Tobacco Use

·         The use of tobacco products, including cigarettes, cigars, pipes, chewing tobacco and snuff, is associated with more mortality and morbidity than any other personal, environmental or occupational exposure

·         Tobacco smoke contains more than 4,000 compounds including 43 known carcinogens

·         The greatest number of deaths attributable to cigarette smoking are due to lung cancer, ischemic heart disease, and chronic obstructive lung disease

·         Lung cancer is caused by multiple carcinogens and promoters in cigarette smoke

·         Cellular changes are dose related and the incidence of lung cancer is directly related to the number of cigarettes smoked

·         Smoking cessation reduces but does not completely eliminate the risk of lung cancer

·         Cigarette smoking is a multiplicative risk factor with hypercholesterolemia and hypertension for the development of coronary artery disease and arteriosclerosis

·         It is also a multiplicative risk factor for acute Myocardial Infarction and stroke in women on oral contraceptives; Smoking cessation reduces but does not eliminate these effects

·         Tobacco smoke is synergistic with asbestos exposure and radon decay in causing lung cancer

·         Tobacco smoke exacerbates bronchitis, asthma, and pneumoconiosis

·         Tobacco smoke also increases prevalence of peptic ulcers

·         The fetus is especially vulnerable to maternal smoking

·         10 cigarettes per day can cause fetal hypoxia which results in low birth weight, prematurity, and increased incidence of spontaneous abortion as well as serious complications at the time of delivery

Air Pollution 

·         As you know from the news air pollution is a continuing problem especially in industrialized areas

·         Any organ can be effected by air pollution, the lungs are most vulnerable

·        Factors That Determine Lung Injury

·         Solubility in water: example: sulfur dioxide (SO,) dissolves readily in upper airway secretions and cause damage there

·         Particle size and airway anatomy: example: particles 1-5 micrometers are most dangerous; those larger unlikely to reach distal airways while smaller act as gases

·         Concentration and chemical reactivity

·         Duration of Exposure

·         Host Clearance Mechanisms

Pneumoconiosis

·         Pneumoconiosis is a term which originally was used to describe the non-neoplastic lung reaction to inhaled mineral dusts

·         The term now includes disease induced by organic as well as inorganic particulates and some experts include chemical fume and vapor induced lung diseases as pneumoconioses

·         The four most common mineral dust pneumoconioses result from exposure to:

1)       Coal dust

2)       Silica

3)       Asbestos

4)       Beryllium

·         The reaction of the lung to mineral dusts depends on: size, shape, solubility and reactivity of the particle

·        A unifying concept for the devilment of the lesions in all pneumoconiosis

·        Coal Dust:

·        Simple Coal Workers' Pneumoconiosis

·         Cellular accumulations of macrophages occur forming macules and nodules with little or no pulmonary dysfunction

·         Complicated Coal Workers' Pneumoconiosis

·         Occurs on a background of Simple CWP and generally requires years to develop

·         Marked fibrosis is manifest and pulmonary function is compromised

·        Caplan's Syndrome

·         Is defined as the coexistence of rheumatoid arthritis with a pneumoconiosis, leading to the development of distinctive nodular pulmonary lesions which develop rapidly

·         Also seen in asbestosis and silicosis

·         Lesions exhibit central necrosis surrounded by fibroblasts, macrophages and collagen

·        Coal Workers' Pneumoconiosis (CWP)

·         With PMF (Progressive Massive Fibrosis)  there is increased pulmonary dysfunction, pulmonary hypertension and cor pulmonale (right sided heart failure)

·         Increased TB in patients with CWP? cause or socioeconomic

·         Increased chronic bronchitis and emphysema independent of smoking and lung cancer with smoking

·        Asbestosis and Asbestos-Related Diseases

·         Epidemiologically, asbestosis exposure is linked to:

1)       interstitial fibrosis

2)       bronchogenic carcinoma

3)       pleural effusions

4)       localized fibrous plaques

5)       mesotheliomas

6)       laryngeal and perhaps other extrapulmonary neoplasms including colon cancer

·         The risk of bronchogenic carcinoma is increased about fivefold for asbestos workers and this is greatly increased with concomitant cigarette smoking

·         The risk of mesotheliomas (a rare tumor) is 1,000 fold greater in asbestos workers and this is not increased by concomitant cigarette smoking

·         The clinical findings in asbestosis are indistinguishable from those of CWP or any other diffuse interstitial lung disease

Alcohol Abuse

·         Ethanol is the most widely used and abused agent throughout the world * 15-20 million alcoholics in USA * Approx. 100,000 deaths per year

·         High blood alcohol levels produce inebriation and may produce coma, respiratory arrest and death

·         Ethanol is metabolized to acetaldehyde by alcohol dehydrogenase in the gastric mucosa and liver and by P-450 and catalase in the liver

·         The metabolism of ethanol is directly responsible for most of its toxic effects

·         The lesions and mechanisms of disease related to alcohol abuse are many

Drug Abuse

·         Drug abuse, addiction and overdose are major problems in the USA where over 2 million people are addicted to cocaine

·         Common drugs of abuse include: CNS depressants, CNS stimulants, narcotics and hallucinogens

Injury Related to Therapeutic Drug Use

·         Some common adverse drug reactions include: blood dyscrasias and cutaneous, cardiac, renal, pulmonary, hepatic, CNS and systemic reactions

·        Adverse Effects of Exogenous Estrogens 

·         Endometrial carcinoma: 3-6 fold increased risk after 5 yrs. ; more than 10 fold after 10 yrs. ; risk reduced when progestins are added

·         Breast carcinoma: increased risk is small and not influenced by addition of progestins

·         Thromboembolsim: synthetic estrogens stimulate production of coagulation factors, however estrogen not a statistical factor

·         Cardiovascular disease: Unopposed estrogens elevate HDLs and reduce LDLs while progestins; do just the opposite

·         40-50% decrease risk of ischemic heart disease in women taking unopposed estrogens and the addition of progestins does not alter benefit

·         Risk of strokes seems unaltered

·        Effects of Oral Contraceptives

·         Breast carcinoma: CONTROVERSIAL but appears as a slight increase in patients under 45 yrs. particularly nulliparous under 25 yrs. ; negligible in women over 45 yrs.

·         Endometrial cancer: no risk, in fact may protective

·         Cervical cancer: probably some risk but may be related to risky life style

·         Ovarian cancer: they protect against ovarian cancer with greater protection coming with longer usage

·         Thromboembolism: increase risk with older higher dosage estrogens (>50 micrograms); reduced with lower dosages; combinations with progestins reduced risk of acute MI but increased risk of venous thrombosis

·         Hypertension: All types cause a slight increase in blood pressure especially in older women with family history

·         Cardiovascular disease: Recent evidence seems to absolve oral contraceptives,  however smoking and pill use cause a 10 fold risk in myocardial infarctions

·         Hepatic adenoma: well-defined association especially in older women who have been on the pill for many years

·         Gallbladder disease: Slight risk with older formulations

·        Acetaminophen

·         Drug is ordinarily safe with large window between usual therapeutic dose (0.5 gm) and toxic dose (15-25 gm).

·         Can cause hepatic necrosis with large doses

·         Toxicity begins with nausea, vomiting, diarrhea and sometimes shock. Later, jaundice and with serious overdose, liver failure & occasionally renal & heart damage

·        Aspirin

·         Ingestion of as little as 2-4 gm by children or 10-30 gm by adults may be fatal

·         Respiratory alkalosis followed by metabolic acidosis which may prove fatal

·         Chronic salicylism is manifested by headache, dizziness, ringing in the ears, difficulty hearing, mental confusion, drowsiness, nausea, vomiting and diarrhea

·         Morphologic consequences of chronic aspirin toxicity is most often acute erosive gastritis which may lead to G1 bleeds and ulceration; petechial hemorrhages may appear

·         Mixtures of aspirin and acetaminophen taken over several years may cause renal papillary necrosis (analgesic nephropathy)

Injury by Non-therapeutic Toxic Agents

·        Carbon Monoxide

·         Colorless, odorless gas produced by brining gasoline, oil, wood, coal and natural gas; also in tobacco smoke

·         Ambient air should not exceed 9 pprn

·         Can reduce exercise capacity and aggravate myocardial ischemia

·         High levels can cause headaches, dizziness, loss of motor control and coma

·         Hemoglobin has approx. 200 fold greater affinity for CO than oxygen

·         Approx. 900 accidental death due to asphyxia and caused by indoor carbon monoxide pollution each year

·        Lead

·         Environmental sources are due to use of leaded gasoline, soil contaminated with exterior lead paint, water supply due to lead plumbing and house dust in homes with interior lead paint

·         Consumer may be exposed to lead-glazed ceramics, lead solder in cans, and illegally produced alcoholic beverages 

·         Inhalation is the most important route of occupational exposure

·         Absorbed lead is mainly taken up by bone and developing teeth (80-85%) with 5- 10% accumulating in the blood and the rest in the soft tissues

·         Leads toxicity related to:

·         High affinity for sulfhydryl groups: example: inhibits enzymes involved in heme biosynthesis and hence hypochromic anemia

·         Competition with calcium ions: example: thus stored in bone and interferes with nerve transmission and brain development

·         Inhibition of membrane-associated enzymes: example: inhibits sodium-potassium pumps resulting in renal damage and hypertension 

·         Impaired metabolism of 1,25-dihydroxyvitamin D: result vitamin D deficiency

Injury by Physical Agents

·        Mechanical Trauma

·         Mechanical forces may inflict damage in several ways and the type of injury depends on the type of object, amount of energy discharged and the tissues or organs that bear the impact

·         Soft tissues react similarly to mechanical forces and the patterns of injury may be summarized as:

·         Abrasion: wound produced by scraping or rubbing which results in the removal of only the superficial layer of tissue (skin/mucosa)

·         Contusion: or bruise is usually produced by a blunt object and is characterized by damage to blood vessels and extravasation of blood into tissues

·         Laceration: is a tear or disruptive stretching of tissue caused by force of a blunt object; lacerations usually have jagged, irregular edges

·         Incised wound: wound inflicted by a sharp instrument

·         Puncture wound: caused by long narrow instrument; penetrating and perforating

·        Thermal Injury

·         Bums cause approx. 5,000 deaths per year and many times that number of hospitalized patients

·         Clinical significance of bums depends on:

1)       depth of burn

2)       % of body surface involved

3)       possible presence of  internal injuries from inhalation of hot and toxic fumes

4)       promptness & efficacy of therapy

·        Electrical Injury

·         Injuries of two types:

1)       burns

2)       ventricular fibrillation or cardiac and respiratory center standstill resulting from disruption of normal electrical impulses

·         Electromagnetic fields associated with high-power lines: some studies have linked these to increased risk for cancer especially leukemia’s, lymphomas and CNS tumors

·        Ionizing Radiation

·         The primary target of ionizing radiation is DNA and understandably tissues with a  high rate of cell turnover, such as bone marrow and the GI mucosa, are extremely vulnerable to radiation

·         Other parameters determining whether injury will occur in a tissue include: rate of dose delivered, capacity of cells to repair the themselves and effect of oxygen

·        Effects on Organ Systems

·         Is depicted in the next slide but remember the hematopoietic and lymphoid systems are extremely susceptible to radiant injury

Nutritional Diseases

·         Food is essential for life, yet it contains numerous natural constituents and additives that may threaten human health

·         Additionally either over or under nutrition will effect the life and well-being of the individual

·         An adequate diet should provide:

1)       energy in the form of carbohydrates, fats and proteins

2)       essential amino acids and fatty acids to the used as building blocks for synthesis of structural and functional proteins and lipids; and vitamins and minerals, which functions as coenzymes or hormones or as important structural components

·         Common causes of undernutrition in the USA include:

1)       ignorance and poverty

2)       chronic alcoholism

3)       acute and chronic illnesses

4)       self- imposed dietary restrictions

·        Protein-Energy Malnutrition (PEM)

·         Severe PEM is a disastrous disease which is far too common in developing countries

·         PEM refers to a range of clinical syndromes and is obvious in its most severe forms

·         Children are the most common victims of PEM

·         A child whose weight falls to less than 80% of normal is considered malnourished

·         Marasmus

·         A child whose weight falls to 60% of the normal weight for his/her sex and age, the child is considered to have MARASMUS

·         A marasmus child suffers growth retardation and loss of muscle; the serum albumin levels are either normal or only slightly reduced; there is fat loss as well as muscle thus the extremities are emaciated

·         Additional Manifestations

·         Anemia

·         Manifestations of multivitamin deficiencies

·         Immune deficiency, particularly T cell-mediated immunity; patients thus usually have concurrent infections

·        Kwashiorkor

·         Occurs when protein deprivation is relatively greater than the reduction in total calories; is most common in Africa

·         Is a more severe form of malnutrition than marasmus

·        Clinical Manifestations

·         Hypoalbuminemia giving rise to generalized or dependent edema

·         Skin lesions: hyper-/hypo- pigmentation and desquamation; "flaky-paint" appearance

·         Hair changes: loss of hair, loss of hair color or alternating bands

·         Enlarged, fatty liver

·         Tendency to develop apathy, listlessness and loss of appetite

·         Defects in immunity and secondary infections

·        Anorexia Nervosa and Bulimia

·         Anorexia nervosa is self-induced starvation, resulting in marked weight loss

·         Bulimia is a condition in which the patient binges on food and then induces vomiting

·         These eating disorders are more common in previously healthy young women

·        Clinical Findings in Anorexia Nervosa

·         Clinical findings generally similar to PEM

·         Additionally, the effects on the endocrine system are prominent

·         Amenorrhea, decreased thyroid hormone release, cold intolerance, bradycardia, constipation, and changes in skin and hair are common; skin becomes dry and scaly and body hair is fine and pale

·         Bone density is decreased most likely owing to low estrogen levels • Anemia, lymphopenia, and hypoalbuminemia may occur

·         Cardiac arrhythmia and sudden death resulting from hypokalemia have occurred

·        Bulimia

·         Major medical complications include:

1)       electrolyte imbalances predisposing the patient to cardiac arrhythmia

2)       pulmonary aspiration of gastric contents

3)       esophageal and cardiac rupture

·         Menstrual irregularities are common but amenorrhea is less common than in anorexia nervosa as body wt. and hormone levels are more normal

·        Obesity

·         Obesity is an epidemic in the USA with approximately 25% of the population over the age of 20 yrs. being clinically obese

·         Obesity is a disorder of energy balance

·        Vitamin Deficiencies

·         Vitamin A (Retinol), B (Thiamine), B2 (Riboflavin),  B3 (Niacin), B6 (Pyridoxine), B12, C, D, E, K 

From: anupama sukhlecha <anupama_acad@...>
Subject: Re: [netrum] Environmental diseases in Afghanistan: Anupama
To: netrum@yahoogroups.com
Date: Friday, July 3, 2009, 11:24 AM

Dear Dr Bashaar, Noristan is really very beautiful. It could be made into a tourist destination ( without altering the natural flora and fauna). Anupama --- On Thu, 2/7/09, Mohammad Bashaar <bashaarulfat@ yahoo.com> wrote: From: Mohammad Bashaar <bashaarulfat@ yahoo.com> Subject: [netrum] Environmental diseases in Afghanistan: Anupama [4 Attachments] To: netrum@yahoogroups. com Date: Thursday, 2 July, 2009, 12:22 PM Dear Anupama, I concur and support your words, that not merely it is the problem in Afghanistan, it is a global and universal problem, but something has been done in other parts of the world to have better environment for existence. As everyone knows, that Afghanistan naturally is very beautiful, more of its part are mountainous with forests, from other side, it is not industrialized state, thus we are very pro to have good environment. But the 3 decades war ruined everything, and its needs hard efforts to overcome. Attached are some pictures from Noristan Province of Afghanistan, who is the real picture of natural environment. Best Regards   Mohammad Bashaar --- On Thu, 7/2/09, anupama sukhlecha <anupama_acad@ yahoo.co. in> wrote: