLYGENIC DISEASES 186
Information from single gene disorders 186
Animal models 186
Linkage studies 186
Expression profiles 187
Whole-genome association studies (WGAS) 187
CANCER GENETICS 187
CANCER AS A MULTI-STEP GENETIC DISEASE 187
INHERITANCE OF CANCER GENES 187
Colon cancer 187
CANCER GENES 188
Tumour suppressor genes 188
Retinoblastoma and the two-hit theory of carcinogenesis 188
Loss of heterozygosity 188
Oncogenes 189
Retroviruses 189
Transfection 189
DNA repair genes 190
IDENTIFYING DISEASE GENES 190
GENOME MAPPING 190
Physical maps 191
Low-resolution mapping 191
Karyotyping 191
Dosage mapping 191
Fluorescence in situ hybridisation (FISH) 191
High-resolution mapping 191
Sanger sequencing 191
Sequence tagged sites 191
Cloning 192
Chromosomal comparative genomic hybridization (CGH) arrays 194
Genetic linkage and monogenic disease 194
Linkage disequilibrium 194
LOD scores 194
Genetic linkage – a clinical example 195
Calculating the recombination frequency 195
Calculating the LOD score 195
LOD problems encountered in linkage studies 195
Locus heterogeneity 195
Incomplete penetrance 196
Phenocopies 196
Genetic linkage and polygenic disease 196
Restriction fragment length polymorphism 196
Variable number of tandem repeats 196
Single nucleotide polymorphisms 196
Genome microarrays 197
Personal genomics 198
Next generation sequencing (NGS) 198
Bioinformatic tools 198
THE HUMAN GENOME PROJECT 199
Can a DNA sequence be patented? 199
Beyond the sequence 199
What the HGP has already told us 200
Statistics 200
Functions 200
Structure 200
Variation 200
Comparison with other species 200
Using data from the HGP 200
Investigating the human genome 200
Gene families 200
Molecular phylogenetics 201
Protein modelling 202
X-ray crystallography 202
Nuclear magnetic resonance 202
Homology modelling 202
Model organisms 202
Mammals as model organisms 202
The mouse 202
Non-mammals as model organisms 203
Retroviruses 203
Bacteria and other microbes 204
Saccharomyces cerevisiae (baker’s yeast) 204
Archaea 204
Caenorhabditis elegans (round worm) 204
Drosophila (fruit fly) 204
Danio rerio (zebrafish) 204
GENETIC DISEASE, DIAGNOSIS AND THERAPY 204
GENE TESTING 204
Ethics 204
Genetic counselling 204
CONGENITAL DISEASE 205
Teratogens 205
PHARMACOGENOMICS 205
Antibiotics and pharmacogenomics ( Clinical boxes 5.15 and 5.16) 207
Evidence-based treatment (see also Ch. 7) 207
GENETIC MEDICINE 207
Metabolic manipulation 207
Protein augmentation 208
Stem cell therapies 208
Embryonic stem cell transplantation 208
Haematopoietic stem cell transplantation 208
Non-haematopoietic stem cell transplantation 208
Gene transfer 208
Ex vivo approach 208
In vivo approach 209
RNA modification 209
Future of genetic therapy 209
Chapter 6: Pathology and immunology 211
INTRODUCTION 212
INFECTION 213
BIOLOGICAL AGENTS 213
The burden of infectious disease 213
The variety of biological infectious agents 213
BACTERIA 213
STRUCTURE 214
Cytoplasm 214
Cell membrane (plasma membrane) 214
Cell wall 214
BACTERIAL CLASSIFICATION 215
OTHER BACTERIAL SURFACE FEATURES 215
UNUSUAL TYPES OF BACTERIA 215
REPLICATION 215
VIRUSES (see Information box 6.2) 216
NUCLEOCAPSID STRUCTURE 216
Genomic material 216
Capsid 216
HOST CELL INFECTION 216
VIRUS CLASSIFICATION 217
VIRUSES AND CANCER 218
FUNGI (see Information box 6.3) 218
STRUCTURE 218
Chapter 7: Epidemiology: science for the art of medicine 277
INTRODUCTION 277
THE EPIDEMIOLOGICAL APPROACH 277
EPIDEMIOLOGY AS THE DETECTIVE 277
The Broad Street pump 277
PATTERNS OF LIFE AND DEATH 280
Descriptive studies 280
Measuring disease occurrence 280
Disease incidence 280
Disease prevalence 281
Rates and relationship between incidence and prevalence 281
Measuring disease outcome 281
Births and deaths 282
Confidential enquiries 282
Disease surveillance 282
Cancer registration 283
Congenital anomalies notification 283
Communicable disease surveillance 283
Notification of infectious diseases 283
Examining data from different sources 283
Infectious disease surveillance and information sources 283
Global infectious disease surveillance 284
Special surveillance systems 284
Monitoring adverse reaction to drugs 284
Measures for health of populations 284
Mortality and life expectancy 284
Morbidity 285
The population census and health surveys 285
Measures for quality of life (QALYs) 285
Health inequalities 285
Health inequalities in the UK 286
Changes in health outcomes over time 286
Interpretation of data 286
Data inadequacies 286
Clustering 288
Socio-economic factors 288
Health-related behaviours 288
Healthcare facilities 288
Environmental factors 288
Migration 289
Standardisation of rates 289
Direct method of standardisation 290
Indirect method of standardisation 290
Choice of method for standardisation 291
EPIDEMIOLOGICAL ENQUIRY 291
SOME BASIC CONCEPTS IN EPIDEMIOLOGY 291
The distribution of data 291
The normal or Gaussian distribution curve 292
Measures of centre 292
The mean 292
The median 292
The mode 292
Measures of spread: standard deviation from the mean 292
Outliers 292
Ordered data and the interquartile range 292
How accurate is the distribution summary? 293
Contingency tables 293
Some statistical concepts used in epidemiological enquiry (hypothesis tests and p values) 293
Hypothesis tests 294
Tests of probability: p values and confidence intervals 294
AN OVERVIEW OF EPIDEMIOLOGICAL ENQUIRY 296
Investigation by observation: causation or association? 296
Observational studies 296
Cross-sectional studies 297
Sampling for cross-sectional studies 297
Interpreting the data from cross-sectional studies 297
Case–control studies 297
Selecting the sample for case–control studies 298
Analysing and interpreting data from case–control studies 299
Strength of the association 299
Consistency of findings 300
Specificity of the association 300
Relationship in time 301
The biological gradient 301
Demonstration of reversibility 301
Biological plausibility 302
Coherence of the evidence 302
Cohort studies 302
Selecting the sample for cohort studies 302
The Whitehall studies 302
Assembling the cohort 303
The prospective follow-up 303
Whitehall II 303
Analysing and interpreting data from cohort studies 303
The role of genetics in observational studies 304
Association between genotype and risk factor 304
Interaction with environmental factors 305
Investigation by experiment 305
Evaluation of clinical effectiveness: RCTs 305
Selecting the sample: experimental and control groups 305
Ethical considerations during the planning stage of clinical trials 306
The CRASH trial 306
Achieving similar groups for comparison: randomisation to minimise bias 306
Selecting the sample for the 4S trial 306
Calculating sample size 307
Power calculations 307
Measuring the outcomes during a trial 307
'Blinding’ to avoid bias during a trial 307
Outcomes of interest: end-point definition 308
Ethical principles during a trial: stopping a trial and interim analyses 308
Interim analyses 310
What outcomes should be considered in an interim analysis? 310
How should the information be obtained? 310
How should the information be treated? 310
How should the decision be made to stop a trial? 310
Measuring outcomes: follow-up 310
Analysing and interpreting the results 310
Analysis by intention-to-treat 310
Sensitivity analysis 311
Measures of treatment effect 311
Statistical significance 311
Clinical significance: the number needed to treat 311
Interpreting the results 312
Tests of significance 312
Presenting the results 313
Dissemination 313
Statistical assessment of data 313
Choosing a statistical test 313
Looking for differences in quantitative data ( Fig. 7.18) 313
Looking for differences in categorical data ( Fig. 7.19) 314
Looking for patterns in data ( Fig. 7.20) 314
Degrees of freedom 314
The t-test 315
Evaluating probability for t -values 315
Criteria for applying the t-test 316
The χ 2 test 316
Evaluating probability for χ 2 values 316
Criteria for applying the χ 2 test 317
Linear association: correlation and regression 317
Multivariate analysis 318
INVESTIGATION BY REVIEW 319
META-ANALYSIS 319
Cumulative meta-analysis 319
Experiment or review? 320
Differences between reviews and RCTs 320
Definition of best evidence 321
HEALTH EDUCATION AND PROMOTION 321
HEALTH EDUCATION 321
Approaches to health education 321
Strategies for disease prevention and health promotion 321
Population strategies 321
High-risk strategy 322
Two concepts of ‘risk’ 322
Essentials for effective health education 322
Ethical considerations in prevention and health promotion 322
Case scenario: a new diagnosis of diabetes 322
Elicit the person’s health beliefs 323
Information phase 323
Explanation of the diagnosis 323
Chapter 8: The nervous system 337
INTRODUCTION 337
EMBRYOLOGY 337
Neurulation 338
Brain development 338
Ventricles 338
Spinal cord development 338
Developmental disorders of the nervous system 339
GROSS ANATOMY 339
CENTRAL NERVOUS SYSTEM 339
Brain 339
Cerebrum (telencephalon) 339
Cerebral cortex 340
Basal ganglia 341
Limbic system 341
Diencephalon 341
Brainstem 341
Midbrain 343
Pons and medulla 344
Cerebellum 344
Spinal cord 344
Grey matter 345
White matter 345
PERIPHERAL NERVOUS SYSTEM 345
Somatic nervous system 346
Cranial nerves 346
Olfactory (I) nerve 346
Optic (II) nerve 346
Oculomotor (III) nerve 346
Trochlear (IV) nerve 346
Trigeminal (V) nerve 346
Sensory division 346
Motor division 346
Abducens (VI) nerve 346
Facial (VII) nerve 347
Vestibulocochlear (VIII) nerve 347
Glossopharyngeal (IX) nerve 347
Vagus (X) nerve 347
Accessory (XI) nerve 348
Hypoglossal (XII) nerve 348
Spinal nerves 348
Structure of peripheral nerves 348
Nerve fibre classification 349
MENINGES 349
Dura mater 349
Arachnoid mater 350
Pia mater 351
THE VENTRICULAR SYSTEM 351
Secretion and circulation of CSF 351
Absorption of CSF 352
Functions of CSF 352
Metabolic functions 352
Mechanical functions 352
CELLS OF THE NERVOUS SYSTEM 352
Size 352
Morphology 352
Connectivity 353
Chemistry 353
BLOOD SUPPLY TO THE BRAIN AND BRAIN METABOLISM 353
ARTERIAL BLOOD SUPPLY 353
Anterior cerebral circulation 353
Posterior cerebral circulation 354
Arterial blood supply to the spinal cord 354
Venous drainage 355
BLOOD–BRAIN BARRIER 355
METABOLIC REQUIREMENTS OF THE BRAIN 356
TRANSMISSION OF NEURAL SIGNALS 356
ACTION POTENTIALS 356
Equilibrium potentials 356
Depolarisation and hyperpolarisation 357
Generation of action potentials 357
Initiation 357
Upstroke 357
Repolarisation 357
Refractory period 358
Conduction of action potentials 358
SYNAPSES 358
Electrical synapses 358
Chemical synapses 358
NEUROTRANSMISSION 359
Neurotransmitters 359
Neurotransmitter release 359
Neurotransmitter receptors 359
Summation 360
Neurotransmitter inactivation 360
Presynaptic receptors 360
Types of neurotransmitters 360
Amino acids 360
Excitatory amino acids 360
Inhibitory amino acids 362
Acetylcholine 362
Monoamines 362
Purines 363
Peptides 364
MOTOR CONTROL AND PATHWAYS 364
MOTOR CORTEX 365
Primary motor cortex 365
Premotor and supplementary motor cortices 365
Lateral motor pathways 365
BRAINSTEM 365
Medial motor pathways 365
Upper and lower motor neurons 366
SPINAL CORD 367
Motor reflexes 367
Stretch reflex 367
Muscle spindles 367
Golgi tendon organ reflex 368
Cutaneous reflexes 368
Locomotion 368
Muscle tone 368
Spinal cord injury 368
CRANIAL NERVE REFLEXES 369
CEREBELLUM 369
Anatomy 369
Functional subdivisions 370
Cerebellar cortex and circuitry 371
BASAL GANGLIA 372
EYE MOVEMENTS 373
Control of eye movements 374
Gaze stabilisation 374
Gaze shift 374
SENSORY SYSTEMS 375
Sensory receptor transduction 375
Receptive field structure 376
Touch and proprioception 376
Touch and conscious proprioception pathway 376
Somatosensory cortex 377
Other proprioception pathways 378
Pain and temperature 378
Thermoreceptors 378
Nociceptors 378
Pain and temperature pathways 378
Summary of the ascending sensory pathways 379
Pain regulation 379
Analgesic agents 380
Placebo effect 380
Visceral sensation 381
Referred pain 381
Phantom pain 381
SPECIAL SENSES 381
VISION 381
The anatomy of the eyeball 381
Optics of the eye 381
Pupillary reflexes 382
Retina 383
Photoreceptors 383
Retinal processing 385
Central visual pathways 386
Visual perception 386
VESTIBULAR SYSTEM 386
Anatomy 386
Central vestibular pathways 388
AUDITORY SYSTEM 388
Sound 388
External and middle ear 389
Inner ear (cochlea) 389
Central auditory pathways 390
Sound frequency coding 392
Sound localisation 392
SMELL 392
TASTE 392
Central pathways of taste 392
CENTRAL AUTONOMIC NETWORKS 392
Examples of central autonomic control 394
Thermoregulation 394
Regulation of feeding and satiety 394
Orexigenic pathway 394
Anorexigenic pathway 394
Regulation of thirst and drinking 395
Regulation of sexual function 395
CONSCIOUSNESS 395
SLEEP AND WAKEFULNESS 395
Arousal system 396
NREM sleep 396
REM sleep 396
EMOTION 396
Limbic system 396
The pathways of fear 397
Emotion recognition 397
Emotional expression 397
Prefrontal cortex and emotion 398
MOTIVATION AND GOAL-DIRECTED BEHAVIOURS 398
The brain reward system 398
Drugs and the brain reward system 398
HIGHER CORTICAL FUNCTIONS 399
COGNITION 399
MEMORY 399
Declarative memory 399
Anatomical structures and declarative (explicit) memory 400
Long-term potentiation and depression 400
ATTENTION 401
AGNOSIAS 401
APRAXIAS 401
LANGUAGE 401
BRAIN DEATH 402
Chapter 9: Bone, muscle, skin and connective tissue 403
INTRODUCTION 403
IMAGING IN MEDICINE 403
THE SKELETAL SYSTEM 404
CARTILAGE 404
BONE MICROANATOMY 405
Bone matrix 405
Cellular content of bone 405
BONE FORMATION 406
SKELETAL COMPONENTS 406
STRUCTURE OF BONE 406
Compact bone 410
Spongy bone 411
Blood and nerve supply to bone 411
BONE DEVELOPMENT 411
Endochondral ossification 411
Intramembranous ossification 412
BONE GROWTH 412
Bone growth in length 412
Growth in bone thickness 414
Factors affecting bone growth 414
Bone remodelling 414
BONE’S ROLE IN CALCIUM HOMEOSTASIS 415
Parathyroid hormone 415
Vitamin D 416
Calcitonin 416
Other factors affecting bone mass 416
Oestrogen 416
Exercise 416
Diet and bone mass 417
BONE HEALING 417
JOINTS 418
BONY JOINTS 418
FIBROUS JOINTS 418
Suture 418
Syndesmosis 418
Gomphosis 419
Schindylesis 419
CARTILAGINOUS JOINTS 419
SYNOVIAL JOINTS 419
Synovial joint structure 419
Articular cartilage 420
Articular capsule 420
The synovium 420
The synovial fluid 421
Accessory ligaments 422
Articular discs 422
Blood and nerve supply to the joint 422
Types of synovial joints 422
Planar or gliding synovial joint 422
Hinge joint 423
Pivot joints 424
Condyloid or ellipsoidal joint 424
Saddle joint 425
Ball and socket joint 425
A complex joint 428
TENDONS AND LIGAMENTS 428
Bursae and tendon sheaths 431
ANATOMICAL RELATIONSHIPS 432
SKELETAL MUSCLE 432
THE NEUROMUSCULAR JUNCTION AND MUSCLE INNERVATION 432
Neurotransmitter release 433
Acetylcholine receptors 433
Neuromuscular blockade 434
Breakdown of acetylcholine 434
Motor units 434
Development of sustained tension 435
Muscle tone 435
Sensory innervation of muscle 435
ISOTONIC VERSUS ISOMETRIC CONTRACTION 435
THE SKELETAL MUSCLE FIBRE 435
The contractile proteins 436
Thin filaments 437
Thick filaments 437
The sliding filament model of muscle contraction 438
THE CONTRACTILE PROCESS 438
Excitation–contraction coupling 438
Intracellular calcium release ( Fig. 9.17A) 438
Cross-bridge formation and muscle contraction ( Fig. 9.17B) 440
Calcium removal and muscle relaxation 440
Muscle length and tension 440
MUSCLE METABOLISM 440
Creatine phosphate 441
Creatine supplementation 441
Muscle fatigue 441
TYPES OF MUSCLE FIBRES 441
THE CONNECTIVE TISSUE OF MUSCLE 441
MUSCLE GROWTH AND REPAIR 442
MUSCLE NOMENCLATURE 442
Muscle shape 442
Muscle names 443
POSTURE AND LOCOMOTION 443
STANDING 444
WALKING 444
Stance phase 444
Swing phase 444
Stabilisation 444
Gait analysis 444
SPECIALISED CONNECTIVE TISSUES: SKIN, HAIR AND NAILS 444
STRUCTURE OF SKIN 444
Epidermis 445
Melanocytes 445
Dermis 446
Sweat glands 447
Sebaceous glands 447
Subcutaneous layer 447
HAIR 447
Structure of hair 447
Structure of hair follicle 447
Types of hair 448
NAILS 448
GENERALISED CONNECTIVE TISSUE 448
Chapter 10: Endocrinology 451
INTRODUCTION 451
THE ENDOCRINE SYSTEM 451
Peptide hormones: secretion and mechanisms of action 452
Steroid hormones: synthesis, actions and metabolism 453
Modified amino acids: thyroid hormones and catecholamines 454
NEUROENDOCRINOLOGY 455
IMPORTANT CONCEPTS IN ENDOCRINOLOGY 455
Patterns of hormone secretion 455
Negative feedback 455
Endocrine disease 455
Endocrine testing 456
Measuring hormones in blood 458
ENDOCRINE REGULATION – THE ROLE OF THE HYPOTHALAMUS AND PITUITARY 458
Functional anatomy of the hypothalamus and pituitary 458
The hypothalamus controls hormone secretion by the anterior pituitary 458
Prolactin secretion is under inhibitory regulation ( Fig. 10.12) 461
GROWTH HORMONE 461
Growth 461
The regulation of growth hormone 461
Actions of growth hormone 462
THYROID GLAND AND THE REGULATION OF METABOLISM 464
THE STRUCTURE AND LOCATION OF THE THYROID 464
Iodine – an important trace element 464
HORMONE SYNTHESIS IN THE THYROID GLAND 465
CONTROL OF THYROID FUNCTION 466
Thyroid hormones in blood 466
Peripheral metabolism of thyroxine 466
Functions of thyroxine ( Table 10.5) 466
HORMONES AND ‘STRESS’ 467
Adrenal cortex and medulla 468
Structure of adrenals 468
Stress: the adrenal medulla 468
Stress: the adrenal cortex 469
Actions of cortisol 469
ENDOCRINE CONTROL OF GLUCOSE METABOLISM (details of biochemistry in Chs 2 and 3) 471
Regulation of plasma glucose concentration 471
ENDOCRINE PANCREAS 471
Insulin synthesis 471
Control of insulin secretion ( Fig. 10.27) 471
Glucagon 472
Diabetes mellitus 472
Glycosuria 472
Type 1 diabetes 473
Type 2 diabetes 473
Obesity 473
Complications of poorly controlled blood glucose 1: diabetic ketoacidosis 474
Complications of poorly controlled blood glucose 2: HONK 474
Complications of poorly controlled blood glucose 3: hypoglycaemia 474
ENDOCRINE CONTROL OF BLOOD CALCIUM (details of bone in Ch. 9) 475
CALCIUM HOMEOSTASIS 475
CONTROL OF BLOOD CALCIUM AND PHOSPHATE CONCENTRATIONS 475
MALE REPRODUCTIVE ENDOCRINOLOGY 478
Male reproductive tract ( Fig. 10.35) 478
Hypothalamic–pituitary–testicular axis 479
Spermatogenesis 480
FEMALE REPRODUCTIVE ENDOCRINOLOGY 481
Female reproductive tract 481
Follicular development 481
HORMONAL CONTROL OF THE OVARY AND MENSTRUAL CYCLE 481
The menstrual and ovarian cycles 482
PUBERTY 484
PREGNANCY 486
FERTILISATION 486
The establishment of pregnancy 486
Hormone production by the placenta 487
Pregnancy tests 488
FOETAL DEVELOPMENT 488
PARTURITION – LABOUR 488
Lactation 489
INFERTILITY (SUBFERTILITY) 491
THE ENDOCRINOLOGY OF AGEING (INCLUDING MENOPAUSE) 491
Chapter 11: The cardiovascular system 493
INTRODUCTION 493
CLINICAL ANATOMY OF THE CARDIOVASCULAR SYSTEM 493
THE HEART 493
The pericardium 493
The heart chambers 494
The apex of the heart 494
The heart valves 494
Heart sounds and murmurs 495
THE HUMAN CIRCULATION 497
The pulmonary circulation 499
The systemic circulation 500
The arterial system 500
Aortic arch 501
Thoracic aorta 501
Abdominal aorta 501
Common iliac arteries 502
Peripheral arterial pulses 502
The venous system 503
Jugular venous pulse 503
Regional circulations 503
The coronary circulation 503
Coronary blood flow 504
The cerebral circulation 504
The hepatic circulation 504
The skeletal muscle circulation 505
The cutaneous circulation 505
EMBRYOLOGY 505
DEVELOPMENT OF THE HEART 506
The chambers of the heart 506
The atria 507
The ventricles 507
The great arteries 508
DEVELOPMENT OF THE VASCULATURE 508
The foetal circulation 508
The neonatal circulation 510
CELLULAR STRUCTURE AND FUNCTION OF THE HEART 510
STRUCTURE OF HEART MUSCLE 510
Cardiomyocytes 510
Intercalated discs 510
T-tubules and sarcoplasmic reticulum 510
THE CONTRACTILE PROCESS 510
Cardiac muscle contraction 510
Cardiac muscle relaxation 511
Cardiac muscle metabolism 512
ELECTRICAL ACTIVATION OF THE HEART 512
Pacemaker cells 512
The cardiac conduction system 513
Nerve supply to the heart 513
Parasympathetic supply 513
Sympathetic supply 514
Adrenal medulla 515
Electrocardiography 515
The ECG 515
The normal ECG 516
The electrical axis of the heart 517
Cardiac arrhythmias 518
Anti-arrhythmic drugs 520
Conduction disorders 520
THE CARDIAC CYCLE 522
Atrial systole 524
Ventricular systole 524
Ventricular diastole 524
The pressure–volume loop 524
CARDIAC OUTPUT AND HEART FAILURE 525
Preload 525
Myocardial contractility 525
Afterload 526
Ventricular hypertrophy 526
Causes of heart failure 526
Pathophysiological mechanisms activated by heart failure 526
Treatment of heart failure 527
BLOOD VESSELS 528
THE VESSEL WALL 528
Arteries 529
Veins 529
ATHEROSCLEROSIS 530
Evolution of the atherosclerotic plaque 530
Endothelial damage 530
Uptake of modified LDL particles, adhesion and infiltration of macrophages 530
Smooth muscle proliferation and formation of fibrous cap 531
Plaque rupture 531
Risk factors for atherosclerosis 532
Non-modifiable risk factors 532
Modifiable risk factors 532
Markers of risk 532
Prevention and treatment of atherosclerosis 533
Non-atherosclerotic arteriosclerosis 533
ISCHAEMIC HEART DISEASE 534
Angina 534
Stable angina 534
Variant angina 534
Treatment of angina 534
Acute coronary syndromes 534
Unstable angina 534
Myocardial infarction 534
Non-ST elevation myocardial infarction 535
ST elevation myocardial infarction 537
Complications of myocardial infarction 537
THROMBOEMBOLISM 539
Thrombus formation 539
Deep vein thrombosis 540
Pulmonary embolism 540
Non-thrombotic emboli 541
THE MICROCIRCULATION 541
Capillary structure 541
The capillary bed 542
Capillary exchange 542
Diffusion 543
Free diffusion 543
Channel-based diffusion 543
Active membrane transport 543
Influence of blood flow on capillary exchange 543
Water exchange 543
Starling forces 543
Filtration and resorption 544
Oedema 545
Increased capillary hydrostatic pressure 545
Decreased plasma oncotic pressure 545
Increased capillary permeability 545
Reduced lymphatic drainage 545
MECHANICS OF BLOOD FLOW 546
Pressure and vascular resistance 546
Velocity of blood flow 546
Types of blood flow 547
Laminar blood flow 547
Turbulent blood flow 547
Bolus flow 547
Control of blood flow 547
Structure of vascular smooth muscle 547
Vascular smooth muscle contraction 548
Excitation-contraction coupling of smooth muscle 548
Regulation of flow in small arteries and arterioles 549
Sympathetic nervous system mediated vasoconstriction 550
Hormone-mediated vasoconstriction and vasodilatation 550
Non-adrenergic autonomic nervous system mediated vasodilatation 551
Receptor-mediated differential effects of catecholamines 551
Vasoconstriction by catecholamines 551
Vasodilatation by catecholamines 552
Regulation of flow in the microcirculation 552
Autoregulation of blood flow 552
Metabolic byproduct vasodilatation 553
Local vasoactive hormones 553
SYSTEMIC ARTERIAL BLOOD PRESSURE 554
REGULATION OF ARTERIAL BLOOD PRESSURE 554
Baroreceptor reflex 554
Chemoreceptor reflexes 555
Cardiopulmonary reflexes 555
Central regulation of cardiovascular reflexes 555
Regulation of the baroreceptor reflex 555
Long-term control of blood pressure 556
Vasopressin 556
Angiotensin II 556
Aldosterone 556
Atrial natriuretic peptide 556
Orthostasis 556
SHOCK 556
Hypovolaemic shock 557
Cardiogenic shock 558
Vasodilatory (septic) shock 559
Anaphylactic shock 559
Neurogenic shock 559
Homeostatic mechanisms activated by shock 559
Clinical signs of shock 560
Decompensated shock and multi-organ failure 560
Cellular damage in shock 560
Treatment of shock 560
Supportive therapy 561
Fluid replacement 561
Sympathomimetic drug treatment 561
Prognosis in shock 562
HYPERTENSION 562
Diagnosis of hypertension 562
Aetiology of hypertension 562
Pathophysiology of hypertension 562
Secondary hypertension 563
Hypertension due to chronic kidney disease 563
Renovascular hypertension 563
Endocrine causes of hypertension 563
Drug-induced hypertension 564
Coarctation of the aorta 564
Pregnancy-induced hypertension 564
Malignant hypertension 564
Treatment of hypertension 565
Resistant hypertension 565
Chapter 12: Haematology 567
THE HAEMOPOIETIC SYSTEM 567
BLOOD AND ITS CONSTITUENTS 567
Blood plasma 567
Blood cells 567
Red cells (erythrocytes) 567
White blood cells (leucocytes) 568
Neutrophils 568
Monocytes and macrophages 569
Eosinophils 569
Basophils 569
Lymphocytes 569
Platelets 569
STEM CELLS AND THEIR ROLE IN HAEMOPOIESIS 570
BLOOD CELL PRODUCTION AND THE BONE MARROW MICROENVIRONMENT 570
Regulation of haemopoiesis 570
The bone marrow stroma 570
Growth factors 570
Haemopoietic receptors 571
RED CELLS 571
TRANSCRIPTION FACTORS IN ERYTHROPOIESIS 571
Tal-1/SCL 571
Rbtn2/LMO2 571
GATA-2 571
GATA-1 571
GROWTH FACTORS IN ERYTHROPOIESIS 571
Erythropoietin controls the red cell mass 571
Epo production involves a negative feedback loop 572
STROMAL MOLECULES IN ERYTHROPOIESIS 572
Other hormones that influence haemoglobin production 572
Red cell production during life 572
TRANSPORT OF OXYGEN BY HAEMOGLOBIN 573
The oxygen dissociation curve 573
Role of acid in oxygen release 574
Role of 2,3-DPG in oxygen release from haemoglobin 574
TRANSPORT OF CARBON DIOXIDE 574
THE RED CELL MEMBRANE 575
Spectrin 575
HAEMOGLOBIN 575
Coordinating haemoglobin production throughout life 575
RED CELL ENZYMES ARE REQUIRED TO MAINTAIN RED CELL COMPONENTS 576
Glucose is the main source of red cell energy 576
MAINTENANCE AND RECYCLING OF RED CELLS 576
Fate of old red cells 576
Recycling of red cell components 576
ANAEMIAS 576
General features of anaemia 576
Physiological adaptations to anaemia 577
Tissues and perfusion 577
Cardiovascular system 577
Classification of anaemia 578
1) Using the mean cell volume (MCV) 578
2) Acquired or inherited 578
Acquired anaemias due to deficiencies 578
Iron deficiency 578
Iron metabolism 578
Iron loss 579
Iron homeostasis: regulation of ferritin and transferrin receptor levels 579
Causes of iron deficiency 580
Laboratory findings in iron deficiency 580
Megaloblastic anaemia 580
Why are vitamins B 12 and folate important? 580
Vitamin B 12 (cobalamin, Cbl) 581
Causes of vitamin B 12 deficiency 581
Folate 581
Causes of folate deficiency 581
Laboratory findings in B 12 and folate deficiency 581
Acquired anaemias due to blood loss 582
Acute blood loss 582
Chronic blood loss 582
Acquired anaemias due to chronic disease 582
Anaemia of chronic disease (ACD) 582
Mechanism of ACD 582
Diagnosis of ACD 583
Anaemias due to haemolysis 583
Acquired autoimmune haemolytic anaemia (AIHA) 583
Laboratory findings in AIHA 585
Other acquired anaemias 585
Non-immune haemolytic anaemias 585
Mechanical red cell fragmentation 585
Marrow infiltration 585
Marrow failure 585
Rare inherited anaemias 585
Inherited anaemias 586
Red cell membrane disorders 586
Hereditary spherocytosis 586
Red cell enzyme disorders 586
Glucose-6-phosphate dehydrogenase deficiency 586
Haemoglobin disorders 587
Sickle cell disease 587
Elevated foetal haemoglobin levels are beneficial 587
Precipitants of sickle cell disease 587
Laboratory findings in sickle cell disease 587
The thalassaemias 587
α Thalassaemia 588
β Thalassaemia 588
Laboratory findings in the thalassaemias 589
ONCOGENESIS AND DISORDERS OF BLOOD CELL PRODUCTION 589
NORMAL BLOOD PRODUCTION RELIES ON COORDINATED GENE EXPRESSION 590
ONCOGENESIS 590
The search for oncogenes in human blood disease 590
Oncogenes and tumour suppressor genes 590
Oncogenes 590
Mutations 590
Chromosome translocations 590
Viral activation 590
Tumour suppressor genes 590
THE LYMPHOID SYSTEM 590
Primary lymphoid tissues 591
Secondary lymphoid tissues 591
MYELOPROLIFERATIVE DISEASES 591
The myeloproliferative diseases 591
Polycythaemia 591
Polycythaemia rubra vera 592
Essential thrombocythaemia 592
Myelofibrosis 592
MYELODYSPLASTIC SYNDROMES 592
LEUKAEMIAS 592
The acute leukaemias 592
Incidence and causes 593
Laboratory findings 593
Chronic leukaemias 593
Chronic myeloid leukaemia 593
Chronic lymphocytic leukaemia (CLL) 593
Laboratory findings 595
LYMPHOMAS 595
Non-Hodgkin lymphoma (NHL) 595
Chromosome translocations 595
Viral infection 595
Other implicated factors 595
Hodgkin disease 595
PLASMA CELL DISORDERS 596
Multiple myeloma 596
Clinical feature of multiple myeloma 596
Laboratory features of multiple myeloma 596
HAEMOSTASIS AND THROMBOSIS 596
NORMAL HAEMOSTATIC MECHANISMS 596
The role of the endothelium and platelets in the maintenance of haemostasis 597
Coagulation cascade 598
The intrinsic pathway 598
The extrinsic pathway 598
The common pathway 598
Natural anticoagulants are required to maintain the balance 599
The fibrinolytic system 599
Clinical consequences of fibrin degradation products 599
Plasminogen activators: tissue and urinary plasminogen activator 599
Fibrinolysis inhibitors 600
Assessment of the coagulation system 600
Full blood count and film 600
The bleeding time 600
Coagulation tests 600
COAGULATION FACTOR DISORDERS 601
Inherited disorders 601
Haemophilia A 601
Haemophilia B (Christmas disease) 601
Clinical and diagnostic features of haemophilia 601
Von Willebrand disease 601
Inherited platelet disorders 602
Acquired disorders 602
THE THROMBOCYTOPENIAS 602
Thrombocytopenia caused by impaired platelet production 602
Thrombocytopenia caused by increased platelet destruction 602
Non-immune causes of thrombocytopenia 602
Disseminated intravascular coagulation 602
Thrombocytopenia due to an altered distribution, or dilution 602
Immune causes of thrombocytopenia 602
Immune thrombocytopenic purpura 603
Heparin-induced thrombocytopenia 603
THE THROMBOPHILIAS 603
The inherited thrombophilias 603
Protein C deficiency 603
Protein S deficiency 603
Activated protein C resistance 603
The acquired thrombophilias 603
Anti-phospholipid syndrome 604
Lupus anticoagulant 604
Anti-cardiolipin antibody 604
BLOOD GROUPS AND TRANSFUSION MEDICINE 604
DEFINITION OF A BLOOD GROUP 604
BLOOD GROUP ANTIGENS 604
ANTIBODY PRODUCTION 604
BLOOD GROUP SYSTEMS IN TRANSFUSION MEDICINE 604
The ABO system 604
ABO antigens 604
Changes in blood groups 606
The Rhesus system 606
Production of antibodies to blood group antigens 606
ABO blood group system antibodies 606
Rh blood group antibodies 607
Other blood group systems 607
Kell 607
Duffy 608
I/i 608
Platelet antigens 608
BLOOD TRANSFUSION 608
Guidelines for safe transfusion 608
Management of the blood transfusion process 608
Transfusion reactions 609
Tests used in transfusion medicine 609
Blood grouping 609
The antibody screen 609
The antiglobulin test 610
The cross-match (compatibility test) 610
NON-RED-CELL TRANSFUSION 610
Platelet transfusion 610
White cell transfusion 611
Frozen plasma and plasma concentrate transfusion 611
Chapter 13: The respiratory system 613
INTRODUCTION 613
EPIDEMIOLOGY OF RESPIRATORY DISEASE AND ITS SOCIAL IMPACT 614
SMOKE AND RESPIRATORY DISEASE 614
CLASSIFICATION OF COMMON RESPIRATORY DISEASES 614
OBSTRUCTIVE PULMONARY DISEASE 615
RESTRICTIVE PULMONARY DISEASE 615
ANATOMY OF THE RESPIRATORY SYSTEM 615
ANATOMY OF THE UPPER AIRWAYS ( Clinical box 13.4 and Information box 13.2) 616
Nasal cavity 616
Pharynx 617
Larynx 617
Trachea 617
GROSS ANATOMY OF THE LUNGS 617
The tracheobronchial tree 617
Breath sounds 618
Vocal resonance 619
Specialised tracheobronchial cells 619
Cilia and macrophages 619
Goblet cells and the mucociliary escalator 619
Clara cells 619
The alveoli 619
The gas–blood barrier 620
Cell types at the alveolar level 621
Capillary endothelial cells 621
Type I alveolar cells 621
Type II alveolar cells 621
Macrophages 621
Collateral ventilation 621
The pleura 621
Pleurisy and other pleural conditions 621
Pulmonary lymphatics 622
Pulmonary oedema 622
ANATOMY OF THE PULMONARY CIRCULATION 623
Arteries 623
Veins 623
Right-to-left (arteriovenous) shunts 624
Pulmonary blood flow 624
Volume of blood in lungs 624
Pulmonary arterial and venous pressure 624
Pulmonary blood vessels 624
Variations in pulmonary blood flow 625
Effect of gravity on pulmonary blood flow 625
SURFACE ANATOMY OF THE RESPIRATORY SYSTEM 626
Larynx and trachea 626
Surface markings of the thorax 626
Anterior surface of the chest 626
Lateral surface of the chest 626
Posterior surface of the chest 626
The lungs and pleural cavity 627
MECHANICS OF BREATHING 627
THE DIAPHRAGM AND OTHER MUSCLES USED IN BREATHING 627
Inspiration 627
Expiration 628
PULMONARY PRESSURE CHANGES DURING VENTILATION 628
Intrapulmonary pressure 628
Intrapleural pressure 628
Maximal respiratory pressures 628
PULMONARY VENTILATION 629
Lung volumes and capacities 629
Dead space 629
Functional residual capacity 630
Measuring rates of airflow 630
Forced expiratory volume 630
Peak expiratory flow rate 631
Reversibility of airflow limitation 631
WORK OF BREATHING 631
Airway resistance 631
Asthma 633
Bronchoconstriction 633
Inflammation and secretion 634
Lung inflation and deflation 634
Pressure–volume relationship 634
Compliance 634
Surface tension 635
Flow-related airway collapse 635
Closing capacity and posture 636
PRINCIPLES OF GAS EXCHANGE 636
DIFFUSION 636
Pulmonary diffusion capacity 636
Measuring lung diffusion capacity – single breath CO testing (D L CO) 636
PARTIAL PRESSURES OF GASES IN AIR 637
PARTIAL PRESSURES OF GASES IN ALVEOLI AND BLOOD 637
CARRIAGE OF OXYGEN BY THE BLOOD 637
RESPIRATORY PIGMENTS 638
Oxygen dissociation curve 638
Haemoglobin 638
Myoglobin 638
CARRIAGE OF CARBON DIOXIDE BY THE BLOOD 639
CARBON DIOXIDE DISSOCIATION CURVE 639
DISTURBANCES OF ACID–BASE BALANCE 639
The four classes of acid–base disorder 640
Respiratory acidosis 640
Respiratory alkalosis 640
Metabolic acidosis 640
Metabolic alkalosis 640
MATCHING LUNG VENTILATION TO LUNG PERFUSION 640
VENTILATION–PERFUSION RATIO 641
Uneven perfusion 641
Uneven ventilation 641
Ventilation–perfusion mismatch 641
CONTROL OF BREATHING 642
THE RESPIRATORY CENTRE 642
RESPIRATORY RECEPTORS ( Clinical box 13.21) 642
Respiratory chemoreceptors 642
Central chemoreceptors 643
Peripheral chemoreceptors 643
Lung receptors 644
Pulmonary stretch receptors 644
Cough or lung-irritant receptors 644
Haemoptysis 644
J-receptors 644
Other receptors 644
Muscle stretch receptors 644
Joint proprioceptors 644
Baroreceptors 645
HIGHER CENTRE CONTROL OF BREATHING 645
ENERGY PRODUCTION AND OXYGEN CONSUMPTION 645
RESPIRATORY QUOTIENT AS AN INDICATION OF METABOLIC FUEL 645
METHODS FOR ESTIMATING ENERGY CONSUMPTION 645
Basal metabolic rate 645
CHALLENGES TO NORMAL RESPIRATION 646
EXERCISE 646
ALTITUDE 646
Physiological responses to high altitude 646
Acclimatisation to altitude 646
Mountain sickness 647
BREATH-HOLDING 647
Prolonging the held breath 647
DIVING 647
Effects of pressure in free diving 647
Effects of pressure during ascent from depth 647
Effects of pressure in deep diving 647
DIVER’S REFLEX 648
DROWNING 648
HIGH OXYGEN LEVELS 648
Neurological oxygen toxicity 648
Cellular oxygen toxicity 648
CARBON MONOXIDE POISONING 648
RESPIRATORY FAILURE 648
CAUSES OF RESPIRATORY FAILURE 648
Type I respiratory failure 649
Type II respiratory failure 649
Asthma 649
COPD 649
Emphysema 649
Clinical effects of respiratory failure 649
LUNG DEFENCES AGAINST INFECTION 650
THE UPPER AIRWAYS 650
CONDUCTING AIRWAYS 650
Mucins and ciliary action 650
Other factors 650
INNATE IMMUNITY 650
Destroying the invading organism 650
Defensins 651
Surfactant proteins 651
INFLAMMATORY RESPONSES 651
DEVELOPMENT OF THE LUNGS AND CHANGES IN THE NEWBORN 651
EARLY LUNG DEVELOPMENT 651
Embryonic phase 651
STAGES IN LUNG MATURATION 651
Pseudoglandular phase (6–16 weeks in utero) 651
Canalicular phase (16–24 weeks in utero) 651
Saccular phase (24 weeks in utero to birth) 651
Alveolar phase (32 weeks–8 years) 652
RESPIRATORY SYSTEM CHANGES AT NORMAL DELIVERY 653
RESPIRATORY DISTRESS SYNDROME OF THE NEWBORN 653
Chapter 14: The renal system 655
INTRODUCTION 655
FUNCTIONS OF THE KIDNEY 655
URINE VOLUME AND COMPOSITION 655
BALANCE OF FLUID INTAKE AND LOSS 656
RENAL FAILURE 656
ANATOMY OF THE KIDNEY 657
GROSS STRUCTURE 657
Renal pyramids 658
THE NEPHRON 659
The renal corpuscle (renal glomerulus) 659
The renal tubule 659
Proximal convoluted tubule 659
Loop of Henle 659
Distal convoluted tubule 659
Collecting ducts 659
RENAL VASCULATURE 659
Renal microvasculature 659
Peritubular capillaries 661
Glomerular filtration barrier 661
NERVE SUPPLY TO THE RENAL TRACT 662
DEVELOPMENT OF THE KIDNEY 662
Mesonephros 662
Metanephros 662
PERMANENT KIDNEY 662
Congenital renal agenesis 662
Polycystic kidney disease 663
RENAL FUNCTION 663
GLOMERULAR FILTRATION AND THE PRODUCTION OF PRIMARY URINE 664
Pore size and macromolecules 665
Filtration forces 665
Proteins 665
FUNCTIONS OF THE PROXIMAL CONVOLUTED TUBULE 665
Tight junctions 665
The sodium pump 667
Carrier proteins 667
Ion channels 667
Recovery of bicarbonate by the PCT 667
Water 667
Aquaporins 668
Peritubular capillaries 668
Sugars, amino acids and other small organic molecules 668
Facilitated carriers 668
Sodium and chloride 668
Secretion of organic anions and cations 668
Organic anion transport 668
Para-aminohippuric acid 669
PAH and drug dosage 669
Efflux transporters and drugs 669
Nephrotoxicity 670
Organic cation transport 670
RENAL FUNCTION TESTS 670
Blood and urine tests 670
Relative density of urine 670
Osmolality 670
Specific gravity 670
Refractometry 670
Dry chemistry 670
Analysing urine 670
Proteinuria 670
Renal handling of molecules 671
Renal clearance 672
Clearance of molecules that are only filtered 672
'Inulin’ clearance as an index of GFR 672
Creatinine clearance 672
Urea clearance 673
Current methods for measuring renal clearance (half-life) 673
Clearance of molecules that are filtered and reabsorbed 673
Clearance of molecules that are filtered and secreted 674
Use of clearance methods to assess renal function 674
Advanced clinical tests 674
RENAL CONTROL OF FLUID BALANCE 674
Vasopressin 674
Vasopressin release 674
Vasopressin receptors 674
Calculation of renal water excretion 677
Mechanism of urine concentration and dilution 678
Osmolarity gradient 678
Vasa recta and counter-current hypothesis 678
Transport properties of the loop of Henle 679
Water 679
Sodium and chloride 680
Counter-current mechanism 680
Urea 680
Vasa recta 680
The diluting segment and the DCT 680
Cortical collecting duct 680
RENAL CONTROL OF SODIUM BALANCE 680
Renal sodium handling 681
Sodium recovery 681
The PCT 681
The loop of Henle 681
The DCT 681
The collecting ducts 681
Control of GFR by the renal capillaries 681
Autoregulation 682
Glomerular–tubular balance 682
Receptors involved with sodium balance 682
Baroreceptors 682
The juxtaglomerular apparatus 682
Renin–angiotension–aldosterone system 683
Role of angiotensin II and Na + control 683
Aldosterone 683
Potassium 684
Autoregulation and the DCT 684
Tubulo-glomerular feedback 684
Na + balance summary 684
DIURETICS 684
Osmotic diuresis 684
Carbonic anhydrase inhibitors 684
The thiazide diuretics 685
Loop diuretics 685
Diuretics acting on the late distal tubule and the collecting ducts (K + sparing) 686
Amiloride and triamterene 686
Spironolactone 686
RENAL CONTROL OF ACID–BASE BALANCE 686
Hydrogen ions 686
Sources of H + ions 686
Cell metabolism produces ‘volatile’ H + ions 686
'Fixed’ H + ions 686
Sources of non-respiratory H + ions 686
Disease states 687
Acid–base balance is vital for life 687
Renal mechanisms of HCO3- control 687
HCO3- ions and pCO 2 687
Loop of Henle and HCO3- ions 687
The distal nephron 688
Renal buffers 688
Phosphate buffering 688
Ammonium synthesis 688
Abnormalities of acid–base balance (also see Clinical box 14.14) 689
THE URINARY TRACT 690
URETERS 690
Urinary tract obstruction 690
Congenital problems 691
GROSS STRUCTURE OF THE BLADDER 691
Maintenance of continence 691
Nerve supply 691
Bladder filling and tone 692
CONTROL OF MICTURITION 692
The micturition reflex 692
Renal tumours 692
Benign 692
Malignant 692
RENAL DISEASES 692
GENERAL CLASSIFICATION OF RENAL DISEASE 693
ONSET OF RENAL DISEASE 693
ACUTE KIDNEY INJURY 693
Acute tubular necrosis 694
Nephrotoxic agents 694
Drugs and the elderly 694
CHRONIC KIDNEY DISEASE 694
Causes of chronic kidney disease 695
Progression of chronic kidney disease 695
Chronic kidney disease and hypertension 695
Erythropoietin 695
Pharmacological renal damage and chronic renal failure 695
RENAL REPLACEMENT THERAPY 696
Chapter 15: The alimentary system 699
INTRODUCTION 699
BASIC FUNCTIONS AND STRUCTURE OF THE ALIMENTARY SYSTEM 699
BLOOD SUPPLY TO THE GASTROINTESTINAL TRACT 700
OVERVIEW OF DIGESTION AND ABSORPTION 701
PHYSICAL DIGESTION 701
CHEMICAL DIGESTION 701
Carbohydrate digestion 702
Protein digestion 702
Protein digestion in the stomach 702
Protein digestion in the small intestine 702
Fat digestion 702
ABSORPTION 702
General principles of absorption 703
Carbohydrate absorption 704
Glucose and galactose absorption 704
Fructose absorption 705
Protein absorption 705
Di- and tripeptide absorption 706
Amino acid absorption 706
Fat absorption 706
Bile salt absorption 707
Vitamins 707
Water-soluble vitamins 707
Vitamin B 12 707
Fat-soluble vitamins 707
Absorption of electrolytes and water 707
Pathways for electrolyte and water absorption 707
Calcium absorption 708
Iron absorption 708
Regulation of iron absorption 709
SURFACE ANATOMY OF THE ABDOMEN 709
ABDOMINAL REGIONS 710
Epigastric region 710
Umbilical region 710
Suprapubic (hypogastric) region 710
Left and right hypochondrium 710
Left and right lumbar region 711
Left and right iliac fossa (inguinal region) 711
QUADRANTS 711
MICROANATOMY OF THE GASTROINTESTINAL TRACT 711
INNERVATION OF THE ALIMENTARY CANAL 713
MOUTH 714
TEETH 714
TONGUE 714
MASTICATION 714
SALIVARY GLANDS 714
FUNCTIONS OF SALIVA 715
Lubrication 715
Protection 715
Digestion 715
COMPOSITION OF SALIVA 715
Organic constituents 716
Inorganic constituents 716
SECRETORY MECHANISMS 716
The salivon 716
Mechanisms of secretion of saliva 716
Stage one – the primary secretion 716
Stage two – modification of the primary secretion 716
Secretion of organic constituents 717
CONTROL OF SALIVARY SECRETION 717
Parasympathetic nervous system 718
Sympathetic nervous system 718
Intracellular messengers producing salivary secretion 718
PHARYNX AND OESOPHAGUS 718
SWALLOWING 718
Oral or voluntary phase 718
Pharyngeal phase 718
Oesophageal phase 719
STOMACH AND DUODENUM 719
ANATOMY OF THE STOMACH 719
Gastric and duodenal musculature 720
The gastric mucosa 721
CONTROL OF GASTRIC SECRETIONS 722
STIMULATION OF GASTRIC ACID SECRETION 722
Cephalic phase 722
Gastric phase 723
Intestinal phase 723
INHIBITION OF GASTRIC ACID SECRETION 723
Cephalic phase 724
Gastric phase 724
Intestinal phase 724
STIMULATION OF PEPSINOGEN SECRETION 724
CELLULAR MECHANISMS OF GASTRIC ACID SECRETION 724
Morphological changes in parietal cells ( Fig. 15.16) 724
Intracellular messenger for the action of acetylcholine, gastrin and histamine 725
Ion movements during acid secretion 726
Proton pump 726
Sodium pump 726
GASTRIC MUCOSAL PROTECTION 726
Peptic ulceration 727
GASTRIC MOTILITY 727
GASTRIC MUSCULATURE 727
ELECTRICAL AND CONTRACTILE ACTIVITY OF GASTRIC SMOOTH MUSCLE 727
GASTRIC MOTILITY DURING THE INTERDIGESTIVE PERIOD 728
GASTRIC MOTILITY DURING A MEAL 728
Receptive relaxation 728
Mixing of gastric contents 728
Gastric emptying 728
Gastric contents 728
Duodenal contents 729
Other factors 730
NAUSEA, RETCHING AND VOMITING 730
EXOCRINE PANCREAS 730
PANCREATIC ENZYMES 730
Mechanisms of enzyme secretion 731
Alkaline secretion 731
CONTROL OF PANCREATIC JUICE SECRETION 734
Cephalic phase 734
Gastric phase 734
Intestinal phase 734
Interactions between acetylcholine, cholecystokinin and secretin 734
Intracellular messengers for acetylcholine, cholecystokinin and secretin 734
Inhibition of pancreatic secretion 734
THE LIVER AND BILIARY SYSTEM 734
ANATOMY OF THE LIVER 735
Gross anatomy of the liver 735
Blood supply to the liver 735
Microanatomy of the liver 735
FUNCTIONS OF THE LIVER 737
The liver and carbohydrate metabolism 737
The liver and protein metabolism 737
The liver and lipid metabolism 737
The liver and red blood cells 738
Metabolism of bilirubin 738
The liver and bile production 738
Bile secretion 738
Cellular mechanisms of bile secretion 739
Bile-salt-dependent secretion 739
Bile-salt-independent flow 739
The liver and drug metabolism 739
Immunological functions of the liver 740
The liver and hormones 740
Storage function of the liver 740
SOME DISEASES OF THE LIVER 740
Hepatocellular disease 740
Some causes of hepatitis 741
Cirrhosis of the liver 741
Portal hypertension 741
Ascites 742
Porto-systemic encephalopathy 742
GALL BLADDER 742
Bile is concentrated in the gall bladder 743
Emptying of the gall bladder 743
Enterohepatic circulation of bile salts 743
SMALL INTESTINE 743
STRUCTURE OF THE SMALL INTESTINE 744
SMALL INTESTINAL FLUID SECRETION 744
SMALL INTESTINAL MOTILITY 745
Intestino-intestinal inhibitory reflex 745
Gastro-ileal reflex 745
LARGE INTESTINE 746
LARGE INTESTINAL FLUID SECRETION 746
MUSCULATURE OF THE LARGE INTESTINE 746
LARGE INTESTINAL MOTILITY 746
MOTILITY OF THE RECTUM AND ANAL CANAL 747
DEFECATION 747
Chapter 16: Diet and nutrition 749
INTRODUCTION 749
WORLDWIDE DIETARY PATTERNS AND FOOD GUIDES 750
FOOD GUIDES 750
FOOD LABELLING 750
DIETARY REFERENCE VALUES 751
NUTRITIONAL REQUIREMENTS 751
VARIATIONS IN NUTRITIONAL REQUIREMENTS 752
Preconception 752
Pregnancy 752
Lactation 753
Infancy 753
NUTRITIONAL STATUS 754
CLINICAL ASSESSMENT OF NUTRITIONAL STATUS 754
FOOD INTAKE 754
Detailed dietary assessment 754
'USUAL WEIGHT’ AND WEIGHT LOSS/GAIN 754
BODY MASS INDEX 755
CHILDREN 755
MEASURES OF BODY COMPOSITION: ADULTS 755
ESTIMATING BODY FAT 755
Skinfold thickness 755
Arm circumference 755
Waist circumference and waist/hip ratio 756
OTHER MEASUREMENTS OF NUTRITIONAL STATUS 756
PLASMA PROTEINS 756
VITAMIN STATUS 756
MUSCLE STRENGTH 756
IMMUNOLOGICAL SKIN TESTING 756
MALNUTRITION SCREENING TOOLS 756
ENERGY AND NITROGEN BALANCE 756
CONVERSION OF MACRONUTRIENTS TO ENERGY 756
ENERGY BALANCE 757
Basal metabolic rate (BMR) and resting energy expenditure 757
Total energy expenditure 757
Measuring energy expenditure 757
Total energy expenditure and the effect of physical activity 757
Energy expenditure during daily living 757
Estimates of energy consumption for different types of activity 758
Energy expenditure during exercise 758
Anaerobic carbohydrate metabolism 758
Aerobic carbohydrate metabolism 758
NITROGEN BALANCE AND PROTEIN REQUIREMENTS 759
Dietary nitrogen 759
Protein requirements 759
Essential and non-essential amino acids 759
Obligatory nitrogen loss 759
Minimum nitrogen requirement 759
Nitrogen excretion 759
Energy and protein metabolism during fasting and feeding 760
Fed state 760
Absorbed carbohydrate in the fed state 760
Absorbed fat in the fed state 761
Protein in the fed state 761
Fasted state 761
The need for glucose in the fasted state 761
Decreased insulin – fasting state 762
Fat in the fasted state 762
Prolonged fasting/starvation 762
Metabolic response to stress: sepsis and trauma 763
Energy metabolism during illness 763
Insulin and the inflammatory response 763
Protein metabolism in illness 763
Protein metabolism and acute phase response in illness 764
VITAMINS 765
Vitamins as coenzymes 765
Vitamins as antioxidants 765
WATER-SOLUBLE VITAMINS 765
The B vitamins 765
Vitamin B 1 (thiamine) 765
Vitamin B 2 (riboflavin) 766
Vitamin B 3 (niacin) 766
Vitamin B 6 (pyridoxine) 766
Biotin 766
Pantothenic acid 766
Folic acid 766
Vitamin B 12 (cobalamin) 766
Vitamin C (ascorbic acid) 766
FAT-SOLUBLE VITAMINS 766
Vitamin A 766
Vitamin D (calciferol) 767
Vitamin E (tocopherols) 767
Vitamin K 767
TRACE ELEMENTS: MINERALS 767
IRON 767
COPPER 767
ZINC 768
SELENIUM 768
MAGNESIUM 768
CALCIUM 768
PHOSPHATE 768
IODINE 768
FLUORIDE 769
WATER AND ELECTROLYTES 769
WATER 769
Daily water requirements 769
ELECTROLYTES 769
WATER AND ELECTROLYTE DEPLETION 769
Intravenous fluid replacement 769
WATER OVERLOAD 770
THE CONTROL OF FOOD INTAKE 771
APPETITE AND SATIETY 771
THE PHYSIOLOGICAL CONTROL OF EATING 771
PERIPHERAL SATIETY SIGNALS 771
Gastric distension and emptying 771
Balance of chemical contents in the gut 771
Peptides and hormones 772
PERIPHERAL HUNGER SIGNALS 772
Ghrelin 772
LONG-TERM SATIETY SIGNALS 772
Leptin 772
Insulin 773
Oestrogen 773
DIET AND DISEASE 773
ASSOCIATION BETWEEN DIET AND DISEASE 773
Reactive oxygen species or free radicals 773
Formation of reactive oxygen species 773
Body defence against cancer or invading bacteria 774
Oxidative stress 774
Defence against reactive oxygen species – antioxidants 774
DIET AND CARCINOGENESIS 774
Antioxidants 774
Obesity 775
NUTRITION AND CANCER TREATMENT 775
DIET AND CARDIOVASCULAR DISEASE 775
Dietary prevention of atherosclerosis 775
Atherogenesis 776
Homocysteine 776
Diet and hypertension 776
Dietary approach to hypertension 776
Cardioprotective diets 777
Some therapeutic diets 777
Dietary treatment of coeliac disease 777
Dietary restrictions in renal disease 777
Protein 777
Energy 777
Potassium 777
Phosphate 777
Sodium and fluid 777
Dietary control in diabetes mellitus 777
Exercise in diabetes 778
Lipid lowering 778
Artificial nutrition 778
Enteral nutrition 778
Complications of enteral feeding 778
Parenteral nutrition 778
MALNUTRITION 779
Malnutrition and disease states 779
Diagnosis of malnutrition 779
Refeeding syndrome 779
Avoidance of refeeding syndrome 780
OBESITY 780
Aetiology of obesity 781
Psychogenic factors 781
Environmental factors and exercise 781
Treatment of obesity 782
Dietary management 782
A psychological model for dietary modification 782
Pharmacological management 783
Appetite suppression 783
Inhibition of fat absorption 783
Surgical management 783
Increasing physical activity 784
Prevention of obesity 784
Index 785