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Inhalants are gen- effects; they may also cause cerebral hem- erally classified into four categories: orrhage (stroke) buy cheap hyzaar 12.5mg line, hyperthermia (elevated • Aerosols body temperature) discount 50mg hyzaar visa, altered mental status discount hyzaar 12.5mg without a prescription, • Gases panic, and psychosis. Their use is now often concurrent A wide variety of substances are abused with the use of other drugs. One of the in this way, often because they are readily most powerful hallucinogens is LSD. For example, effects vary with the individual, the dose, commonly used inhalants are airplane and the environment in which the drug glue, typewriter correction fluid, marking pen- is used. Generally, the effects develop cils, industrial and household chemicals, Medical Consequences of Abuse of Other Drugs and Substances 219 gasoline, nitrites (poppers, snappers, or rush), ten to crimes committed to obtain drugs or and nitrous oxide. Sub- all age groups practice inhalant abuse, it stance abuse also has medical consequences. Drug-Related Illness Although the effects of inhalants are brief, they can be serious, especially with Dermatologic Complications prolonged or long-term use. Adverse ef- fects of inhalants vary according to the Many of the medical complications type of substance inhaled. Organic sol- related to drug abuse result from nonster- vents such as airplane glue can produce ile injections or from adulterants, rather cardiac arrhythmia, bone marrow depression, than from the drug itself. Abscess Prolonged use of nitrites is thought to suppress the immune system, increasing the Bacterial infection may cause pus to col- individual’s susceptibility to infection. In Nitrites are frequently used to enhance association with drug use, improper sexual pleasure; consequently, individuals cleansing of the skin before injection or the who use nitrites in this way and are also use of a nonsterile needle may lead to an exposed to human immunodeficiency abscess. Skin at the site becomes warm, red, virus (HIV) may be at greater risk for devel- swollen, and painful with a purulent (pus) oping HIV infection because of their sup- discharge. Skin around the area frequent- pressed immune system and subsequent ly becomes necrotic (dies). Treat- senses, driving during intoxication is haz- ment of an abscess consists of draining the ardous. Even though the effects of purulent material and debriding (remov- inhalants are brief, their use can result in ing) the area of dead tissue. No specific medical treat- usually prescribed, especially if individu- ment is usually indicated for inhalant als demonstrate systemic symptoms. An acute inflammation of the tissues without necrosis (tissue death) is called cellulitis. When associated with intra- MEDICAL CONSEQUENCES OF venous drug abuse, cellulitis is caused by ABUSE OF OTHER DRUGS AND the invasion of a variety of organisms or SUBSTANCES by irritation of the tissues from the drug itself. The tissue becomes red and tender, Substance abuse leads to psychological, and there may be adenopathy (swelling social, and vocational impairments and of- of lymph nodes). Treatment of cellulitis 220 CHAPTER 7 CONDITIONS RELATED TO SUBSTANCE USE depends on the cause. If the fibrous changes are extensive, they affect the oxygen-exchanging abili- Injections with nonsterile needles or in- ty of the lungs. Symptoms similar to those jections of drugs that have been contam- of emphysema may develop. Changes in inated by adulterants may leave needle lung elasticity can eventually result in pul- track scars. Injections cause a mild inflam- monary hypertension and subsequent heart matory reaction and, with subsequent failure. Injection of a drug into an artery ter 11 for a discussion of pulmonary hyper- instead of a vein can cause an extreme tension and heart failure. If not treated occur if organisms localize in the lung after properly, gangrene may develop, necessitat- the nonsterile injection of a substance.

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Greater trochanter of femur Fold of buttock Hamstring group of muscles Popliteal fossa FIGURE 10 discount 50mg hyzaar with amex. Care must be taken order hyzaar 50mg with visa, however purchase hyzaar 50mg on line, not to inject into the sci- EXTREMITY atic nerve. Thigh Objective 15 Identify various surface features of the The femur is the only bone of the thigh, but there are three buttock and lower extremity by observation or palpation. The anterior group of muscles, referred Objective 16 Discuss the clinical importance of the buttock, to as the quadriceps femoris, extends the knee joint when it is femoral triangle, popliteal fossa, ankle, and arches of the foot. The medial muscles are the adductors, and when contracted they draw the thigh medially. The “ham- strings” are positioned on the posterior aspect of the thigh Surface Anatomy (see fig. The tendinous Buttock attachments of the hamstrings can be palpated along the poste- rior aspect of the knee joint when it is flexed. The hamstrings or The superior borders of the buttocks, or gluteal region, are formed their attachments are often injured in athletic competition. It can be seen as a the natal cleft (gluteal cleft) extends vertically to separate the depression inferior to the location of the inguinal ligament on buttocks into two prominences, each formed by pads of fat and the anteromedial surface in the upper part of the thigh (see by the massive gluteal muscles. The major vessels of the lower extremity, as well as pated in the lower portion of each buttock. Hernias are frequent in the ischial tuberosities support the weight of the body. More important; the femoral triangle serves as an arte- standing, these processes are covered by the gluteal muscles. The inferior border of The greater trochanter of the femur can be palpated on the the gluteus maximus muscle forms the fold of the buttock. At the knee, the lateral and medial condyles of the femur and tibia can be buttock: O. Surface and Regional © The McGraw−Hill Anatomy, Sixth Edition Anatomy Companies, 2001 Chapter 10 Surface and Regional Anatomy 327 importance in setting fractures of the leg is knowing that the top Femoral triangle of the medial malleolus lies about 1. The heel is not part of the leg; rather, it is the posterior part of the calcaneus. It warrants mention with the leg, how- Adductor group ever, because of its functional relationship to it. The tendo of muscles calcaneus (tendon of Achilles) is the strong, cordlike tendon Rectus femoris m. The muscles forming the belly of the calf are the gastrocnemius and soleus. The superficial veins of the leg can be observed on many individuals (see fig. The great saphenous vein can be seen subcutaneously along the medial aspect of the leg. The less con- spicuous small saphenous vein drains the lateral surface of the Vastus medialis m. If these veins become excessively enlarged, they are called varicose veins. Shinsplints, proba- Patella bly the result of a stress fracture or periosteum damage of the tibia, is a common condition in runners. A fracture of one or both Lateral epicondyle malleoli is caused by a severe twisting of the ankle region. Skiing of femur fractures are generally caused by strong torsion forces on the body Medial epicondyle of the tibia or fibula. The structural features and surface anatomy of the foot are in- dicative of these functions.

It is believed that some of the endocrine cells develop as contrast purchase hyzaar 12.5 mg fast delivery, is derived from nonneural tissue (the same embryonic buds from pancreatic ductules and that others arise from neuroec- tissue that will form the epithelium over the roof of the mouth) purchase 50 mg hyzaar with mastercard. Adrenal Glands Thyroid Gland The adrenal glands begin development during the fifth week The thyroid gland is derived from endoderm and begins its devel- from two different germ layers buy hyzaar 50mg without a prescription. Each adrenal gland has an outer opment during the fourth week as a thickening in the floor of the part, or adrenal cortex, which develops from mesoderm, and an primitive pharynx. The thickening soon evaginates (outpouches) inner part, or adrenal medulla, which develops from neuroecto- downward as the thyroid diverticulum (exhibit II). The mesodermal ridge that forms the adrenal cortex is in roglossal duct connects the descending primordial thyroid tissue the same region from which the gonads develop. As the descent continues, the tongue starts to de- The neuroectodermal cells that form the adrenal medulla are velop, and the opening into the thyroglossal duct, called the fora- derived from the neural crest of the neural tube. By adrenal medulla is gradually encapsulated by the adrenal cortex, a the seventh week, the thyroid gland occupies a position immedi- process that continues into the fetal stage. The formation of the ately inferior to the larynx, surrounding the front and lateral sides adrenal gland is not completed until the end of the third year of age. Notice that the adrenal gland, like the pituitary, has a dual origin; part is neural and part is not. Like the pituitary, the adrenal cortex and adrenal medulla are in fact two different endocrine tis- Rathke’s pouch: from Martin H. Although they are located in the same organ, they secrete dif- foreman cecum: L. The placenta is also an endocrine gland; it secretes summarized in table 14. Endocrine System © The McGraw−Hill Anatomy, Sixth Edition Coordination Companies, 2001 EXHIBIT II The embryonic development of the thyroid gland. Detection of hCG in urine is an indication of pregnancy and is the basis of home 22. Describe the location of the pineal gland and the action of pregnancy tests. Endocrine System © The McGraw−Hill Anatomy, Sixth Edition Coordination Companies, 2001 480 Unit 5 Integration and Coordination Basal metabolism rate (BMR) and thyroid scans (see CLINICAL CONSIDERATIONS fig. Radiographs and electrocardiograms also may be helpful system and the consequences of glandular dysfunctions. Hypersecretion of an endocrine gland is generally Disorders of the Pituitary Gland caused by hyperplasia (increase in size) of the gland, whereas The pituitary is a remarkable gland. It simultaneously carries out hyposecretion of hormones is the consequence of a damaged or several functions, yet more than 90% of the gland must be de- atrophied gland. The diagnosis and treatment of endocrine problems can be difficult because of three complex physiological effects of Panhypopituitarism hormones. Total pituitary impairment, termed panhypopitu- Thus, the clinical symptoms obscure the source of the prob- itarism, brings about a progressive and general loss of hormonal lem. For example, the gonads stop functioning and the per- bolic problems because the primary action of hormones is to son suffers from amenorrhea (lack of menstruation) or aspermia regulate metabolism. The Common diagnostic methods will be discussed in this sec- thyroid and adrenals also eventually stop functioning. People tion, along with the more important endocrine disorders that af- with this condition and those who have had their pituitary sur- fect the major endocrine glands. Diagnosis of Endocrine Disorders Certain endocrine disorders affect the patient’s physical appearance Abnormal Growth Hormone Secretion and behavior; therefore, observation is very important in diagnosis.

The Hepatocytes play an extremely important role in the me- reduced complex combines with molecular oxygen to form an tabolism of drugs and xenobiotics—compounds that are oxygenated intermediate generic 12.5 mg hyzaar with mastercard. One atom of the molecular oxygen foreign to the body discount hyzaar 50mg visa, some of which are toxic discount hyzaar 12.5 mg fast delivery. The kidneys ultimately dispose of these substances, but for effective elimination, the drug or its metabolites must be made hydrophilic (polar, water-soluble). This is because re- absorption of a substance by the renal tubules is dependent on its hydrophobicity. The more hydrophobic (nonpolar, lipid-soluble) a substance is, the more likely it will be reab- sorbed. Many drugs and metabolites are hydrophobic, and the liver converts them into hydrophilic compounds. The Liver Converts Hydrophobic Drugs and Xenobiotics to Hydrophilic Compounds Two reactions (phase I and II), catalyzed by different en- zyme systems, are involved in the conversion of xenobi- otics and drugs into hydrophilic compounds. In phase I re- actions, the parent compound is biotransformed into more polar compounds by the introduction of one or more polar groups. The enzymes involved are mostly located in the smooth ER; some are located in the cytoplasm. For example, alcohol dehydrogenase is located Phase I reactions in the metabolism of FIGURE 28. CHAPTER 28 The Physiology of the Liver 517 volatile fatty acids), whereas cellulose is not well digested then combines with two H and two electrons to form water. Only a small amount of long-chain fatty 3 acids, bound to albumin, is transported by the portal blood; P450 -drug complex and is transferred from the cy- 3 the most is transported in intestinal lymph as triglyceride- tochrome P450 to the drug molecule. The drug product with an oxygen atom incorporated is released from the com- rich lipoproteins (chylomicrons). The cytochrome P450 released can then be recycled for the oxidation of other drug molecules. In phase II reactions, the phase I reaction products un- The Liver Is Important in dergo conjugation with several compounds to render them Carbohydrate Metabolism more hydrophilic. Glucuronic acid is the substance most The liver is extremely important in maintaining an ade- commonly used for conjugation, and the enzymes involved quate supply of nutrients for cell metabolism and regulating are the glucuronyltransferases. Glucose is taken up by hepatocytes by a facilitated carrier-mediated process Aging, Nutrition, and Genetics and is converted to glucose 6-phosphate and then UDP- Influence Drug Metabolism glucose. UDP-glucose can be used for glycogen synthesis, The enzyme systems in phase I and II reactions are age-de- or glycogenesis. These systems are poorly developed in is the major precursor of glycogen. However, recent evi- human newborns because their ability to metabolize dence seems to indicate that the lactate in blood (from the any given drug is lower than that of adults. Older adults also peripheral metabolism of glucose) is also a major precursor have a lower capacity than young adults to metabolize drugs. Insufficient protein in the diet to Glycogen is the main carbohydrate store in the liver, and sustain normal growth results in the production of fewer of may amount to as much as 7 to 10% of the weight of a nor- the enzymes involved in drug metabolism. The glycogen molecule resembles a tree It is well known that drug-metabolizing enzymes can be with many branches (see Fig. Glucose units are linked induced by certain factors, such as polycyclic aromatic hy- via -1,4- (to form a straight chain) or -1,6 (to form a drocarbons. Persons who smoke inhale polycyclic aromatic branched chain) glycosidic bonds. The advantage of such a hydrocarbons, increasing the metabolism of certain drugs, configuration is that the glycogen chain can be broken down such as caffeine. Briefly, drug me- During fasting, glycogen is broken down by glyco- tabolism by the liver can be controlled by a single gene or genolysis.

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