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mechanically ventilated patients, biotrauma, the immune
system and sepsis, fluid and electrolyte imbalances associ-
ated with trauma, effects of endotoxin and cyclic nucleo-
tides on lung glucose oxidation, pathophysiology update
for practicing nurses, and oxidative stress in critical illness
and therapeutic strategies.
Diane Klein passed away in July of 2017, just as this book, on
which she had worked for almost 10 years, was going to press.
This book would not have existed if not for Diane’s interest and
hard work. Matthew Sorenson, Laurie Quinn, and the staff at
Pearson are grateful for Diane’s contributions and commitment
to this project.

Thank You
Our appreciation first and foremost goes to Pamela Fuller for be- Neftali Cabezudo, PhD, RN-BC
lieving in this project. Without the editorial skill and patience of VA Program Co-Director & Faculty, VANAP USF
Laura Horowitz, this project would not have seen final fruition. Nursing Education & Professional Development
We would be remiss if we did not acknowledge the valuable work VA Northern California Health Care System
of the contributors who provided time, energy, and depth to this Mather, California
work. The feedback of the reviewers was also crucial in shaping
Marcy Caplin, PhD, RN, CNE
this book. Finally, thanks go to the students in our classrooms
RN/BSN & Graduate Nurse Educator Programs
whose energy, questions, and drive for knowledge provided the
Kent State University
genesis of this project.
Kent, Ohio
Matthew Sorenson
Laurie Quinn Margaret-Ann Carno, PhD, MBA, MJ, RN,
Diane Klein CPNP,D, ABSM, FAAN
Professor of Clinical Nursing and Pediatrics
School of Nursing
University of Rochester

Contributors Rochester, New York

Patricia Caudle, DNSc, CNM, FNP-BC
Michael P. Adams, PhD Associate Professor
Adjunct Professor of Biological Sciences Frontier Nursing University
Pasco-Hernando State College Hyden, Kentucky
Hillsborough Community College
Formerly Dean of Health Professions Will Chapleau, EMT-P, RN, TNS
Pasco-Hernando State College Director of Performance Improvement
New Port Richey, Florida American College of Surgeons
Chicago, Illinois
Omar AL-Rawajfah, PhD, RN
Dean, Faculty of Nursing Claire DeCristofaro, MD
AL AL-Bayt University Clinical Assistant Professor, DNP Program
Mafraq, Jordan The Medical University of South Carolina
Charleston, South Carolina
Kyle T. Bergan, DNP, MS, RN, EMT-B, CEN
Clinical Adjunct Faculty Suzanne DeYoung, MSN, DNP
DePaul University Assistant Professor
Chicago, Illinois Greenville Technical College
Staff Nurse, Emergency Department Greenville, South Carolina
West Suburban Medical Center Carolyn J. Driscoll, PhD RN FNP-C
Oak Park, Illinois Nurse Practitioner
Jean K. Berry, PhD, APN Hepatology Section
Clinical Associate Professor Emerita Division of Gastroenterology, Hepatology, and Nutrition
University of Illinois Virginia Commonwealth University Health System
College of Nursing, Richmond, Virginia
Department of Biobehavioral Health Science Hon-Vu Q. Duong, MD
Chicago Illinois Clinical Instructor of Ophthalmology
Linda Blevins, DNP, MFA, ELS, RN Westfield Eye Center
Board-Certified Editor in the Life Sciences Las Vegas, Nevada
President, Charis Communications LLC Senior Lecturer of Neurosciences, Anatomy & Physiology
Springboro, Ohio Nevada State College
Henderson, Nevada
Adam M. Boise, MS, APRN
Concord Surgical Associates
Concord Hospital
Concord, New Hampshire

iv
Julie Eggert, PhD, GNP-BC, AGN-BC, AOCN, FAAN Art Hsieh, MA, NRP
Professor and Coordinator, Healthcare Genetics Emergency Care Program
Doctoral Program Santa Rosa Junior College
Mary Cox Professor Santa Rosa, California
Clemson University
Immaculata Igbo, PhD, MSc
Clemson, South Carolina
Professor
Jennifer S. Eisenstein, DNP, APRN, FNP-C Pathophysiology & Pharmacology
Nurse Practitioner Prairie View A&M University – College of Nursing
The Eisenstein Clinic Houston, Texas
Arlington Heights, Illinois
Linda Janusek, PhD, RN, FAAN
Mary Alice Estes, RN, MSN, CNE Professor
Instructor - Associate Degree Nursing Niehoff Endowed Chair for Research
Alvin Community College Department of Health Promotion
Alvin, Texas Loyola University Chicago
Maywood, Illinois
Sarah Schwarz Farabi, PhD, RN
Postdoctoral Fellow Rita W. Kaspar, PhD, RN, CNP
University of Colorado, School of Medicine Columbus, Ohio
Denver, Colorado
Linda J. Keilman, DNP, GNP-BC, FAANP
Katherina Fontanilla, DNP, RN Associate Professor
Nursing Instructor Gerontological Nurse Practitioner
College of Southern Nevada Michigan State University
Henderson, Nevada College of Nursing
East Lansing, Michigan
Sarah Gabua, DNP, RN, CNE
Nursing Instructor Amy Mitchell Kennedy, MSN, RN
Aspen University Nursing Content Manager
Denver, Colorado Newport News, Virginia
Lisa Gaston, MSc, ACNP Vicki Keough, PhD, APRN-BC, ACNP, FAAN
Manager, Clinical Nurse Consultant Dean and Professor
Celgene Marcella Niehoff School of Nursing
Melrose Park, Illinois Loyola University Chicago
Maywood, Illinois
Matthew W. Gifford, OD
Red Eye Eyewear Joanne Kouba, PhD, RDN
Chicago, Illinois Associate Professor
Marcella Niehoff School of Nursing
Eileen D. Hacker, PhD
Loyola University Chicago
Associate Professor Emerita of
Maywood, Illinois
Biobehavioral Health Science
University of Illinois at Chicago Susan Krawczyk, CRNA, DNP
Chicago, Illinois NorthShore University Health System
School of Nurse Anesthesia
Rebecca Hernandez, MSN, APRN, FNP-BC
Park Ridge, Illinois
Clinical Assistant Professor
School of Nursing Bhuma Krishnamachari, PhD
The University of Texas – Rio Grande Valley Assistant Dean of Research
Edinburg, Texas New York Institute of Technology College of Osteopathic
Medicine
Jeanne B. Hewitt, PhD, RN
Glen Head, New York
Associate Professor, College of Nursing
Director, Community Outreach and Engagement Core Christina M. Lattner, MSN Ed, ECRN,
Children’s Environmental Health Sciences Core Center AGNP-C, ­ANP-BC, RN-BC
University of Wisconsin Assistant Clinical Professor
Milwaukee, Wisconsin School of Nursing, College of Science and Health
DePaul University
Karen Hill, RN, BS, MN, PhD
Chicago, Illinois
Associate Professor
Southeastern Louisiana University Kathy Lauer, PhD, RN
Hammond, Louisiana Assistant Professor
College of Nursing
Barbara J. Holtzclaw, PhD, RN, FAAN
Rush University
Professor
Chicago, Illinois
Associate Dean for Research
Earl and Fran Ziegler College of Nursing
University of Oklahoma Health Sciences
Oklahoma City, Oklahoma

v
MariJo Letizia, PhD, APN/ANP-BC, FAANP Matthew Pastore, MS, LGC
Professor Genetic Counselor Lead
School of Nursing Clinical Assistant Professor of Pediatrics
Loyola University Chicago Nationwide Children’s Hospital
Maywood, Illinois Columbus, Ohio
Pamela F. Levin, PhD, APHN-BC Lynn Perkins, PhD, MSN, RN
Professor Nursing Faculty
College of Nursing Minneapolis Community and Technical College
Rush University Minneapolis, Minnesota
Chicago, Illinois
Tammy Poma, ANP-BC, CNN-NP
Laura Logan, MSN, RN, CCRN Nephrology Nurse Practitioner
Clinical Instructor University of Chicago
DeWitt School of Nursing Chicago, Illinois
Stephen F. Austin State University
Peter T. Pons, MD
Nacogdoches, Texas
PHTLS Associate Medical Director
Shari J. Lynn, MSN, RN Brighton, Colorado
Faculty
Jori Reigle, MS, RN
Department of Acute and Chronic Care
Lecturer/Adjunct Clinical Instructor
Johns Hopkins School of Nursing
School of Nursing
Baltimore, Maryland
University of Michigan
Dawna Martich, MSN, RN Flint, Michigan
Nursing Education Consultant
Judith L. Reishtein, PhD, MS, RN
Pittsburgh, Pennsylvania
Course Facilitator
Herbert L. Mathews, PhD College of New Rochelle
Department of Microbiology and Immunology The State University of New Jersey
Loyola University Chicago New Rochelle, New Jersey
Maywood, Illinois
Bernadette T. Roche, APN, CRNA, EdD
Patricia McCarthy, PhD Adjunct Associate Professor
Professor School of Nursing
Associate Chair & Program Director DePaul University
Department of Communication Disorders & Sciences Chicago, Illinois
Rush University
Laura Robbins-Frank, MSN, RNC, APN
Chicago, Illinois
Instructor
Daniel R. Mead, MSN, RN Marcella Niehoff School of Nursing
Student Nurse Practitioner- Internal Medicine/Geriatrics Loyola University Chicago
University of Cincinnati Chicago, Illinois
Charge Nurse-Telemetry
Kathryn Wirtz Rugen, PhD, FNP-BC, FAANP
Norwegian American Hospital
National Nurse Practitioner Consultant,
Adjunct Faculty
Centers of Excellence in Primary Care Education
DePaul University
Veterans Health Administration
Chicago, Illinois
Clinical Associate Professor
Elizabeth Moxley, PhD, RN University of Illinois at Chicago
Assistant Professor Chicago, Illinois
School of Nursing
Karen L. Saban, PhD, RN, APRN, CNRN, FAHA
DePaul University
Associate Professor
Chicago, Illinois
Associate Dean for Research
Cathy Marie Murks, RN, APN-NP Loyola University Chicago
Nurse Practitioner Maywood, Illinois
The University of Chicago Medicine
Deborah Saber, PhD, RN, CCRN-K
Chicago, Illinois
Assistant Professor
Martha Olson, DNP, MSN School of Nursing
Professor The University of Maine
Iowa Lakes Community College Orono, Maine
Emmetsburg, Iowa
Jessica Simmons, MSN, APN, FNP-C, CWON, DNC
Cynthia Parkman, PhD, RN Nurse Practitioner - Internal Medicine
Faculty Mercy Health
School of Health and Human Services -- Nursing Rockford, Illinois
National University
San Diego, California

vi
Marsha Snyder, PHD, PMHNP/CNS, BC, CADC Barbara E. Connell, RN, MSN
Clinical Associate Professor Program Director
University of Illinois Southwestern Community College
Chicago, Illinois Sylva, North Carolina
Angela Starkweather, PhD, RN, ACNP-BC, CNRN, FAAN Ann Crawford, PhD, RN, CNS, CEN, CPEN
Director, Center for Advancement in Managing Pain Professor, College of Nursing
Professor University of Mary Hardin-Baylor
University of Connecticut Belton, Texas
Storrs, Connecticut
Diane Daddario, DNP, ANP-C, ACNS-BC,
Marcia Stout, DNP, APN, FNP-C, CWON, CHSE
RN-BC, CMSRN
Adjunct Assistant Professor
Nursing Faculty
College of Health Professions
Pennsylvania State University
Rosalind Franklin University of Medicine and Science
University Park, Pennsylvania
North Chicago, Illinois
Amy K. Winston, AuD Jean E. DeMartinis, PhD, FNP-BC
Clinical Audiologist Associate Professor, College of Nursing
Assistant Professor University of Massachusetts
Department of Communication Disorders and Sciences Amherst, Massachusetts
Rush University Medical Center Fernande E. Deno, MSN, RN, CNE
Chicago, Illinois Nursing Instructor
Anoka-Ramsey Community College
Coon Rapids, Minnesota
Reviewers David J. Derrico, RN, MSN, CNE
Clinical Assistant Professor
Jean K. Berry, PhD, APN College of Nursing
Clinical Associate Professor Emerita
University of Florida
College of Nursing, Department of
Gainesville, Florida
Biobehavioral Health Science
University of Illinois Kirsty Digger, DNS, RN, CEN
Chicago, Illinois Associate Professor
School of Nursing
Sophia Beydoun, MSN, RN State University of New York
Nursing Faculty
Delhi, New York
Henry Ford College
Dearborn, Michigan Julie B. Doyle, EdD, RN
Faculty
Theresa Capriotti, DO, MSN, CRNP Geisinger Lewistown Hospital School of Nursing
Clinical Associate Professor
Lewistown, Pennsylvania
Villanova University
Villanova, Pennsylvania Tonya Eddy, PhD, RN
Assistant Professor
Hilary Carlson, RN, CPNP University of Central Missouri
Adjunct Clinical Instructor
Warrensburg, Missouri
School of Nursing
Columbia University Abimbola Farinde, PharmD, PhD
New York, New York Professor
Columbia Southern University
Margaret-Ann Carno, PhD, MBA, MJ, D, CPNP, Orange Beach, Alabama
ABSM, FAAN
Professor of Clinical Nursing and Pediatrics Rebecca A. Fountain, PhD, RN
School of Nursing Assistant Professor
University of Rochester University of Texas
Rochester, New York Tyler, Texas

Lori Ciafardoni, MSN/ED, RN Karla Hanson, MS, RN

Assistant Professor Instructor
State University of New York College of Nursing
Delhi, New York South Dakota State University
Sioux Falls, South Dakota
Anne Clayton, MS
Instructor Pamela G. Harrison, EdD, RN, CNE
College of Nursing Professor
Michigan State University Indiana Wesleyan University
East Lansing, Michigan Marion, Indiana

vii
Patty Hawley, MSED Janet Pinkelman, MSN, RNC-MNN
Instructor Professor of Nursing
Ferris State University Owens Community College
Big Rapids, Michigan Toledo, Ohio

Deborah Henry, PhD(c), RN Colleen M. Quinn, EdD, MSN, RN

Director of Nursing Professor
Blue Ridge Community College Broward College
Flat Rock, North Carolina Pembroke Pines, Florida

Barbara J. Holtzclaw, PhD, RN, FAAN Christine Recktenwald, MSN, RN

Professor / Associate Dean for Research Assistant Teaching Professor
University of Oklahoma Health Sciences Center University of Missouri
Earl and Fran Ziegler College of Nursing St. Louis, Missouri
Oklahoma City, Oklahoma
Jori Anne Reigle, BA, MS, RN
Arthur Hsieh, MA, NRP Lecturer/Adjunct Clinical Instructor
Paramedic Program Director School of Nursing
Santa Rosa Junior College University of Michigan
Windsor, California Flint, Michigan

Tara Rich, RN, MSN

Immaculata Ngozi Igbo, PhD, MSc, BSc Department Head
Professor
ADN/PN Program Director
College of Nursing
James Sprunt Community College
Prairie View A&M University
Kenansville, North Carolina
Houston, Texas
Carol Rizer, CRNA, DNP
Linda J. Keilman, DNP, GNP-BC, FAANP Assistant Professor
Associate Professor, College of Nursing The University of Texas
Michigan State University Tyler, Texas
East Lansing, Michigan
Janet Czermak Russell, DNP, APN-BC
Christine Kleckner, MA, MAN, RN Associate Professor of Nursing
Nursing Instructor Essex County College
Minneapolis Community and Technical College Newark, New Jersey
Minneapolis, Minnesota
Leighsa Sharoff, EdD, RN, PMHNP/CNS, AHN-BC
Barbara Lane, MSN, RN-BC Associate Professor
Program Coordinator Simulation Coordinator
School of Nursing Hunter College, City University of New York
Lincoln University New York, New York
Fort Leonard Wood, Missouri
Angela Starkweather, PhD, RN, ACNP-BC, CNRN, FAAN
Claire M. Leonard, PhD Director, Center for Advancement in Managing Pain
Professor, Biology Professor
Pre-Professional Advisor College Science & Health University of Connecticut
William Paterson University Storrs, Connecticut
Wayne, New Jersey Monica L. Tenhunen, DNP, RN, GNP-BC, ANP-C
Assistant Professor
Laura Logan, MSN, RN, CCRN
Department of Nursing
Clinical Instructor, DeWitt School of Nursing
Texas A&M University
Stephen F. Austin State University
Commerce, Texas
Nacogdoches, Texas
Kimberly Valich, MSN, RN
Terrence Miller, PhD, BS Assistant Professor
Biology Instructor Medical Surgical III Course Coordinator
Central Carolina Community College Department of Nursing
Sanford, North Carolina University of Saint Francis
Crown Point, Indiana
Jeremy Morse, PhD, ARNP, ANP-C
Director of Institutional Support & Donor Relations
Palm Beach Atlantic University
West Palm Beach, Florida

viii
Preface
Why We Wrote This Text
One of the challenges of teaching pathophysiology is help-
ing students understand the underlying concepts behind
the details. This book started with conversations on how
best to facilitate student understanding. We chose to create
this book as a way of fostering student learning and clini-
cal application.
The goals of Pathophysiology: Concepts of Human Dis-
ease are not only to provide students with the latest infor-
mation about pathophysiology that is relevant to clinical
practice, but also to empower students with competencies
that will endure throughout their nursing career. The ap-
proach we have taken to pathophysiology reflects the shift
in focus of healthcare from mainly understanding diseases
in their later stages to understanding risk factors and in-
terventions that can maintain good health and slow pro-
gression of disease in humans. For example, obesity, lack
of regular physical activity, and tobacco use are risk factors
for many common diseases such as diabetes mellitus, hy-
pertension, atherosclerosis, cancer, and asthma. Therefore,
we address risk behaviors that underlie leading causes of
morbidity and mortality. The focus of this book will en-
hance students’ understanding of disease processes and
their ability to explain and motivate patients in their care
to make therapeutic lifestyle changes.
Because of the rapid expansion of knowledge related
to pathophysiology and the content saturation experi-
enced by students in pathophysiology courses as well as
other nursing courses, the concept-based approach for or-
ganization of content is used Pathophysiology: Concepts of
Human Disease. This will help students to understand the
elements common to many disease states. An explanation
of the major physiologic concept addressed in each chapter
and a list of related concepts are provided in the Chapter
Overview of each chapter. The concepts we have used in-
clude the following:
The most extensive coverage for each concept ad-
dressed is given to conditions, risk factors, and behaviors
underlying the leading causes of morbidity and mortality.
This ensures that the most prevalent disorders are given
the most coverage. Identification of the conditions em-
phasized in the book is based on the Centers for Disease
Control and Prevention’s National Center for Health Sta-
tistics ( http://www.cdc.gov/nchs/index.htm) and the
national healthcare agenda as described in Healthy People
2020, published by the National Institutes of Health (NIH).
According to the NIH, “The leading health indicators re-
flect the major health concerns in the U.S. at the beginning
of the 21st century. The leading health indicators were se-
lected based on their importance as public health issues.”
Chapter content related to Healthy People 2020 focus areas
is highlighted in special boxes. Summary tables are used to
cover less common conditions.
The Cover
Starting with the cover, we emphasize the major focus of
this text: human beings. Pathophysiology does not occur
in a ­vacuum. Diseases, disorders, and syndromes occur in
­people—in individuals—and happen to neonates and infants,
to children and adolescents, to men and women, to older
adults. We call them “patients,” but they are people first: par-
ents, workers, students, lovers, siblings. The people shown on
the cover appear as patients in case studies in the text.
Connor Whelan
Connor Whelan is the infant son of parents who
are delighted to welcome him to the world. Con-
nor has Down syndrome and a congenital heart
defect. You will meet Connor in Chapter 25, “Car-
diac Structural Disorders.”

Acid–Base Balance Intracranial Regulation Angela Wang

Addiction Metabolism Jennifer Yang hears from her daughter’s school
Cellular Regulation Mobility that Angela should be tested for cognitive diffi-
Cognition Mood and Affect culties. The tests reveal possible toxins. You will
Comfort and Pain Nutrition and Digestion meet Jennifer and Angela in Chapter 3, “Environ-
Elimination Oxygenation mental Influences on Disease and Injury.”
Energy Balance Perfusion
Environment Reproduction
Fluid and Electrolyte Sensory Perception Matthew Horn
Balance Sexuality
Matthew Horn visits his healthcare provider for an
Hemostasis Stress and Coping annual checkup and complains that his right hand
Immunity Thermoregulation shakes when he’s just sitting around or watching
Infection Tissue Integrity TV. The shaking seems to disappear when he’s
Inflammation and Trauma actively using his hand. That, along with other
­Oxidative Stress symptoms, leads to a suspicion of Parkinson disease. You will meet
Matthew in Chapter 34, “Disorders Affecting Motor Function.”
ix

Irene Rollins
Irene Rollins, age 67, has ovarian cancer and
is near the end of her life. You will meet Irene in
Chapter 53, “Pathophysiology at the End of Life.”
The background image on the cover depicts a strain of the
influenza virus. Influenza is a contagious respiratory ill-
ness that can be mild, moderate, or deadly. Every year in
the United States, millions of people are infected with an
influenza virus, hundreds of thousands are hospitalized,
and tens of thousands die.
The individuals featured on our
cover highlight another important
aspect of Pathophysiology: Concepts of
Human Disease: We cover the lifespan
from birth to death. Information spe-
cific to infants and children, pregnant
women, and older adults is high-
lighted with icons to draw attention
to these specific populations.
Unit Structure
Pathophysiology: Concepts of Human Disease comprises 53
chapters divided into 15 units. The first four units provide
in-depth coverage of pathophysiologic mechanisms; the
rest of the units cover disorders, diseases, syndromes, and
injuries grouped by concept. On each unit opener there is
a visual that summarizes the content of the unit. These are
great tools for students to review the unit.
Unit I: Foundations of Pathophysiology
Unit I introduces students to the foundational concepts and
key components of the study of pathophysiology, including
everything from terminology to genetics and the influence
of the environment and stress on the human condition.
• Chapter 1: Introduction to the Basics of Patho-
physiology introduces the readers to the basics of
pathophysiology, including essential terminology, an
overview of health and illness, the leading indicators
of morbidity and mortality, and the importance of
x
evidence-based practice. It also provides an overview
of the structure of the chapters and features. With
the Human Genome Project ushering in an era of ge-
nomics and proteomics, healthcare providers require
increased understanding of the molecular biologic as-
pects of disease. This includes not only genetics, (e.g.,
inherited single-gene disorders), but also genomics,
which involves the interactions among many genes in
the human genome and the influence of environment
and lifestyle on gene expression.
• Chapter 2: Genetics, Genomics, and Epigenomics
addresses new knowledge and technologies related
to genomics being used in molecular diagnostic and
predisposition testing, as well as ways to increase cus-
tomization of preventive strategies and treatment regi-
mens for people with different phenotypes of many
acute and chronic conditions.
• Chapter 3: Environmental Health Influences on
­Disease and Injury covers environmental influences
on disease and injury. This topic is essential to patho-
physiology but is rarely included in textbooks. The
impact of the environment on the development of
disease in humans is enormous. This chapter covers
­everything from environmental hazard classifications
to the impact of the environment on assessing patients
to the pathophysiologic mechanisms underlying alter-
ations caused by environmental hazards.
• Chapter 4: Stress and Adaptation is another topic that
is underrepresented in other pathophysiology texts.
The effects of stress on physical and mental health are
a key component of human disease, and we cover it in
detail.
Unit II: Risks Underlying the Leading Causes of
­Morbidity and Mortality
Unit II stresses one of the major themes of Pathophysiology:
Concepts of Human Disease: health promotion and disease
prevention. Each of the major risk categories underlying
the leading causes of morbidity and mortality are ­covered
in this unit. Again, most other pathophysiology texts
­devote little or no coverage to these important topics.
• Chapter 5: Health Risks of Obesity and Physical
Inactivity
• Chapter 6: Risks Related to Substance Use Disorders
• Chapter 7: Risks Related to Sleep Alterations
Unit III: Fluid, Electrolyte, and Acid–Base Imbalances
Unit III covers the critical content of fluid and electrolyte
balance and acid–base balance, both of which are key fac-
tors in maintaining health.
• Chapter 8: Fluid and Electrolyte Imbalances
• Chapter 9: Acid–Base Imbalances
Units IV: Cell Injury, Inflammation, and Alterations of
Cell Growth and Regulation
Unit IV completes the foundational content by covering
cell injury and aging, inflammation, and neoplasia.
• Chapter 10: Mechanisms of Cell Injury and Aging
• Chapter 11: Inflammation
• Chapter 12: Neoplasia
Units V through XIV
In Units V through XIV (Chapters 13 – 49), we cover the
most prevalent disorders within each concept. We have
endeavored to cover the essential “need to know” content
and to keep “nice to know” material to a minimum in an
effort to combat the content saturation students face. Each
unit covers one or more concepts:
• Unit V: Infection and Disorders of Immunity
• Unit VI: Disorders of Oxygenation
• Unit VII: Disorders of Perfusion
• Unit VIII: Disorders of Mood and Cognition
• Unit IX: Disorders of Sensory Perception and
Thermoregulation
• Unit X: Disorders of Mobility
• Unit XI: Disorders of Endocrine Regulation
• Unit XII: Altered Tissue Integrity
• Unit XIII: Disorders of Digestion, Metabolism, and
Elimination
• Unit XIV: Disorders of Sexuality and Reproduction
Unit XV: Trauma and Multisystem Conditions
The last unit is unique to Pathophysiology: Concepts of Hu-
man Disease. Trauma is a major cause of morbidity and
mortality, but it is not covered in most other pathophysi-
ology texts. And our last chapter covers a phenomenon
that every patient and every nurse will experience. It is an
important topic that is often overlooked, but we have cov-
ered it in detail.
• Chapter 50: Mechanisms of Traumatic Injury
• Chapter 51: The Pathophysiology of Primary and
Secondary Traumatic Injury
• Chapter 52: Biologic, Chemical, and Radiologic
Agents of Disease
• Chapter 53: Pathophysiology at the End of Life
Unique Content
Pathophysiology: Concepts of Human Disease endeavors to
cover all topics related to human disease and injury, in-
cluding many that are rarely covered in pathophysiology
textbooks. Our unique chapters include:
• Chapter 3: Environmental Health Influences on
­Disease and Injury
• Chapter 6: Risks Related to Substance Use Disorders
• Chapter 7: Risks Related to Sleep Alterations
• Chapter 29: Emotional Regulation and Mood
• Chapter 30: Neurocognitive and Neurodevelopmental
Disorders
• Chapter 50: Mechanisms of Traumatic Injury
• Chapter 51: The Pathophysiology of Primary and
Secondary Traumatic Injury
• Chapter 52: Biologic, Chemical, and Radiologic
Agents of Disease
• Chapter 53: Pathophysiology at the End of Life.
In-Chapter Assessments
While developing this first edition of Pathophysiology: Con-
cepts of Human Disease, the authors – who are experienced
classroom teachers – wanted to build in many opportuni-
ties for students to assess their understanding of the ma-
terial as they are reading the content. Therefore, every
chapter includes the following sets of questions:
• Check Your Progress: Found at the end of each num-
bered section, these questions are designed to assess
students’ understanding of the content.
• Case Studies: Each part of each case study ends with
questions that cover the content in the section as well
as the content of the case study.
• Review Questions: These are NCLEX-style ques-
tions found at the end of each chapter. They are writ-
ten at the Understand, Apply, Analyze, and Evaluate
levels of Bloom’s taxonomy.
Answers to the Check Your Progress and Case Study ques-
tions are in the instructor resources for the print book and
are pop-ups in the student eText. Answers for the Review
Questions are in Appendix A in the print book and are
given, along with rationales, as the student answers the
questions in the eText.
xi
Chapter Guide 5.2 Etiology and Pathophysiology of Obesity 5
The chapters in Pathophysiology: Concepts of Human Disease have been developed
in a consistent structure to facilitate learning. Readers will see the same basic format used
throughout the book. Stretch
Cancer Arthritis
marks

Acanthosis Tissue Cellular

Inflammation Pancreatitis
nigricans Integrity Regulation
Chapter 5
Each chapter starts with Chapter Outline Health Risks of Obesity
and Learning Outcomes, a list of the
numbered sections in the chapter along and Physical Inactivity
Obstructive Jean Barry Metabolism/
with the learning outcome for each. Sleep
sleep apnea Mobility
Chapter Outline and Learning Outcomes
5.1 Chapter Overview and Case Studies 5.3 Health Risks of Obesity

Stroke Outline the global prevalence of, medical conditions

Key Terms and Abbreviations come
next. Each Key Term is included in the
associated with, and concepts related to obesity and
Outline the health risks and functional outcomes
associated with obesity.
Depression
physical inactivity. 5.4 Health Risks of Physical Inactivity
Perfusion
5.2 Etiology and Pathophysiology of Obesity
Oxygenation
Describe the etiology of obesity and outline the
Discuss the role of physical inactivity/activity in the
Mood and Affect
development and progression of chronic diseases and
pathophysiologic consequences, including chronic
diseases and metabolic syndrome.
recommendations for physical activity.

glossary at the endCoronary

of the print book and
Social stigma
is hyperlinked to heart diseasein the eText.
its definition KEY TERMS
The Abbreviations list contains the abbre- Adipocytes, 12
Anorexigenic, 5
Pulmonary Metabolic equivalent of task
(MET), 17
Physical fitness, 16
Polygenic, 7
viations specific to the topic that are usedHeart failure complications
Body mass index (BMI), 11
C-reactive protein, 10
Metabolic syndrome, 10
Monogenic, 7
Polymorphisms, 7
Reactive oxygen species (ROS), 8
throughout the chapter. Epigenetics, 8 Nonalcoholic fatty liver disease
(NAFLD), 13
Satiety, 6
Exercise, 16 Steatohepatitis, 13
Nonalcoholic steatohepatitis, 13
Hepatomegaly, 13 Steatosis, 13

Figure 5.2 ■ Concepts related to obesity and physical inactivity.

Obesity, 3
Hyperinsulinemia, 8 Visceral adiposity, 8
Orexigenic, 5
Insulin resistance, 8

ABBREVIATIONS
NPY—neuropeptide Y
andGLP-1—glucagon-like
CCK—cholecystokinin
a@MSH—a@melanocyte stimulating
hormone energy expenditure.
peptide-1 These processes involve a variety
POMC—pro-opiomelanocortin

Yashika Devon: Introduction

AGE—advanced glycosylation end HDL—high-density lipoprotein ROS—reactive oxygen species
product of chemical
IL-6—interleukin 6 mediators in
PYY—peptideboth
YY central and peripheral neu-
AGRP—agouti-related peptide T2D—type 2 diabetes mellitus
rochemical pathways (Figure 5.3 ■).
LDL—low-density lipoprotein
ARC—arcuate nucleus
Yashika Devon is a 16-year-old female who has BMI—body mass index
MC4R—melanocortin 4 receptor TNFa—tumor necrosis factor alpha
NAFLD—nonalcoholic fatty liver
gained approximately 40 pounds over the previous CART—cocaine and amphetamine-
regulated transcript peptide
disease

year. There is no apparent medical reason for her

weight gain (e.g., hypothyroidism); her vital signs
Regulation of Food Uptake
and all diagnostic and laboratory tests5.1are Chapter Overview and Case Studies 3
normal. She avoids partici-
2
The hypothalamus is the regulating center of appetite and
5.1 Chapter patingOverview
in physical activity and sports
depression. One ofprograms
4
atPeople
the goals of Healthy her2020high
promote good health through nutrition and maintenance
is to school for energy homeostasis. It receives input from all peripheral
a
and Case Studies variety of reasons, including self-consciousness
of a healthy body weight. about
There has been a dramatic increase in the prevalence
her physical M05B_SORE4783_01_SE_C05.indd 2
organs along with neural pathways from the brainstem. 6/7/17 2:19 PM

appearance.
One of the major Her
challenges of the 21st diet
century consists
is the pre-
vention and treatment of obesity. The World Health Orga-
largely
of obesity of
in the United high-fat
States foods,
over the last and
two decades.
Prevalence estimates of obesity in 2014 by state ranged
she rou- Appetite is stimulated and depressed within the arcuate
tinely
definessnacks all evening
or excessive onfrom
cookies, pretzels,
5.1 ■). The and chips. The first section in each chapter is Chap-
nization (WHO) obesity as abnormal
nucleus (ARC) of the hypothalamus. Appetite is stimu-
20 to 35% (Figure 5 total excess cost related
fat accumulation that may impair health.1,2 More than 33%
of U.S. adults and 17% of U.S. children are obese.3 Obe-
to the current prevalence of overweight and obesity
among adolescents is estimated to be $254 billion.6 This ter Overview and Case Studies. Here
1. Yashika has already been deemed obese. What would be the
sity is a factor in the development of a number of medi- number includes $208 billion in lost productivity second- lated
the by the introduce
authors activation of orexigenic
the topic, explain (appetite stimu-
cal conditions, including diabetes, cardiovascular disease ary to premature morbidity and mortality and $46 billion
first objective assessments necessary to create a baseline plan
(coronary artery disease, myocardial infarction, angina in direct medical costs.6 If current trends in the develop- lating) neurons expressing neuropeptide
the concepts related to each topic, and Y (NPY) and
pectoris, heart failure, stroke, hypertension, and atrial
of care for her?
fibrillation), metabolic syndrome, cancer, arthritis and
ment of overweight and obesity continue, the total health-
care costs related to obesity could reach $861–$957 billion
agouti-related protein (AGRP).
present the case studies that will be And it is depressed by
disability, gallbladder disease, acute pancreatitis, nonal- by 2030; this would account for 16–18% of U.S. health
2. Yashika is known to consume high-fat and high-calorie foods.
coholic fatty liver disease, pulmonary complications, and expenditures.6 threaded throughout
anorexigenic (appetitethe chapter.
depressing) neurons, which express
What is the recommended caloric intake for her age and life- a@melanocyte stimulating hormone (a@MSH) derived from
style
Healthy People (sedentary)?
2020
Nutrition and Weight Status
pro-opiomelanocortin (POMC), and cocaine and amphet-
The overall goal of the Nutrition and Weight Status objectives for
Healthy People 2020 is to promote health and reduce the risk of
Food Insecurity amine-regulated transcript peptide (CART). Neural affer-
Food insecurity is the inability to access sufficient safe, nutritious
chronic disease through healthful diets and the achievement and food that is needed to maintain a healthy and active life.2 ents and hormonal signals from the periphery signal to
Check Your Progress: Section 5.1
maintenance of healthy body weights. In addition, these objec-
tives emphasize that efforts to modify diet and weight should
address individual behaviors along with the policies and envi-
■
■
Eliminate very low food security among children.
Reduce household food insecurity and in doing so reduce
higher brainsections
The main center are
signals (e.g., those relaying reward) to
double-numbered
hunger.
ronments that support these behaviors. Those objectives are
1. How does the WorldFood
broadly divided into the following categories: HealthCare and
Worksite Settings, Weight Status, Food Insecurity, Food and
Health Organization define the term
and Nutrient Consumption
with a the
regulate matching
hedoniclearning outcome. At the
or pleasurable aspects of food inges-
tives are as follows: obesity?
Nutrient Consumption, and Iron Deficiency.1 The primary objec- ■Increase the contribution of fruits to the diets of the population
aged 2 years and older.
end
tion. of each
Signals section, there
regarding smell, Check
is asight, memory of food, and the
■ Increase the number of states with nutrition standards for
2. What
foods and beverages provided are somechildren
to preschool-aged of the in
Increase the variety and contribution of vegetables to the diets
major
■

health
of the population aged 2 problems
years and older. associated with Your
social Progress
context boxwhich
under that features
it wastwo or are also integrated.
eaten
child care. ■Increase the contribution of whole grains to the diets of the
three open-ended questions about the
■
obesity?
Increase the proportion of schools that offer nutritious foods population aged 2 years and older.
Additionally, hormones can modulate hypothalamic gene
and beverages outside of school meals. Reduce consumption of calories from solid fats and added
content just presented.
■
■ Increase the number of states that have state-level policies sugars in the population aged 2 years and older.
3.foodWhat
that incentivize are
retail outlets thefoods
to provide
encouraged by the Dietary Guidelines for Americans.
current
that are trends
■ in physical
Reduce consumption
2 years and older.
of saturated fatactivity
in the populationamong
aged U.S. expression and modulate energy intake. These hormones
■
adults and adolescents?
Increase the proportion of Americans who have access to a
food retail outlet that sells a variety of foods that are encour-
■Reduce consumption of sodium in the population aged 2 years
and older. and their roles in energy intake are described in Figure 5.4 ■
aged by the Dietary Guidelines for Americans. ■ Increase consumption of calcium in the population aged
Healthcare and Worksite Settings
2 years and older. and in the following sections.
■ Increase the proportion of primary care physicians who regu-
larly measure the body mass index of their patients. Iron Deficiency

Selected Adipose Tissue Hormones Involved

■ Increase the proportion of physician office visits that include ■ Reduce iron deficiency among young children and females of

5.2 Etiology
and
counseling or education related to nutrition or weight. childbearing age.
■ Increase the proportion of worksites that offer nutrition or ■ Reduce iron deficiency among pregnant females.

with Food Intake and Obesity

weight management classes or counseling.
Weight Status References

Pathophysiology of Obesity
■ Increase the proportion of adults who are at a healthy weight. 1. U.S. Department of Health and Human Services. (2017). Nutrition

xii
■
■
Reduce the proportion of adults who are obese.
Reduce the proportion of children and adolescents who are
and weight status. Available at http://www.healthypeople.gov/2020/
topics-objectives/topic/nutrition-and-weight-status
Leptin is an adipocyte-derived secretory product that pro-
■
considered obese.
Prevent inappropriate weight gain in youth and adults.
2. World Health Organization. (2014). Trade, foreign policy, diplomacy and
health. Available at http://www.who.int/trade/glossary/story028/en vides signals to the brain about the amount of adipose tissue
Energy homeostasis is regulated primarily by the brain, energy reserves. Leptin is synthesized in white adipocytes
 rderHCAP— because increased risk associated embolismwith age, gender, and smok-
tified.14 SCLC is slightly more PE—pulmonary
healthcare-associated
found in sputum. The systemic signs and symptoms include fatigue and
weight loss. Weight loss is considered a negative prognos-
tissueobtained at surgery.
can be lavaged (washed), brushed, or biopsied for infections of the lung
e risk factors pneumonia ing habits is taken into
PH—pulmonary account.
hypertension Becauseanalysis.
cells for cytologic of the extraordinarily aggressive nature of cussed in Chapter 26
mong HIV— women. 15
human immunodeficiency SCLC—smallLarge cell lungcell cancer carcinoma is a poorly differentiated epithelial
tic sign. ■■ Needle SCLC, surgeryrequires
aspiration typically 5.3
is not indicated.
insertion Health
of a thin needleRisks
Instead, treatment of Obesity 11
virus ■ ■ Presence of benign chronic lung conditions. The
When pres-
lung cancer is not discovered incidentally on a includes adjuvant therapies with
into a peripheral tumor. This technique is not used for multiple chemotherapeu- Tuberculosis
ng cancers—approximately cell cancer that cannot be histologically
TB—tuberculosis identified
chest x-ray, the presenting symptoms asthatsqua-
initiate the diagnos- tictumors
agents or and radiation. 21 The survival for untreated SCLC
NSCLC—non–small cell lung ence cancer of benign URI—upper chronic
respiratory lung disorders is associated
tract infection with central tumors near large blood vessels. Tuberculosis (TB) is
non–small
is the most cell lung cancer mous cell
Herinventilator-associated
laboratory carcinoma,
results are adenocarcinoma,
as
tic workup may
follows:
beor small
an obstructive cell carci-
pneumonia with atelectasis, is only 2–4
Thoracentesis months,
requires but SCLC
insertion of a is more sensitive
large-gauge needle to multiple ease caused by the
BMIpain, (calculated as the weight in kilograms divided by the
■■
PAH—pulmonary arterial
an increase VAP— lung cancer, but the degree of risk
dyspnea varies
associated with a pleural effusion, hemoptysis, chemotherapy
into the pleural spaceregimens
to remove and radiation
fluid and than
cellsarefornon–small Primarily, TB affects
g cancer
even percent comprises three pri-
hypertension noma.
pneumonia Like adenocarcinoma,hoarseness, there are multiplesyndrome.
or a paraneoplastic subtypes cell cancers. 22
30:may be affected
among different disorders; for example, the cancer risk square of analysis.height in meters) is classified as follows sues
ma,
or insquamous people cell carcinoma, Test of large cell carcinomas that often present asRange
bulky, solitary Mediastinoscopy is used to sample lymph nodes in
Resultis increased Normal in 6000-year-old Eg
■■

rview
Pathologists
o; only 2% of furtherCarrilyn
with
classify
Proust:
diffuse Introduction
pulmonary fibrosis
tumors in the periphery of theCarrilyn
lung.
14 Proust:
times Application
Large cell carcinomas Normal:
the upper mediastinum. A small incision is made in
Carrilyn Proust: Outcome
the18.5924.9
neck above the sternum, a thin lighted scope is
American, the Maya
ans of Peru. In Europ
compared Fasting to blooda 2–4 times
glucose increased
90 mg/dL risk with chronic
Ms. Proust’s 6 100
primary caremg/dL
provider orders a chest Ms. Proust’s oncologist diagnoses her with
ous cell carcinomas
7,8 Carrilyn
as either
Proust, age 43, presents
tend to metastasize early andx-ray,
to her primary
widely;
which reveals 50%a mass metastasize
in the lower lobe of to Overweight:
inserted
stage
into the
25.0929.9
mediastinum, and
0 NSCLC—specifically, adenocarcinoma.
suspicious nodes in London were due
obstructive Total pulmonary
care provider’s office complaining of a chronic,
andcholesterol
disease 180 (COPD). Ms. Proust’s100–199
mg/dL mg/dL
right lung. For further evaluation, the
can be biopsied. expectancy was less
yations
ss, differentiated.
or caused by neo-
a pipe Being well-
nonproductive cough the brain
shortness of breathby the time cancer isprimary
diagnosed Clinical staging reveals that the that malignancy
abscesses, and vas- with Viral
■■ even minorinfections.
physical activities, Viral
such as infections may participate care
in provider
lung schedules Ms. Proust for Obese: Ú
The 30.0
appropriate
appears to betreatment
confined tofor the non–small
1-cm mass incell her cancer to the mid-20th centu
5es may dividing cancer cellsstairs.
retain recentlySmall
diagnosedcell lung cancer comprises aggressive, highly opment of cities and
times com-
be malignant or climbing Ms. Fasting
Proust wastriglycerides with a 125viral uppermg/dL a pulmonary computed tomography (CT) scan. In addition, a spu-
6 150 mg/dL depends on right
thelower lung staging
clinical field. No oflymph node involvement
the cancer at time oforthe metastasis is
mposed of cancerous tumor
respiratory carcinogenesis,
tract infection, particularly
which was treated symptomatically. She the human tum
papillo-
sample is collected for analysis. Ms. Proust’s sputum sample
diagnosis identified.
and on the Ms. individual’s
Proust undergoes
2 uncomplicated
health status. Clinicalsurgical excision epidemic. The discov
than (e.g., thatsize for and shape
suspects thatof hertheHigh-density
shortness of malignant,
breath is secondary tofast-growing
her 5524.5%
viral tumors
mg/dLof lungabnormal
respi- contains athat
moderate
40–50 metastasize
amount of blood. Ms.early
mg/dL A
Proust’s CT revealsBMI
an above
(men) in diameter in the lower staging is lymph 40
of the kg/m
tumor. Postoperative is considered
pathologic
based on the tumor size (T), location of cancer in
staging revealsextreme
no apparent or morbid
bacterium tuberculosis
zing (spreading) from
mavirus,
ratory infection. She states which is
that her primary present
concern is in her chronic cancers. mass approximately 1 centimeter node involvement or cancer metastasis. However, because tuberculosis is still a
ion
re isis
or invading a unregulated
dose–
local body and
cough, which faster
is lipoprotein
preventing her and
from widely
sleeping at night. into
She has regional
been lymphlobe of nodes.
her right lung.In the
Cytology ofpast, small
her sputum obesity.
sample reveals sus- Patients
lymph nodes
who
(N),Proust’s
of Mrs. have
and metastases
smoking greater
(M) with
history than
a system devel-
and subsequent 30.0
increased BMI
risk for are further
TB still represen
on.1 Benign growths ■■ Dietary factors. Epidemiologic
but she reports that studies suggest pected malignant thatcells. Ms. Proust is referred to an oncologist for oped by the American
cancer Joint radiation
recurrence, Committee and on Cancer (AJCC)
chemotherapy
19
are added to her
orly
nt
nantand differentiated
dura-
(noncancerous). cellsover-the-counter
taking an
retain cough cell cancers
suppressant,
were often called oat
further cell
50–59
evaluation cancer
and treatment. because of
mg/dL (women) subdivided into
(Figure 19.2 ■). three
treatment Surgery
plan to help obesity
alone may
reduce herbe classes:
riskthe
for treatment 30 of
cancer recurrence.
disease burden. Worl
low serum levels of antioxidants
this treatment is not effectively reducing her cough. She is afebrile
are associated with choice when5.NSCLC Discussisthe localized
rationalewith no regional lymph individuals were in
tics smoking
ing
sources toofbe identified
pulmonary as adeno-
and denies any recent history fever their distinctive
or chills. She reports that she small
has cell size3. and On the appearance,
basis of her gender, what buttypethat
of lung cancer does for pathologic staging in Ms. Proust’s of TB is higher am
ations that may affect an
been “coughing increased
soLow-density risk
hard that sometimes for
bloodcancer.
comes up.” Ms. Diets
90 mg/dL
Proust containing foods 6with
Ms. Proust 100
most mg/dL
likely have?
Obese
node involvement and no metastases (stages
treatment.
classfor6.I:individuals
30934.99 kg/m 2 0 and I).
20

arcinoma
er respiratory tract, butorhave hasfewer nor-
a 20 pack-year
lipoprotein terminology
history of cigarette smoking. She began is no smokinglonger used. There is ainvery
4. What finding strong
Ms. Proust’s linear
history and physical examination However, Although Ms. with stage
Proust hasIBa non–small
small tumor cellwithcan-
no lymph node
(3.2 million). Additio
at age 21high
and quit levels
smoking at ofagevitamin
41. She denies Aallergies
andtoEanyand cruciferous vege-
suggests that Ms. Proust does not have small cell carcinoma? cer, additional treatment modalities, 2 chemotherapy
suchexplain
as are infected with TB
s include alterations of
on
ging is faster
studies and the prognosis
medications or foods. Her vitalrelationship
signs are within normalbetween limits. SCLC and smoking, and only 1% of Obese class II: 35939.9
involvement
kg/m
or metastasis, the rationale for adding
mated 1.5 million ind
od flow to or from the tables (e.g., broccoli and cauliflower) were associated chemotherapy and radiation therapy to her surgical treatment.
2 were HIV negative
hip between 1. On the basis of Ms. Proust’s
At SCLC
this history, occurs
time, in
describe the pathophysi-
Yashika’s nonsmokers.
biochemical Small
laboratory cell
5VCIG+ lung
values cancer
are within can
5VCIG++ Obese class
5VCIG+++ III: Ú 40 kg/m 5VCIG+8
positive.23 In the Uni
with
ologic a lower
mechanism risk for
of her shortness lung cancer. Results are inconsis-
of breath.
e, is the
andmost lungcommon form
2. What of develop in major
the normal range. The presence of the velvety hyperpigmented
factor in Ms. Proust’s history puts her at risk for a bronchi
neo- or in the periphery of the lung. Check Your Progress: Section 19.2 $TCKP reported in 2014 (2.96
ulmonary tent,respiratory
plastic but drinkingdisorder? green tea may be protective against 2TKOCT[ 2TKOCT[ 2TKOCT[ 2TKOCT[ 1.5% decrease from 20
in womenare
smoking than in men.16 The rash (acanthosis Enlarging cancer
nigricans) inis mediastinal
consistent withlymph nodes
hyperinsulinemia VWOQTcan gradu- and
children11and adolescentsindividuals.
VWOQT 1. What are VWOQTthe clinical manifestations of superior VWOQT vena cava
Each lung
Casecancer. Study11ally appears multiple times in the chapter with an CLINICAL 5.3 Health POINT: Risks
syndrome? of Obesity
For individuals
(agedwas 24 2–
13 ti
andhas
the significantly
bronchial
infectious respira- James increased insulin
Gerrity: Introduction resistance. impede Yashikablood is return
at risk to
for the superior
diabetes and vena cava,
cardiovascular caus-
■■ Gender.
Introduction, Women or maymorebe more susceptible
Applications, to the carcino-section.
Outcome 19 years), the BMI 2.
value is plotted on the CDC growth charts
Identify the three components of tumor staging.
to t
ishasone and an It is important
oothesized
ntsignificantly
epithelial that the
impair increase
James disease.
Gerrity, age 72, ing
moderate the insidious
emphysema development of a superior vena caval 3. Compare and contrast needle aspiration and thoracentesis in infection and the dise
ous respiratory disor- The
Her laboratory genic
patients
resultstarare effects
featured
as follows: of smoking,
in the case possiblystudies because
reflect of
the differences
diversity
BMI of the
(calculated as the determine the BMI-for-age percentile.
for lung cancer. In this classification, over-
is a weight in kilograms divided by the
the diagnostic workup that M. tuberculosis or
and
of oxygen those
to the with
alveoli lower
and hearing loss. He
and has
Yashika
been married
Mr. Gerrity issyndrome.
for
meets with
48 years
In superior her family nursecaval
venal practitioner,
syndrome, and together
there
population
to his wife, Olivia.
inforDNA of inthe
years repair
United
a nonsmoker, but
mechanisms States across
and all age groups.
hormonal factors. In the weight is defined as a BMI 30 at or above the 85th
but have not caused
percentile and
kers
change.
sure to inhale more
Perfusion
doubles also he worked
deeply, structure
40they an
progressive
industrial a plan to
factory, dur- work on of
blockage increasing
blood return physical
square from activity.
ofthe height They
upper inset meters) is classified
part as follows : of fever and pleural e
est
s; pulmonary vascular United
Result States, women younger
ing which time he was routinely exposed to various chemicals. Mr.
Normal anRange
than 50 years of age have increased par-
/GFKCUVKPWO .[ORJPQFG .[ORJPQFG
95thBenign
/GVCUVCVKE .[ORJPQFG .KXGT $QPG
xposure
ildhood
erations to
and
in blood smoke.
flow Squamous
Gerrity’s realistic
medications include angoals
of
inhaledthe for increasing
body;
bronchodilator andblockageinhaled physical activity
results in slowlythrough developing signs OGVCUVCUKU lower than the 19.3
OGVCUVCUKU percentile.
VWOQT Lung Obesity
OGVCUVCUKU Lesions
is defined as ameans BMI that clinically
at or
and the infection is
ry system. Malignant a disproportionately
corticosteroid. Despite meticulous adherencehigh
ticipation in school and rate
to his medication of
community lung
regi- cancer.
physical Normal:
activity programs. 18.5924.9 Addi- 31a p
onasting
hmors in
thethat men
blood
number than
glucose
demonstrate
in women
men, 90
Mr. mg/dL
Gerrity andis very aware such
that his as
breathingdistention
6 100
has mg/dL
worsened and of veins in the
Figure neck
19.2 ■ The andstaging chest
system wall,
for lung cancersabove
depends the
on tumor95th While
size percentile
(T), many lung
presence of for
tumors
cancer inchildren
are malignant,
lymph nodes of
(N), the
benign
and same massesageindividuals
and sex.with

h cigarette
malignant smoking.
cells demon- tionally, Yashika is referred
that he is using his inhaler much more frequently. Mrs. Gerrity hears an
facial and upper to the
extremity nutritionist
edema, forOverweight:
metastases (M).
dietary
and mental education. 25.0929.9 A child’s weight
changes.
often occur as granulomas. Pulmonary granulomas are
status is determined on an age- and
the disease during th
sex-specific
otal cholesterol 180 mg/dL
announcement on the radio that free flu shots 100–199 mg/dL
are being offered at a small, localized collections of macrophages that form in the first year, up to
eplication and destruc-
o
ith referred
vironmental Etiology
to as undifferenti-
cellular metastasis.
asting triglycerides will only125 mg/dL
and 3.
Mr. Gerrity declines, explaining
Pathogenesis
local health clinic. She decides to receive the influenza vaccination, but
When
Yashika
to the
he is individual
avoids
his wife that the vaccine lies in
participation
certain down, the at
activities Obese:
increased
school. ÚWhat 30.0would
blood return percentile for BMI rather than by the BMI categories used for adults.
6 150 mg/dL
mon riskform
unction
for ofindi-
lung
affect the NSCLC. The17primary
make him feel worse.
cause
you to counsel
thelung
of heart may
cancer
her about cause thisworsening
is cigarette aspectsmoking,
of Aher of health?
the
thesigns and symp- Classifications of overweight and obesity for children and adoles-
on that is sufficient to
High-density 1. 55
Whichmg/dL
factor from Mr. Gerrity’s work history 40–50 is a risk mg/dL
factor for (men) BMI above 40 kg/m2 is considered extreme or morbid
nandular
lt,the exposed
alterations epithelial
in respi- cancers.
result of the
developing A4.cancer?
lung toms associated
carcinogenic character with vena
offrom
multiplecaval syndrome. The severity cents are determined in this way because children’s body compo-
chemicals
poprotein
inadequate nutrition.
What kind of statement Yashika
M19_SORE4783_01_SE_C19.indd 7 indicates
obesity. understanding
Patients who have greater than 30.0 BMI are further 4/13/17 6:34 PM

ains
t-known more riskthan one cell sub-smoke.
in cigarette
lung cancer does Mr.of
of the the
The symptoms
chemicals
2. On the basis of his history, what other possible risk factors for
education anddepends bind
counselingandonmutate
the was
that location
DNA givenoftothe her? blockage M19_SORE4783_01_SE_C19.indd 8
Each disorder that is covered has been
ated to oxygenation in Gerrity have?
50–59 mg/dL (women) subdivided into three sitionclasses:
obesity varies by 30 age and gender. A calculator for determining BMI
he most expo-
. neoplastic,
Other common
and infec- lung
(see the cancers feature and on Geneticshow quickly and Genomics it occurs. The most common cause of
for Clinical chosen for its prevalence, i.e., the
status for children and adolescents can be found at https://www
,ow-density
clicbutaromatic
the majority Practice). ofCheck
adenocar-
90 mg/dLYour 12 There
Progress: vena
isSection caval
a linear 6 100
19.1 syndrome mg/dL isbetween
relationship SCLC. the Obese inten- class I: 30934.99 kg/m2 authors focused on the disorders that
poprotein
denocarcinomas
can occur as occur sity primar-
of smoking and malignantprogressive epithelial changes. As in .cdc.gov/obesity/childhood/defining.html
healthcare providers will see ■ most often
Check Your Progress: Section 5.2
1. Describe the difference between and benign pul-
monary growths. Clinical Manifestations Obese class II: 35939.9 kg/m2
gd throughout
ries.and may initially 2.present
other cancers, as a pulmonary
exposure disorderto carcinogens causes a stepwise in clinical practice. For every disorder,
40 kg/m2 Obesity in childhood and adolescence is a major
the chap- How does having affects a person’s
At this
content
cause
time,
to clinical
pulmonary situ- Yashika’s
h neoplastic, infectious,
symptoms.
biochemical
nutritional 1. What
status? Most laboratory
patients
adipose values
tissue are
withhormones
lung within
canceranddo Obese
not seek
gastrointestinal class
medical hor-Úcare
III:
public thehealth
contentproblem
is broken associated
into three sec- with short- and
e normal range. The presence ofisuntil
the velvety
they hyperpigmented
after they
in thebecome symptomatic. The most com-
3. Describe how perfusion affected by a pulmonary disorder.
ly slow growing but metasta- mones are involved regulation of food uptake? tions: Etiology and Pathogenesis,
sh (acanthosis nigricans) is consistent monwith hyperinsulinemia
symptom is a persistent and cough with or without spu- long-term complications. Obese youths are more
ding blood vessels or through2. What are someand of the genetic components CLINICALof obesity? POINT: For children and adolescents Clinical Manifestations,
(aged 2– and Linking
s for Clinical Practice
sulin resistance. Yashika is at risk
alveolar cancers are a distinct3. What foods contain high
sease.
fortumdiabetes
production. cardiovascular
Cough
19.2 levels
is not a specific
of
Malignant the 19
antioxidants
Lung Tumors
symptom
years), the BMI
vitamin
7
forvalue
E
likely to have
lung is plotted
diabetes,
on the
such
risk factors fortocardiovascular
Pathophysiology
CDC
as
growth
hypertension,
charts Diagnosis
to
dyslipidemia,
and disease and
and insulin
that grow along preexisting andcancers, vitamin
and initially it is typically attributed to cigarette
C? determine the BMI-for-age percentile. In this Treatment.
classification, over-
Yashika meets with her family nurse smoking, practitioner,
COPD, and
or atogether 4/13/17 6:34 PM
respiratory infection. Other common resistance. Additionally, obese children and adolescents are
astasizing
ey structure or destroying
a plan to work on theincreasing physical activity. They set weight is defined as a BMI at or above the 85th percentile and
breath.
FR, c-MET, and A pleural Linking Pathophysiology
signs and symptoms
12
EGFR tyrosine kinase inhibitors. The importance of this genetic to Diagnosis
of lung and
cancer Treatment
are sputum streaked at risk for musculoskeletal problems, sleep apnea, and
alistic
read togoals
thealmostfor increasing physical activity
pleura. with through
blood, increased
recurrent par-
pneumonia lower
or than the 95th
bronchitis, percentile. Obesity is defined as a BMI at or
ma genes
occurs such as researchDiagnostic
exclusively is that ittests
will allowfor targeting
lung cancer of the specificchest
include sensitivities
x-ray, com- dyspnea, social and psychologic problems. 31 The approach to the pre-
5.3 Health Risks of Obesity
ipation
ractivated
site. in school
Mediastinal
signal and
of acommunity
tumor withphysical
chest
oncology activity
pain, programs.
hoarseness,
medications that Addi-
and
will above
paraneoplastic
interfere with the12 95thChapter
syndromes. percentile for children
185 Health Risks of ofObesity
the same andage and sex.
Physical Inactivity
much
nally, more
Yashika common puted
in men tomography (CT), sputum cytology, and directly vention, treatment, and management of obesity is multifac-
with lung
alized. can-is referred
Retroster- tumor
to the nutritionist for dietary education.
growth.12,13 A child’s weight status is determined on an age- and sex-specific
ell carcinomas are also sampling
called cells■from the tumor
■ Obstructive or pleural fluid.
pneumonia occurs Anwhenabnormal
lung cancer blocks torial. Children and adolescents’ physical activity and
pain varies
3. with the
Yashika
receptors avoids
are inparticipation
chest
Obesity
x-ray
is known
in activities
often at school.
triggers
tothe increase
What
diagnosticwouldtheworkup
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forformany for
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diseases,
BMI rather than resulting
by the BMIin categories used for adults.
use
, KRAS they originate the
CLINICAL bron- POINT: bronchi,
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been and
directly mucus
linked insulin
clearance. secretion,
The dietary increased
behaviors are nutrient
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include size).
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communities,
ietal pleural
What kindpain of statement the in lifespan.
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indicates risks of obesity include
cents are not (anonly
determined thein thisdelivery
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lor 4.
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(EGFR) medially
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than gene.
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visualize aretumors complications are associated with inflammation and 32oxida- diabetes. Weig
aryngeal
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present inincreased
inapproximately
the hilar or60%
with obesity,
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but also
area. The
the status
Cigarette functional
scan smoke
fortive
area is usu-
and psy-
children
stress andinduced
adolescents can be found
by obesity and at https://www
diabetes. 35 Oxidative increased risk
.ent in small cell interventions including dietary and physical activity modi-
contains chosocialover 200 risks that
carcinogens thatoccur as with
actimages initiatorsincreasing body weight.
.cdc.gov/obesity/childhood/defining.html
(polycyclic ■
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Check Your
ally cell lung
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5.2nodes, of the liver, upper stress can cause vascular
fications and endothelial
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hydrocarbons),
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to assess
produce hormone inflammation,
Obesity in childhoodand
foraltered gene
and adolescence
effective expression.
prevention is
and Furthermore,
a major
treatment of obesity.seems to prece
Of greatest
h1.non–small
What adipose cell taminants
tissue hormones Obesity
such as
for metastases. is associated
radioactive elements,
and gastrointestinal hor- with the
arsenic, development
nickel, molds, of a range of
ppropriate neuro- the
public effects
health of maternal
problem obesity
associated
importance, extend
however,with beyond
short-
is the
and
parental perinatal
and familial and Examinati
involvement
agents butare not and additives. disorders,
■
Cytologic especially
analysis T2D, but
of freshly also manysputum
expectorated other systemic
in mones
neurologicinvolved or in■■the regulation of food uptake? period. Children of obese women have antherapy;
increased rate
and orthopedic
looks components
for centrally of disorders,
located which
lung cancers. are covered
long-term complications.
more thor- 4/13/17 with family
6:34 PM
Obese youths
behavioral are morethis hasofbeenan increasing
cited as the i
2. Whatcell
uamous are carci-
some of the genetic obesity? likely to hospitalization
have risk factors during
for the first
cardiovascular 5 years of
diseaselife, particularly
and ing
33 ■levels of o
■■ oughly most widely supported treatment for children.
thyroid
3. Whathormone,
foods contain high levels ofin
Bronchoscopy theother requires
antioxidantschapters. the
vitamin This
insertionE descriptive
of a thin lighted
diabetes,
terminology
for
suchinfections and nervous
as hypertension, system, metabolic,
dyslipidemia, and insulin and respira- for normal-we
Lifespan has Considerations
tube through
widespread the are ramifications
nose or mouth, down the
for trachea
the to
public’s the under- 36
levels.
and vitamin C? Obesity during pregnancy is associated with
highlightedarea withoficons
concern for children,
in theand lung.socialAny suspicious- resistance. tory conditions.
Additionally, Because
obese childrenof the
and risks to
adolescentsboth mother
are and a BMI of 40 or
ude fatigue and
standing of obesity stigma as appearing
well as treatment, increased maternal and fetal risks. Maternal compli-
pregnant women, tissue canand be older
lavaged (washed), brushed, atbiopsied
or risk for fetus
for associated with problems,
musculoskeletal obesity during sleep pregnancy,
apnea, and it is impor-
negative prognos- adults. reimbursement,
cells for cytologic analysis.
education, and consumer protection
social and tant forPMoverweight
psychologic problems.
cations include pregnancy-induced hypertension,
and obese women toto
The approach have
theweight
pre- coun- Dyslipidemia
.3 Health Risks of Obesity
programs. This designation as a disease is 4/13/17 based 6:34on the gestational diabetes, respiratory complications, venous
Dyslipidemias
■■ Needle aspiration requires insertion of avention, thin needle seling
treatment, before andconception
management so that they can
of obesity achieve weight
is multifac-
incidentally on a recognition that obesity
into a peripheral tumor. This technique istorial.
is a complex condition
not used
with
for before
mul- thromboembolism, preterm delivery, cesarean deliveries,
teins are obesi
besity loss
Children andbecoming
adolescents’pregnant. physical
■ activity and
itiate theisdiagnos-
known to increase tiple the riskmany
centralcauses,
tumors or tumors
for many of which diseases,
near large arebloodbeyond the individual’s
vessels. and surgical and anesthetic complications.34 Examples of
sition of ather
duce dietary behaviors are influenced by many factors; these
ia withquality
atelectasis, of life and functional
■■ control.
Thoracentesis
capacity,
In addition,
requires insertion
and
obesityshorten ofcauses suffering,
a large-gauge needle In older adults,
ill health, risks tooverweight
the fetus and and obesity
neonate are associ-
include congenitalthe abnormali-
include (but are notwithlimited to) levels
families, communities, developme
e lifespan. pain,
hemoptysis, Health riskssocietal intoof obesity
the stigma,
pleural include space not
discrimination, only the
to remove and early
fluid and cells mortality.
for ated higher
ties, neonatal of functional
hypoglycemia, limitationsdelivery, miscar-
premature
schools, healthcare providers, faith-based institutions, gov- disease. Dyslip
athologic risks for morbidity Obesity andismortalityconceptually thatdefinedare as an excess of body when compared riage, and with normal-weight adults.
34 Obesity-associated 37
analysis.
ernmentAlthough agencies, and the media. 32 Asstillbirth.
for adults, lifestylewith the
maternal
creased with obesity, ■■ but alsoisthe
Mediastinoscopy
fat and functional
clinically is used
defined and bypsy-
to sample the body
lymphmass nodes index
in (BMI). obesity in older adults is associated
hyperglycemia due to diabetes can cause increased Hypertension
fetal
hosocial risks that occur thewith upper increasing
mediastinum. body A weight.
small incision interventions
is madeadverse in including outcomes dietary and physical
described in this activity
chapter,modi- there is some
fications and Hypertension
2008, the Obesity Society the defined
neck above obesity the sternum,
as a disease. a thin 29 lighted scope is behavioral
evidence that thestrategies
risk of adversemake up the framework
outcomes lessens with age
t inserted into the mediastinum, and for
suspicious effective
nodes prevention and treatment of obesity. Of greatest individuals.43
besity is associated with the development of a range of and mild obesity. 38 In fact, increases in adiposity appear to
f importance, xiii
related to ov
esorders, especially T2D, canbut be biopsied.
also many other systemic havehowever,
a protective is parental
effect onand frailfamilial involvement
older adults and those with
with family behavioral therapy; this has been cited as the risk for hyper
nd
r orthopedic disorders,
Thewhich are covered
appropriate more
treatment forthor- chronic
non–small cell cancer diseases.38 ■
33
 26 Chapter 19 Neoplastic, Infectious, and Pulmonary Vascular Respiratory Disorders

CHAPTER SUMMARY

19.1 Chapter Overview and Case Squamous cell carcinomas usually originate in medial
Chapters end with a Chapter Summary
■■

bronchial mucosa at bronchial bifurcations and metas-

Studies
that gives a bulleted list of highlights for Describe the primary considerations and concepts related
to pulmonary vascular, neoplastic, and infectious respira-
each numbered section/learning outcome. tory disorders.
■■ Pulmonary disorders include alterations caused by
neoplastic growths, infectious diseases, abscesses, and
vascular disorders.
■■ Neoplastic growths may be malignant or benign.
■■ Malignant growths are composed of cancerous cells
that are capable of metastasizing (spreading) from the
site of origin to other body sites or invading local body
sites and causing tissue destruction.
■■ Benign growths contain cells that are nonmalignant
(noncancerous). Infectious diseases that serve as
sources of pulmonary disorders include a variety of
alterations that may affect either the upper respiratory
tract, the lower respiratory tract, or both.
■■ Pulmonary vascular disorders include alterations of
blood flow within the lungs or to or from the pulmo-
nary circuit.
19.2 Malignant Lung Cancer
Differentiate the causes, classification, underlying patho-
genesis, and clinical manifestations of malignant lung can-
cers and approaches to diagnosis and treatment of these
conditions across the lifespan.
■■ Cigarette smoking is the primary risk factor for lung
cancer. There is a 15- to 20-year delay between starting
smoking and development of lung cancer.
■■ Other smoke exposures (cigars, pipes, passive expo-
sure) and exposures to environmental and occupational
carcinogens (radon or asbestos) also increase the risk
for lung cancer.
■■ Genetic susceptibility, benign chronic lung disorders,
and diet contribute to lung cancer risk.
■■ Histologically, carcinomas are classified as adenocarci-
noma, squamous cell carcinomas, and large cell carci-
nomas (all three of which are considered non–small cell
tasize to adjacent lymph nodes and lung tissue.
■■ Large cell carcinomas often present as big, bulky soli-
tary tumors in the lung periphery.
■■ Small cell carcinomas are aggressive, highly malignant,
and fast-growing tumors that metastasize early and
widely.
■■ Symptoms initiating a diagnostic workup include obstruc-
tive pneumonia, dyspnea with a pleural effusion, hemop-
tysis, pain, hoarseness, or a paraneoplastic disorder.
■■ Initial lung cancer symptoms are often nonspecific with
a persistent cough that is attributed to another cause.
■■ Diagnostic tools include sputum cytologic analysis, CT
scan of the thorax, bronchoscopy, fine needle aspira-
tion, thoracentesis, and mediastinoscopy.
19.3 Benign Lung Lesions
Differentiate the causes, classification, underlying patho-
genesis, and clinical manifestations of benign lung lesions
and approaches to diagnosis and treatment of these condi-
tions across the lifespan.
■■ Pulmonary granulomas are formed to control an
inhaled antigen that cannot be digested or in response
to an autoimmune inflammatory process.
■■ Macrophages engulf the antigen, and helper T cells sur-
round the macrophages, preventing a chronic inflam-
matory response.
■■ As macrophages die, the exposed antigen stimulates a
further granulomatous inflammatory response.
■■ Tuberculosis is caused by the rod-shaped aerobic
M. tuberculosis bacillus, which is protected by a waxy
capsule. Transmission is primarily through inhalation
of infected droplets by a susceptible person.
■■ M. tuberculosis can remain latent and in a state of dor-
mancy for years; individuals with latent TB are not
infectious.
■■ Active TB is symptomatic and communicable to other
individuals.
Reactivation of latent TB (secondary TB) occurs when
■■

carcinomas) and small cell carcinomas. there is a decreased T-cell–mediated immunity in a pre-
■■Adenocarcinoma and squamous cell carcinomas are viously sensitized host.
20 Chapter 5 Health■■Risks of Obesity and Physical Inactivity
Review Questions are NCLEX-style to classified as differentiated (retaining more normal cell
features, but cell division is unregulated) or undiffer-
Fungal infections in the lung are endemic to particular
geographic areas: histoplasmosis and blastomycosis
6. You are placed inincharge
entiated (retaining enough features for identification, of an intervention
the Midwest, for the stu-
the St. Lawrence c. hethe
valley, and along will have improved insulin sensitivity and thus
give the students practice with the format. dents of a local elementary
but cell division is faster and the prognosis is worse). Appalachian school. You know
Mountains andthat a key
coccidioidmycosis inimproved
the beta-cell function.
■■ Adenocarcinomas are glandular cancers, usually factorinfor changesouthwestern
in children’s association
United States.with food is d. he will need to use more diabetic medication because
the lung periphery. They grow slowly but can to address: ■■ Fungal infections are transmitted by inhalation of of
metas- the surgery.
fun-
tasize early because of invasion of blood vessels a. the
andparents because they are
gal spores all making
in dust or fromincorrect food
bird droppings and
8. may
A new benurse is teaching a class at the local YMCA. The
lymphatics. choices. asymptomatic in healthy individuals.
students are older adults from the community. The
b. the food insecurity that these children experience
nurse’s topic is the importance of weight management
because it affects their food choices.
as the individuals age. Understanding of this material is
c. the city parks and rec department because there
noted by a student who says:
are not enough state-of-the-art activities at the local
a. “Weight gain will not affect my ability to care for
YMCA.
myself.”
M19_SORE4783_01_SE_C19.indd 26 d. None of the above, since you are just one person. 4/13/17 6:34 PM
b. “Weight loss will not help if I have joint pain.”
7. Mr. Xi is scheduled to undergo a Roux-en-Y gastric c. “Weight gain will affect my ability to do simple tasks,
bypass. He wants to know what he should expect from such as turning in bed, by myself.”
the procedure. You explain that: d. “Weight loss can increase my change of diabetes and
a. he will not be restricted in his diet post procedure. its complications.”

Answers to Review Questions can be b. he will be monitored for increased hepatic glucose
production.

found in Appendix A. Answers to Check

Your Progress and Case Study questions ANSWERS
will be found online for the print book and
Answers to Review Questions can be found in Appendix A. Answers to Case Study and Check Your Progress questions are
available on the faculty resources site. Please consult with your instructor.

will be pop-ups in the eText.

RECOMMENDED WEBSITES
Centers for Disease Control and Prevention: Childhood Physical Activity Guidelines for Americans
Overweight and Obesity https://health.gov/paguidelines/guidelines
https://www.cdc.gov/obesity/childhood/index.html

REFERENCES
1. Maggi, S., Busetto, L., Noale, M., Limongi, F., & Crepaldi, G.
(2015). Obesity: Definition and epidemiology. In A. Lenzi, S.
Migliaccio, & L. M. Donini (Eds.), Multidisciplinary approach to
obesity: From assessment to treatment (pp. 31–39). New York, NY:
Springer.
2. World Health Organization. (2014). Overweight and obesity. Avail-
able at http://www.who.int/mediacentre/factsheets/fs311/en
3. Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M. (2014).
Prevalence of childhood and adult obesity in the United States,
Recommended Websites and 2011–2012. JAMA, 311(8), 806–814.
4. Pi-Sunyer, X. (2009). The medical risks of obesity. Postgraduate
8. U.S. Department of Health and Human Services. (2017). Physi-
cal activity. Available at http://www.healthypeople.gov/2020/
topics-objectives/topic/physical-activity
9. Gurevich-Panigrahi, T., Panigrahi, S., Wiechec, E., & Los, M.
(2009). Obesity: Pathophysiology and clinical management.
Current Medicinal Chemistry, 16(4), 506–521.
10. Yu, J. H., & Kim, M. S. (2012). Molecular mechanisms of appetite
regulation. Diabetes and Metabolism Journal, 36(6), 391–398.
11. Sam, A. H., Troke, R. C., Tan, T. M., & Bewick, G. A. (2012). The
role of the gut/brain axis in modulating food intake. Neurophar-
macology, 63(1), 46–56.

References round out the offerings.

Medicine, 121(6), 21–33.
5. Centers for Disease Control and Prevention. (2016). Overweight
and obesity. Available at http://www.cdc.gov/obesity/data/
prevalence-maps.html
6. Go, A. S., Roger, V. L., Benjamin, E. J., et al. (2013). Heart disease
and stroke statistics—2013 update: A report from the American
Heart Association. Circulation, 127, e6–e245.
7. Centers for Disease Control and Prevention. (2014). Facts about
physical activity. Available at http://www.cdc.gov/physicalac-
tivity/data/facts.html
12. Molina, P. E. (2013). Endocrine physiology (4th ed.). New York, NY:
McGraw-Hill Medical.
13. Kanaya, A., & Vaisse, C. (2011). Obesity. In D. G. Gardner &
D. M. Shoback (Eds.), Greenspan’s basic and clinical endocrinology
(pp. 699–709). New York, NY: McGraw Hill.
14. Skolnik, N. S, & Ryan, D. H. (2014). Pathophysiology, epide-
miology, and assessment of obesity in adults. Journal of Family
Practice, 63(7), S3–S10.
15. Filippatos, T. D., Elisaf, M. S. (2013). Effects of glucagon-like
peptide-1 receptor agonists on renal function. World Journal of
Diabetes, 4(5), 190–201.

M05B_SORE4783_01_SE_C05.indd 20 6/21/17 7:58 PM

19.6 Pulmonary Vascular Disorders 31

GLOSSARY
Acute bronchitis A very common, self-limited lower respiratory
tract inflammation; often referred to as a “chest cold.”
Adenocarcinoma A common form of lung cancer that starts in the
lining of the glands.
Antigenicity The ability to stimulate the formation of antibodies.
Bacillus Calmette-Guérin (BCG) Tuberculosis vaccine that is one
of the most widely used vaccines throughout the world.
Benign In reference to a tumor, one that does not spread to, invade,
and destroy surrounding tissue.
Blastomycosis A fungal infection caused by Blastomyces dermatitidis,
an uncommon fungus that is found in Ohio, the Great Lakes region,
and the Mississippi River valley; it is common in dogs in endemic
areas but also occurs in horses, cows, and bats, and infections in
animals can serve as an indicator of human disease.
Bronchiolitis A condition characterized by inflammation of the
bronchioles.
Coccidiodomycosis A fungal infection caused by Coccidioides
immitis, which is endemic in the soil in the southwestern United
States but can also be found throughout the world; it grows best in
bird feces; also known as San Joaquin Valley fever.
Croup An acute viral infection of the upper respiratory tract com-
monly caused by parainfluenza viruses that spread through in
children younger than 5 years of age in daycare centers, families,
Hospital-acquired pneumonia (HAP) A classification of
At the end of the book, students will
find a complete Glossary.
pneumonia in which the infection was not incubating at the time
of hospital admission and develops 48 hours or more after hospital
admission.
Influenza A highly contagious viral infection that sweeps through
a geographic region as an epidemic that lasts 6–8 weeks during the
winter months.
Pertussis A highly contagious respiratory infections usually caused
by Bordetella pertussis that has been controlled in children through
pertussis vaccination; also known as whooping cough.
Pneumonia An inflammation of the lung parenchyma that is
typically characterized by lung consolidation with alveoli filled
with exudate.
Pulmonary arterial hypertension (PAH) A primary disorder of
increased blood pressure in the pulmonary arteries; characterized
by an increased pulmonary arterial resistance in the absence of left
ventricular failure or chronic thromboembolism.
Pulmonary embolism (PE) Occurs when a substance or object
(e.g., blood clot, fat globule, air bubble, bone fragment, or foreign
matter) is pumped from the right heart into progressively smaller
pulmonary arteries until it wedges in a vessel that is too small for
it to pass.
Pulmonary granulomas Small, localized collections of

xiv
and hospitals; also called laryngotracheobronchitis.
Embolism A condition in which an embolus (a substance or foreign
matter) travels via the bloodstream and subsequently lodges in a
blood vessel, creating a partial or complete obstruction of blood
flow through the affected vessel.
Embolus A substance or object that travels via the bloodstream to a
blood vessel; emboli may comprise various substances, including a
macrophages that form in response to an inhaled antigen that
cannot be degraded or an autoimmune disorder.
Pulmonary hypertension (PH) Increased blood pressure in the
pulmonary arteries; may occur as a primary disorder or secondary
to a primary disease process.
Rhinorrhea A condition characterized by profuse, watery nasal
discharge; commonly known as a runny nose.
 5.1 Chapter Overview and Case Studies 3

5.1 ChapterOverview depression.4 One of the goals of Healthy People 2020 is to

promote good health through nutrition and maintenance

and Case Studies of a healthy body weight.

There has been a dramatic increase in the prevalence
One of the major challenges of the 21st century is the pre- of obesity in the United States over the last two decades.

Chapter Features
vention and treatment of obesity. The World Health Orga-
nization (WHO) defines obesity as abnormal or excessive
fat accumulation that may impair health.1,2 More than 33%
of U.S. adults and 17% of U.S. children are obese.3 Obe-
sity is a factor in the development of a number of medi-
cal conditions, including diabetes, cardiovascular disease
(coronary artery disease, myocardial infarction, angina
pectoris, heart failure, stroke, hypertension, and atrial
To enhance the content offered within the usual structure, we have feature boxes throughout: fibrillation), metabolic syndrome, cancer, arthritis and
disability, gallbladder disease, acute pancreatitis, nonal-
coholic fatty liver disease, pulmonary complications, and
Prevalence estimates of obesity in 2014 by state ranged
from 20 to 35%5 (Figure 5.1 ■). The total excess cost related
to the current prevalence of overweight and obesity
among adolescents is estimated to be $254 billion.6 This
number includes $208 billion in lost productivity second-
ary to premature morbidity and mortality and $46 billion
in direct medical costs.6 If current trends in the develop-
ment of overweight and obesity continue, the total health-
care costs related to obesity could reach $861–$957 billion
by 2030; this would account for 16–18% of U.S. health
expenditures.6

Healthy People 2020 features highlight Healthy People 2020

the role of the Healthy People initiative and Nutrition and Weight Status

the topics and objectives for healthcare The overall goal of the Nutrition and Weight Status objectives for
Healthy People 2020 is to promote health and reduce the risk of
Food Insecurity
Food insecurity is the inability to access sufficient safe, nutritious
that in contains. chronic disease through healthful diets and the achievement and
maintenance of healthy body weights. In addition, these objec-
food that is needed to maintain a healthy and active life.2
■ Eliminate very low food security among children.
tives emphasize that efforts to modify diet and weight should ■ Reduce household food insecurity and in doing so reduce
address individual behaviors along with the policies and envi-
hunger.
ronments that support these behaviors. Those objectives are
broadly divided into the following categories: HealthCare and
Worksite Settings, Weight Status, Food Insecurity, Food and Food and Nutrient Consumption
Nutrient Consumption, and Iron Deficiency.1 The primary objec- ■ Increase the contribution of fruits to the diets of the population
tives are as follows: aged 2 years and older.
Increase the number of states with nutrition standards for
■ ■ Increase the variety and contribution of vegetables to the diets
foods and beverages provided to preschool-aged children in of the population aged 2 years and older.
child care. ■ Increase the contribution of whole grains to the diets of the
■ Increase the proportion of schools that offer nutritious foods population aged 2 years and older.
and beverages outside of school meals. ■ Reduce consumption of calories from solid fats and added
■ Increase the number of states that have state-level policies sugars in the population aged 2 years and older.
14 Chapter 53 Pathophysiology at the End of Life
that incentivize food retail outlets to provide foods that are ■ Reduce consumption of saturated fat in the population aged
encouraged by the Dietary Guidelines for Americans. 2 years and older.
■ Increase the proportion of Americans who have access to a ■ Reduce consumption of sodium in the population aged 2 years
Etiologic factors
food retail outlet that sells a variety of foods that are encour- and older.
aged by the Dietary Guidelines for Americans. ■ Increase consumption of calcium in the population aged
2 years and older.
Healthcare and Worksite Settings
■ Increase the proportion of primary care physicians who regu-
larly measure the body mass index of their
• Disease-related patients.
factors Iron Deficiency
• High levels of
■ Increase the proportion of physician office
• Treatment-related visits that include
factors Reduce iron deficiency
cytokinesamong young children and females of
■
inflammatory
counseling or education related to nutrition or weight.
• Comorbidities childbearing age.
■ • Cachexia-induced
Increase the proportion of worksites that offer nutrition or ■ Reduce iron deficiency among pregnant females.
metabolic
weight management classes alterations
or counseling.
Weight Status References
■ Increase the proportion of adults who are at a healthy weight. 1. U.S. Department of Health and Human Services. (2017). Nutrition
■ Reduce the proportion of adults who are obese. and weight status. Available at http://www.healthypeople.gov/2020/
■ Reduce the proportion of children and adolescents who are topics-objectives/topic/nutrition-and-weight-status
Cachexia-induced
considered obese. Anorexia
16 Chapter 53 Pathophysiology at the End of Life 2. World Health
metabolic Organization. (2014). Trade, foreign policy, diplomacy and
alterations
■ Prevent inappropriate weight gain in youth and adults. health. Available at http://www.who.int/trade/glossary/story028/en
• Carbohydrates
– Gluconeogenesis

Impact of Current Research on Clinical Practice

• Fat
– Increased lipolysis
• Protein
Treatment of Fatigue with a Central Nervous System Stimulant
– Increased proteolysis
– Decreased protein synthesis
Description: Fatigue and depression are common near the Clinical Practice: A statistically significant decrease in the se-
end of life and have a negative effect on the person’s quality verity of fatigue was observed by19.2 day Malignant
14 in the Lung treated 5
groupTumors
of life. In a double-blind investigation in which neither clinicians with methylphenidate. No improvement in fatigue was expe-
nor patients knew whether the patient received the investi- rienced by patients in the placebo group. Patients treated with
5-year survival rate of 4%.3 Early diagnosis of lung cancer ■■ Genetic susceptibility. Genetic susceptibility is sug-
gational medication or placebo, 30 hospice patients in either
occurs in only
inpatient an estimated
or outpatient 15%were
settings of cases; subsequently,
randomized to receive
methylphenidate who had clinically significant depression at the
gested
beginning by study
of the clusters of lung
experienced cancer in families,
M05B_SORE4783_01_SE_C05.indd
improvement
3 and
in depression Impact of Current Research on
Adipose tissue loss 4/13/17 3:27 PM

more than 50% of individuals with lung cancer die within

Ritalin),1 a first-degree relativesself-report
have an increased
scales; lessrisk for devel-
treatment
yearmild
of the
central
with
initial
either methylphenidate
diagnosis.
nervous
(Metadate,
system3 stimulant that increases the levels
based on three depression
was oping
noted inlung cancer. group.
the placebo The increased
improvement
risksupport
These results persists after
the use any
of Clinical Practice features show
Skeletal muscle wasting
Involuntary weight loss

many
ofLung
norepinephrine
placebo
of thewas
and dopamine
cancer is primarily
riska factors
tablet that
arelooked
in the brain,
a preventable
identical
modifiable.
or a placebo.
disorder because
to methyphenidate
These risk factors
The the central
the quality
nervous
increased risksystem
of lifeisoftaken
ing habits
stimulant
associated
patients
into
methylphenidate
with age, gender, to
experiencing
improve
and
account. fatigue or depression
smok-
students how research is used clinically
Anorexia contributes to cachexia;to highlight
it is not thethe importance
involved. Chronicof evidence-
but contained starch instead of the medication. The research associated with terminal illness.
include the following: ■■ Presence of benign chronic lung conditions.
Figure 53.7 The ■pres- however, only factor high levels of
study nurse conducted the physical assessments and admin-
ence of benign chronic lung disorders is associatedcytokines
inflammatory with shift metabolism toward increased degradation of protein and fat and increased production of glucose
■■ istered
Smoking
ported
important
the symptom
cigarettes.
fatigue,
assessment
no factor
risk
Smokingscales.
differences in severity
for cancer.
While is
cigarettes all patients
the most
scores were percent
Eighty-seven observed
re- Research Study: Kerr, C., Drake, J., Milch,
an of
Effects increase in lung cancer,
methylphenidate but
on fatigue the
and
R., et al. (2012).
degree ofArisk
to provide
depression: based
varies for synthesis of acute phase proteins,
substrates
random- whichpractice.
are involved in the inflammatory response. Anorexia and
between the treatment and placebo groups at the beginning of ized,among different
double-blind, disorders; for example,
placebo-controlled cachexia both
Pain contribute
theofcancer
trial. Journal risk
and to involuntary weight loss, loss of adipose tissue, and skeletal muscle wasting.
of lung cancers occur in active smokers or in people
the study. with Management,
Symptom diffuse pulmonary fibrosis is increased 14 times
43(1), 68–77.
who stopped smoking less than 5 years ago; only 2% of
compared to a 2–4 times increased riskInwith certain situations, interventions can be attempted
chronic for a short time. Medications with effects similar to those
lifelong nonsmokers develop lung cancer.7,8
obstructive pulmonary disease (COPD). to alleviate anorexia. For example, anxiety, nausea, dehy- of progesterone may improve appetite, with effects evi-
■■ Cigar or pipe smoking. Smoking cigars or a pipe
Viral infections. Viral infections may
calcium-channel blockers, muscle relaxants, and opioids.
■■ dration,
participate constipation,
in lung and oral infections can be managed, dent after 1–2 weeks of treatment. Prokinetic agents, such
increases the risk for lung cancer by 2–5 times com-
Check Your Progress: Section 53.8 tumorcare
Palliative carcinogenesis,
patients areparticularly
frequently the whichhuman
prescribed maypapillo-
help to increase the patient’s desire for food. A
opioid as metoclopramide (Reglan), increase the rate of gastric
pared to nonsmokers, but the risk is less than that for
1. Describe mavirus, which is present in 24.5%
medications to control pain and/or dyspnea. However, trial
of lungof medications
cancers. can also be attempted to increase appe- emptying; this in turn can reduce the feeling of abdomi-
cigarettethe etiologicAs
smokers. factors
with involved
cigarettes,in causing
there isfatigue
a dose–
near the end of life. ■■ Dietary factors. Epidemiologic studies
these drugs bind to intestinal opioid receptors tite. Corticosteroids
suggest
and slow that such as dexamethasone and predni- nal fullness that some patients with decreased appetite
response relationship based on the amount and dura-
2. What arecigar
the clinical manifestations that stopping
often accompany low serum
peristalsis, as well levels of antioxidants
as causing an increase sone
are maysphincter
inassociated
anal helpwith
to increase appetite and physical strength experience.
tion of or pipe smoking, and smoking
fatigue?
decreases the risk for lung cancer. tone,an increased
leading risk for cancer.
to constipation. 45 Diets containing
In contrast to otherfoods with
thera-
peutic high
andlevels
adverse of vitamin
effects ofA and E and
opioids, cruciferous
tolerance doesvege-
not
■3.
■ Describe theand pharmacologic and nonpharmacologic
Marijuana
approaches
do not support
cocaine smoking.
Impact of Nutrition in Clinical Practice
to management
the existence of fatigue.
Emerging studies
of a relationship between developtables (e.g.,
to the broccoli and
constipating cauliflower)
effects Impact of Nutrition in Clinical Practice
of these were associated
medications.
with a lower risk for lung cancer. Results are inconsis-
Nutrition at the End of Life
features highlight the importance of nutri-
marijuana smoking, pulmonary damage, and lung
cancer.9 The pulmonary effects of cocaine smoking are
tent, but
CLINICAL POINT:drinking
Becausegreen teaconstipating
of the may be protective against
effects ofKouba
Joanne opioid
lung cancer.
medications, 11
all patients on long-term opioid therapy should be placed
tion Constipation
53.9 in health promotion, disease preven-
not fully understood,10 but the changes in the bronchial
Gender. Women
on■a■ preventive protocol may including a At
be more susceptible
for constipation, tothe
theend
laxative. ■ of life, the goal is for the patient to eat for pleasure and
carcino- gastrostomy or nasogastric tubes are limited to patients who state
epithelium are similar to the premalignant epithelial satisfaction. Dietary restrictions are eliminated, and patients are that they are hungry but do not have the mechanical ability to eat.
tion, and nursing management of patients.
changes seen
Constipation is theininfrequent
cigarette smokers.
passage of small amounts of
genic effects of smoking, possibly because
Terminally
in DNA repair ill patients
mechanismsare alsoandpredisposed
hormonal
of differences
encouraged
Intothe
to constipa-
factors. eat and drink whatever foods and fluids appeal to Artificial hydration and nutrition at the end of life is a subject of
■■ Secondhand
hard, dry stool. Thissmoke.common Passive smoke exposure distress-
yet underrecognized doubles them. Patients and family members must receive information about considerable controversy. The benefits must be weighed against
tion because their women
United States, typical diet
youngeris inadequate
than 50 years in both
of agefluid,
have
lung cancer
ing symptom riskinfor
occurs anexposures during childhood
estimated 51–84% and
of hospice and anorexia and cachexia as an expected consequence of end-stage the burdens of such treatment, including the associated risks
leading to increased fluid absorption
a disproportionately high rate offrom lungintestinal
cancer. contents
adolescence and increases for spouses with the number disease. They should be informed that better care or increased of fluid overload, peripheral and pulmonary edema, electrolyte
palliative care patients; the incidence and severity increase as and harder stool, and fiber, decreasing the bulk of stool and
effort to feed the patient will not reverse cachexia because the pro- imbalances, infection, and aspiration into the lungs. A decrease
of pack-years
the time exposure. 43,44,45 Constipation can contrib-
of death approaches. peristalsis. These patients also become physically inactive andprotein degradation is not due just to decreased
cess of muscle in food and fluid intake is part of the normal process of dying;
ute
■■ toOccupational
other symptoms, exposures.
including Exposure
pain andto environmental
vomiting. Etiologygeneral
develop and Pathogenesis
debility with muscle weakness. Generalized
caloric intake and therefore does not respond to interventions such as death approaches, parenteral and enteral feeding does not
and occupational carcinogens increases the risk for lung The primary
pain, diminished cause of lung cancer
consciousness, lossisofcigarette
normalas smoking,
bowel thenutrition or high-calorie foods. Enteral feedings via
routine,
supplemental improve symptoms or prolong life.
Etiology and Pathogenesis result of the carcinogenic character
cancer, and risks are greatly increased when the exposed and inadequate privacy during toiletingofdue
multiple
to needchemicals
for assis-
Peristaltic muscle contractions in the gastrointestinal
The best-knowntract in cigarette smoke.
individual also smokes cigarettes. risk tance are other factorsThe thatchemicals
may contribute bind toand mutate DNA
constipation.
mix intestinal
factors arecontents,
exposuresaiding to radonin digestion
and asbestos.andOther
the move-
expo- (see the feature on Genetics and Genomics for Clinical
mentsuresof unabsorbed content onward
related to lung cancer include polycyclic to the rectum for
aromatic Clinical
Practice).Manifestations
12 There is a linear ofrelationship
Constipation between the inten-
excretion. In constipation,
hydrocarbons, nickel, and thisarsenic,
transit time
whichiscan
prolonged.
occur as sity
In of smoking
evaluating and progressive
a patient epithelial
for constipation, it ischanges.
important As to in
At the end of life, in
contaminants constipation
tobacco or in often
some results from several
industries. other cancers, exposure to carcinogens
first ask about the patient’s normal bowel causes
pattern, a stepwise
includ-
factors, including the primary disease that is causing the ing the typical frequency, amount, characteristics, and time
terminal illness, concurrent diseases, treatment-related of bowel movements. Patients with constipation often
M53_SORE4783_01_SE_C53.indd 14 3/30/17 7:33 AM
variables, medications, dietary factors, and physical report abdominal cramping, pain, and bloating; nausea;
Genetics and Genomics for Clinical Practice
inactivity. Disease-related conditions that contribute to straining on attempting a bowel movement; and rectal
constipation
DNA Mutation in terminally ill patients include primary
in Lung Cancer pressure. On physical examination, common findings
and metastatic tumor growth, spinal cord compression, include abdominal distention, hypoactive bowel sounds,
ascites, and hypercalcemia.
A variety of oncogenes (e.g.,
cKIT), deleted
ing chronic or mutated
neurologic
Concurrent
and tumor
MYC, KRAS, diseases, includ-
EGFR, c-MET,
suppressor conditions,
neuromuscular genes such as
and EGFR
and tyrosine kinase
hemorrhoids. inhibitors.
The
12 The importance of this genetic
rectal examination may reveal fecal
research is that it will allow targeting of the specific sensitivities
Genetics and Genomics for
impaction.
p53, fusion
diabetes, genes such asand
hypothyroidism, EML4-ALK, 12 and activated signal
diverticular
transduction molecules have been associated with lung can-
disease, can of a tumor with oncology medications that will interfere with
Linking Pathophysiology
tumor growth. 12,13
to Diagnosis and Treatment
Clinical Practice features demonstrate
slow bowel motility. Treatment-related variables include
bowel
cer. The pattern for specific genetic alterations varies with the
adhesions from surgery and radiation-induced
type or subtype of lung cancer. For example, KRAS is most
The diagnosis
CLINICAL of constipation
POINT: is based
Cigarette smoking on the
has been frequency
directly linked the foundational importance of genetics
fibrosis. Medications that frequently lead to constipation oftobowel movements
by a and themetabolite
consistency of fecal matter.
common
include
smoke,
genetic mutation
antidepressants,
while epidermal
in adenocarcinomas
anticholinergics,
in women who
anticonvulsants,
growth factor receptor gene (EGFR) The
DNA mutations
optimal management
specific
approach for
of benzo(a)pyrene
constipation
in
is to
cigarette smoke that damages three specific loci on the p53 tumor
and genomics in the study of
occurs more commonly in adenocarcinomas in women who do
not smoke and Asians; p53 mutations occur most commonly
suppressor gene. The p53 tumor suppressor gene mutations are pathophysiology.
present in approximately 60% of all lung cancers. Cigarette smoke
in squamous cell carcinomas but also are present in small cell
contains over 200 carcinogens that act as initiators (polycyclic
carcinomas.12 The EML4-ALK fusion gene in non–small cell lung
cancer does not exist with EGFR or KRAS mutations, and its aromatic hydrocarbons), promoters (phenol derivatives), and con-
presence identifies a subset of individuals with non–small cell taminants such as radioactive elements, arsenic, nickel, molds,
M53_SORE4783_01_SE_C53.indd 16 2/21/17 7:50 PM
lung cancer that will respond to ALK-targeted agents but not and additives.■

xv
M19_SORE4783_01_SE_C19.indd 5 4/13/17 6:34 PM
 Visuals
All of the artwork in Pathophysiology: Concepts of Human Disease has been specifi-
cally created for this text. It is attractive, realistic, and accurate. Visual learners in particular
will be delighted to see the detailed illustrations.

16 Chapterintracranial
5 Increased
Health Risks of Obesity
pressure
and Physical Inactivity
Trauma 6GPUKQPRPGWOQVJQTCZ

Communication

5.4 Health Risks of Physical cardiorespiratory endurance, skeletal muscle endurance,

deficits
Ischemia Intracranial
Regulation
skeletal muscle strength, body composition, and flexibility.

Cognitive deficits
Inactivity Oxygenation Perfusion
Sensory Perception Visual disturbances The primary components of performance-related physi-
cal fitness include agility, balance, coordination, muscle
Historically, high levels of physical activity have been strength and power, speed of movement, and reaction time
associated with improved health outcomes. Cognition The first Cognitive com- deficits(Figure 5.11 ■). There are interrelationships +PURKTCVKQP between health-
'ZRKTCVKQP

Swallowing prehensive and influential reports on the role of physical related physical fitness and performance-related physical
Trauma 0QPVGPUKQPRPGWOQVJQTCZ
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difficulties
activity in health and disease, Physical Activity and Health: A fitness. For example, physical balance may be a component
Report of the Surgeon General, was published in 1996.57 This of performance-related fitness in athletes; however, physi-
Primary
report provided historical background
Subdural
hematoma
Tissue
compression
and discussed the cal balance tumor may also be a component of health-related fit-

evolution of physical activity recommendations, address- ness in patients with a neurologic disorder. The individual
Basement
Proliferation Malignant membrane
ing the physiologic responses and long-term adaptations to importance
cells of any component depends on the health- or
exercise, the effects of physical activity on health andContact dis-with performance-related goal.
basement
ease, patterns and
Stage 1 trends in physical activity, and the role of
membrane
Extracellular
matrix
physical activity in health promotion activities. The report extracellular matrixPhysical Activity and Health-Related
Passage through
+PURKTCVKQP 'ZRKTCVKQP

concluded that people of all ages could benefit from regular

physical activity. Unfortunately,
Genetics Environmentthe number of people par-
Intravasation
Physical Fitness 1
ticipating in physical activity programs since the publica- levels of physical activityKlein_Quinn_Sorenson_9780133474783
Higher Lymphocyte are associated
Central nervous with lower
Lymphatic spread system
tion of this report has not increased substantially. mortality rates for adults of all ages;• Cortex thoseFig17-04.eps
who are moderately 2
Klein_Quinn_Sorenson_9780133474783
The U.S. Department of Disease Prevention and Health
Insulin resistance Venous on a regular basis have lower•• Thalamus
activePlatelets
Ch03, 07 , 17_Artproof
mortality rates than thoseVestibular
Hypothalamus system
Promotion publishedFig27-01.eps the first edition of the Physical Activ- thromboembolism
who are less active. Physical activity
width 366pt height 380pt
• Meninges
has a number of impor-• H receptor 1
• M receptor
ity Guidelines forArtproof_Ch25,
Americans27, in34,2008;
50 the second edition of tant physiologic effects, particularly on the cardiorespiratory,
1

Adherence to
these guidelines are in development. They were developed vessel wall metabolic, endocrine, and musculoskeletal systems and Fourth on ventricle
width 487pt height 230pt
and synthesized from review of scientific evidence on
Hyperinsulinemia the
Extravasation mental health. In addition, physical activity is used to prevent 3
health benefits of physical activity.58 These guidelines reflect Metastatic deposit and treat of a number of chronic diseases, such as cancer. trigger zone (CTZ)
Chemoreceptor

the consensus of several experts on physical activity recom- • Chemoreceptors

mendations andrestoration
Temporary provide the emphasis for health promotion
Angiogenesis
All-Cause Mortality • D receptor
2
• 5-HT receptor
3
of normal glucose
initiatives to address the growing problem of physical activ-
homeostasis
Proliferation
There is a large body of scientific evidence regarding the
Metastatic
ity and sedentary lifestyles. The Physical Activity Guidelines relationship between tumor physical activity and all-cause mortal- Vomiting
CTZ

for Americans can be accessed at http://www.health.gov/ ity rates. Studies examining these relationships are usually center

paguidelines. large longitudinal cohort studies. In such studies, groups 4

of
Before discussing the relationship between physical individuals may be followed over long periods of timeGastrointestinal to
tract
inactivity and various health conditions, it is important examine trends and effects associated with variables such• as Mechanoreceptors
• Chemoreceptors
Respiratory
to review the conceptual definitions Neurologic
of physical activity, physical activity. Available data consistently show an inverse • 5-HT receptor
3

• Viscous, sticky mucusphysical fitness, and exercise. The terms

• Respiratory infections
• Depression physical activity and relationship between physical activity and all-cause mortal-
• Anxiety
• Chronic cough
• Chronic sinusitis exercise are often used interchangeably; however, there are ity; during follow-up observation, the most active individu-
• Bronchiectasis Klein_Quinn_Sorenson_9780133474783
• Pneumonia
• Cysts
commonalities and differences between the two concepts. als experience a greater reduction in the risk of mortality
• Fibrosis
• Pneumothorax Both physical activity and exercise involve
Fig37-09.eps Cardiovascular bodily movement compared with the least active.58 There is evidence to suggest
producedCh37_Artproof
by contraction of skeletal muscle that increases
• Clubbing of fingers and toes
• Cyanosis

energy expenditure above basal levels. This energy expen-

Gastrointestinal width 256pt height 272pt
• Chronic diarrhea
diture is measured in kilocalories ranging on a continuum
• Nutritional deficiencies
• Obstructed pancreaticfromducts low to high. Physical activity Reproductive and exercise are charac-
• Blocked bile ducts
• Delayed puberty
• Gallstones
• Abdominal pain terized according to mode, intensity,• Blockage and orpurpose
vas deferens
absence of (e.g., occu-
• Bowel obstruction/
intussusception pational, leisure-time, household). Exercise (men and women)is a subcategory
• Decreased fertility

• Pregnancy complications
of physical activity that is planned, structured, and repetitive
and with a goal of improvement or maintenance of one or Performance-related
Musculoskeletal more components of physical fitness as the objective.59
Integumentary
physical fitness
The term physical fitness has been defined in a number
• Delayed growth and • Salty skin
development
• Osteopenia
• Agility
• Osteoporosis
• Fractures of ways. The most accepted definition is “the ability to carry • Balance
out daily tasks with vigor and alertness, without undue • Coordination
• Muscle strength and power
fatigue and with ample energy to enjoy leisure-time pur- • Speed of movement
suits and meet unforeseen emergencies.”59 Physical fitness • Reaction time
can be divided into two major components: health-relatedMetabolic Processes
• Diabetes
and performance-related physical fitness. The goal of
health-related physical fitness is to improve some aspect(s) Figure 5.11 ■ The primary skill-related components of
of health; the goal of performance-related physical fitness performance-related physical fitness are demonstrated by
is to improve some aspect of athletic performance. The pri- Simone Biles, who won four gold medals and one bronze medal
mary components of health-related physical fitness include in gymnastics in the 2016 Olympic Games in Rio de Janeiro.

xvi
MyLab Nursing
MyLab Nursing is an online learning and practice environment that works with the text to
help students master key concepts, prepare for the NCLEX-RN exam, and develop c­ linical
­reasoning skills. Through a new mobile experience, students can study Pathophysiology:
Concepts of Human Disease anytime, anywhere. New adaptive technology with remediation
personalizes learning, moving students beyond memorization to true understanding and
application of the content. MyLab Nursing contains the following features:

Dynamic Study Modules

New adaptive learning modules with remediation that personalize the learning experience
by allowing students to increase both their confidence and their performance while being
assessed in real time.

NCLEX-Style Questions
Practice tests with more than 1000 NCLEX-style questions of various types build student
confidence and prepare them for success on the NCLEX-RN exam. Questions are organized
by Chapter.

xvii
Decision Making Cases
Clinical case studies that provide opportunities for students to practice analyzing information
and making important decisions at key moments in patient care scenarios. These 15 unfolding
case studies are designed to help prepare students for clinical practice.

Pearson eText
Enhances student learning both in and o ­ utside
the classroom. Students can take notes,
­highlight, and bookmark important content,
or engage with interactive and rich media to
achieve greater conceptual understanding of the
text content. Interactive features include audio
clips, pop-up definitions, figures, questions
and answers, the nursing process, hotspots,
and video animations. Some examples of video
animations include:
■ Congenital Heart Defect Animations
­illustrate the many congenital heart d
­ efects
that may occur in new-borns and provide
students the opportunity to see, hear, and
understand how congenital heart defects
impair the correct functioning of the heart
and how they may be corrected.

Instructor Resources
Instructor Resource Manual
Lecture Note Power Points
Test bank

xviii
Contents
Unit I: Foundations of Chapter 4: Stress and Adaptation 77
Pathophysiology 2 4.1 Chapter Overview and Case Studies 78
4.2 Conceptualizations of Stress 79
Chapter 1: Introduction to the Basics of
4.3 The Body in Balance 81
­Pathophysiology 4 4.4 The Body Responding to Stress 82
1.1 The Language of Pathophysiology 5 4.5 The Effects of Stress on Health 85
1.2 Overview of Health and Illness 8 4.6 Stress and Mental Health 88
1.3 The Structure of Pathophysiology: Concepts 4.7 Stress and Physical Health 89
of Human Disease 10 Chapter Summary 93
1.4 Leading Indicators of Morbidity and
Mortality 14
1.5 The Importance of Evidence-based Practice 17
Chapter Summary 17
Unit II: Risks Underlying the
Leading Causes of Morbidity
Chapter 2: Genetics, Genomics, and
Epigenomics 22 and Mortality 98
2.1 Chapter Overview and Case Studies 23 Chapter 5: Health Risks of Obesity
2.2 Molecular Basis of Gene Expression 25 and Physical Inactivity 100
2.3 The Human Genome, Genomics, and 5.1 Chapter Overview and Case Studies 101
Epigenomics 27 5.2 Etiology and Pathophysiology of Obesity 103
2.4 Gene Replication, Transcription, and 5.3 Health Risks of Obesity 109
Translation 28 5.4 Health Risks of Physical Inactivity 114
2.5 Mutations 33 Chapter Summary 116
2.6 Categories of Genetic Disorders 34
2.7 Phenotypic Variations in Human Disease 38 Chapter 6: Risks Related to Substance Use
2.8 Genes and Neoplasia/Malignancies 38 ­Disorders 121
2.9 Genetic- and Genomic-based Diagnostic Tests 39 6.1 Chapter Overview and Case Studies 122
2.10 Linking Pathophysiology to Treatment: 6.2 Anatomy and Neurobiology of the Brain 123
Genetic- and Genomic-based Therapies 40 6.3 Alcohol Use Disorder 126
2.11 Advances in Human Genomics 41 6.4 Tobacco Use Disorder 131
Chapter Summary 42 6.5 Cannabis Use Disorder 134
Chapter 3: Environmental Health Influences 6.6 Stimulant Use Disorders 135
on Disease and Injury 47 6.7 Hallucinogen Use Disorder 138
6.8 Opioid Use Disorder 139
3.1 Chapter Overview and Case Studies 48
Chapter Summary 140
3.2 Environmental Hazard Classification 51
3.3 Key Concepts of Environmental Health from Chapter 7: Risks Related to Sleep Alterations 145
Related Sciences 53 7.1 Chapter Overview and Case Studies 146
3.4 Environmental Epidemiology 64 7.2 Normal Sleep 147
3.5 Pathophysiologic Mechanisms 66 7.3 Measurement of Sleep 150
3.6 Hazards and Health Effects of 7.4 Sleep Deprivation 152
Environmental Agents 67 7.5 Insomnia 153
Chapter Summary 72 7.6 Sleep-Disordered Breathing 155
7.7 Narcolepsy 160
7.8 Restless Legs Syndrome 161
7.9 Parasomnias 162
Chapter Summary 164

xix
Unit III: Fluid, Electrolyte, and Chapter 11: Inflammation 271
11.1 Chapter Overview and Case Studies 272
Acid–Base Imbalances 168 11.2 Functions of the Inflammatory Response in
Chapter 8: Fluid and Electrolyte Imbalances 170 Health and Disease 274
8.1 Chapter Overview and Case Studies 171 11.3 Acute Inflammatory Response 276
8.2 Composition and Distribution of 11.4 Regulation and Termination of Acute
Body Fluids 172 Inflammation 281
8.3 Water and Sodium Imbalances 178 11.5 Morphologic Types and Outcomes of
8.4 Chloride Imbalances 185 Acute Inflammation 282
8.5 Potassium Imbalances 186 11.6 Chronic Inflammation 283
8.6 Calcium Imbalances 188 11.7 Systemic Manifestations of Inflammation 284
8.7 Phosphorus Imbalances 190 11.8 Impaired and Excessive Inflammation 285
8.8 Magnesium Imbalances 191 11.9 Overview of Disorders Associated with
Chronic Inflammation 286
Chapter Summary 193
11.10 Linking Pathophysiology to the Diagnosis
and Treatment of Inflammation 287
Chapter 9: Acid–Base Imbalances 197 Chapter Summary 289
9.1 Chapter Overview and Case Studies 198
9.2 Characteristics of Acids and Bases and
Chapter 12: Neoplasia 294
Their Daily Production in the Body 200 12.1 Chapter Overview and Case Studies 295
9.3 Measures of Hydrogen Ion Concentration 200 12.2 Cell Cycle and Cellular Differentiation 297
9.4 Regulation of Acid–Base Balance 201 12.3 Molecular Basis of Cancer 299
9.5 Types and Effects of Acid–Base Imbalances 208 12.4 Carcinogenesis 303
9.6 Laboratory Tests Used in Assessment 12.5 Cancer Invasion and Metastasis 305
of Acid–Base Status 212 12.6 Epidemiology of Cancer 307
9.7 Respiratory Acidosis 216 12.7 Clinical Manifestations of Cancer 311
9.8 Respiratory Alkalosis 218 12.8 Linking Pathophysiology to Diagnosis and
9.9 Metabolic Acidosis 221 Treatment 313
9.10 Metabolic Alkalosis 224 Chapter Summary 318
9.11 Mixed Acid–Base Imbalances 227
9.12 Stepwise Analysis of Acid–Base
Imbalances 228
Unit V: Infection and
Chapter Summary 229 Disorders of Immunity 324
Chapter 13: Mechanisms of Infection
Unit IV: Cell Injury, Inflammation, and Host Protection 326
and Alterations of Cell Growth 13.1 Chapter Overview and Case Studies 327
13.2 The Host–Microbe Relationship 329
and Regulation 236 13.3 From Pathogen to Infectious Disease 331
Chapter 10: Mechanisms of Cell Injury 13.4 Microbial Agents of Infectious Disease 336
and Aging 238 13.5 The Innate and Adaptive Immune
Response to Infectious Microoorganisms 349
10.1 Chapter Overview and Case Studies 239
13.6 Resistance to Infectious Disease 352
10.2 The Cell as the Basic Unit of Disease 240
13.7 Resistance to Different Microbial Pathogens
10.3 Common Causes of Cell Injury 245
as Mediated by Different Host Protective
10.4 Environmental Factors That Cause Mechanisms 353
Cell Injury 249
13.8 Immune Deficient/Susceptible Host 354
10.5 Impact of Injury on Cell Types Present
13.9 Protection from Infectious Disease by
in Many Organs 256
Vaccination 355
10.6 Cellular Responses to Injury 257
Chapter Summary 357
10.7 Cell Death 262
10.8 Aging of the Individual as a Result of
Cellular Aging 264
Chapter Summary 266
xx
Chapter 14: Hypersensitivity and Chapter 19: Neoplastic, Infectious, and
Autoimmune Disorders 363 ­Pulmonary Vascular Respiratory Disorders 465
14.1 Chapter Overview and Case Studies 364 19.1 Chapter Overview and Case Studies 466
14.2 Hypersensitivity Disorders 367 19.2 Malignant Lung Tumors 467
14.3 Autoimmune Disease 374 19.3 Benign Lung Lesions 471
Chapter Summary 378 19.4 Infectious Diseases of the Upper
Respiratory Tract 476
Chapter 15: Immunodeficiency Disorders 381 19.5 Infectious Diseases of the Lower
15.1 Chapter Overview and Case Studies 382 Respiratory Tract 478
15.2 HIV and AIDS 383 19.6 Pulmonary Vascular Disorders 486
15.3 Common Conditions Associated with Chapter Summary 489
HIV/AIDS 391
15.4 Primary Immunodeficiencies 393 Chapter 20: Respiratory Failure 494
Chapter Summary 395 20.1 Chapter Overview and Case Studies 495
20.2 Respiratory Failure: Type I and Type II 496
Chapter 16: Disorders of White
20.3 Disorders Causing Respiratory Failure 501
Blood Cells 400
Chapter Summary 509
16.1 Chapter Overview and Case Studies 401
16.2 Acute Myelogenous Leukemia 403 Chapter 21: Disorders of Oxygen Transport 513
16.3 Acute Lymphocytic Leukemia 406 21.1 Chapter Overview and Case Studies 514
16.4 Chronic Myelogenous Leukemia 408 21.2 Characteristics of Anemia 515
16.5 Chronic Lymphocytic Leukemia 409 21.3 Nutritional Deficiency Anemias 519
16.6 Non-Hodgkin Lymphoma 411 21.4 Hemolytic Anemias 522
16.7 Hodgkin Lymphoma 414 21.5 Anemia of Chronic Disease 527
16.8 Multiple Myeloma 415 21.6 Polycythemia Vera 528
Chapter Summary 416 Chapter Summary 529

Unit VI: Disorders of Unit VII: Disorders of

Oxygenation 422 Perfusion 532
Chapter 17: Restrictive Lung Disorders 424 Chapter 22: Alterations of Hemostasis 534
17.1 Chapter Overview and Case Studies 425 22.1 Chapter Overview and Case Studies 535
17.2 Restrictive Lung Disorders of Pulmonary 22.2 Review of Hemostatic Mechanisms 538
Expansion 427
22.3 Primary Disorders of Hemostasis 539
17.3 Restrictive Lung Disorders of Pulmonary
22.4 Secondary Disorders of Hemostasis 545
Compliance 434
22.5 Issues of Hypercoagulopathy 546
Chapter Summary 436
Chapter Summary 548
Chapter 18: Obstructive Lung Disorders 440
Chapter 23: Vascular Disorders 552
18.1 Chapter Overview and Case Studies 441
23.1 Chapter Overview and Case Studies 553
18.2 Alterations in Respiratory Structure and
23.2 Peripheral Arterial Disease 555
­Function 442
23.3 Chronic Venous Disease 559
18.3 Asthma 445
23.4 Hypertension 562
18.4 Chronic Obstructive Pulmonary Disease 450
Chapter Summary 568
18.5 Cystic Fibrosis 457
18.6 Bronchiectasis 459
Chapter Summary 460

xxi
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 [120] Gesta Regum, i. 4.
[121] Haddan and Stubbs, Councils, iii. 483. The names stand
as follows: “+ Ego Offa Rex Dei dono propriam donationis
libertatem signo sanctæ crucis confirmo. + Ego Ecgferth, filius
Regis, consensi. + Signum Hygeberhti Archiepiscopi. + Signum
Ceolulfi Episcopi. + Signum Æthelheardi Archiepiscopi.” Followed
by eight bishops and three abbats.
[122] It has already been noted that Alcuin found it very difficult
to shed tears.
[123] “Ceolmund the duke,” “Ceolmund the minister,” often
appears in the Mercian documents of the time.
[124] Simeon of Durham, under the year 779, has the entry,
Duke Aldred, the slayer of King Ethelred, was slain by Duke
Thorhtmund in revenge for his lord.
[125] This amounts to an official representation of the three
great powers, the West Saxons, the Mercians, and the
Northumbrians.
[126] Haddan and Stubbs, iii. 486.
[127] An Irishman.
[128] From 784 to 819.
[129] Haddan and Stubbs, iii. 487.
[130] We know nothing certain of this person.
[131] We cannot trace his pedigree.
[132] Simeon of Durham says that he committed suicide.
[133] In theory, at least, we know better now.
[134] a.d. 779 to 788.
[135] James ii. 13.
[136] Pet. iv. 17.
[137] He died in 703.
[138] He resigned in 716, and took from the library of
Wearmouth the Codex Amiatinus as a present to the Pope. This
huge and noble codex is now in the Laurenziana, in Florence.
See my Lessons from Early English Church History, pp. 72-75.
[139] See my Theodore and Wilfrith, pp. 106, 124, and for
Acca’s Cross, pp. 257-61.
 [140] Bishop of Whithern (Candentis-Casae, Ep. 20, usually
Candidae Casae), 777-789; of Hexham, 789-797.
[141] Writing to an Englishman, Alcuin gives his Anglian name
in its Anglian spelling and without a Latin termination.
[142] See p. 123. The full story is given by Simeon of Durham
under the year 790, meaning 791: “In the second year of Ethelred
(i. e. of his restored sovereignty) Duke Eardulf was captured and
taken to Ripon, and was ordered by the said king to be put to
death outside the gate of the monastery. The brethren carried the
body to the church with Gregorian chants, and placed it in a shed
outside the door. He was found after midnight in the church,
alive.”
[143] In April, 796, the Patrician Osbald was made king by
certain leading men of the nation. But after twenty-seven days he
was deserted by the whole of the royal family and the chief men,
and was put to flight and banished from the kingdom. He escaped
with a few followers to the Isle of Lindisfarne, and thence went by
sea with some of the brethren to the king of the Picts. Sim. Dur.
795.
[144] Slain at Cobre (Corbridge has been suggested), April 18,
796.
[145] The Picts of the east of Scotland.
[146] Matt. xviii. 15, “Go and tell him his fault between thee and
him alone.”
[147] John viii. 34.
[148] Cant. viii. 7.
[149] 1 Tim. v. 20.
[150] Matt. xii. 50. It will be seen that Alcuin does not quote
exactly. The Vulgate has frater et soror et mater.
[151] Insula Sanctorum et Doctorum, p. 272.
[152] No doubt oil specially pure, and vegetable; we may safely
say olive oil, for purposes of chrism. Theodore of Canterbury
informs us (Theodore and Wilfrith, S.P.C.K. p. 180) that
“according to the Greeks a presbyter can ... make the oil for
exorcism and the chrism for the sick, if necessary; but according
to the Romans only a bishop can do so”. Hence the mention of
bishops in the letter of Alcuin. See also page 245, note 2.
 [153] In this case Alcuin writes Karli regis; in other cases he
uses the full form Carolus, which comes from rolling the r in
Karlus.
[154] Shekels. On the argument that the didrachma was the
shekel in the New Testament the sicle may be put at 1s. 7½d., but
that gives no idea of its purchasing power then, which was
probably nearer £1. It will be seen that in a later sentence sicles
of pure gold are specified.
[155] See p. 79.
[156] As in year the Anglo-Saxon g was pronounced as y,
hence the name Mayo. In east Yorkshire a gate is still called a
yet.
[157] See Appendix B.
[158] The passage is incomplete, but this is the sense of it.
[159] This is not Lull of Malmesbury, who was so great a help to
Boniface; he died an archbishop in 787.
[160] A presbyter, who succeeded his namesake in the
archbishopric.
[161] We cannot imagine another dignity open to an aged
Archbishop of York to be preferred to that which he already held.
But it is evident that Alcuin referred to his retirement upon an
abbacy, which would set him comparatively free from calls for
exertion.
[162] Eph. v. 23.
[163] It has been supposed that Alcuin refers to some purpose
of bequeathing the library of York to Eanbald II.
[164] Ecclus. vi. 6.
[165] Ethelred of Northumbria was killed and Offa of Mercia
died in this year 796.
[166] James v. 11. Our version would have suited the occasion
better than the Vulgate, “Ye have heard of the patience of Job.”
[167] In the older MSS. in Deo, which has a subtle unintentional
bearing on the controversy with which we are dealing;
unintentional if, as seems certain, we possess MSS. of the
Athanasian symbol of a date earlier than the beginning of the
heresy of Felix.
 [168] The punctuation is that of Wattenbach and Dümmler.
Migne puts a full stop after the Pope and another after the
Patriarch: this would seem to make singuli refer to two persons
only, the two bishops. The Roman controversialist makes a
different punctuation, putting a full stop after the Pope and
running the three others together. The whole passage ought to be
read in the Latin without any punctuation. See Appendix C, p.
319.
[169] Ep. 30, a.d. 793.
[170] But see p. 283.
[171] Bede i. 25, “Imaginem Domini salvatoris in tabula
depictam.”
[172] The historian-monk of St. Gallen says that his new eyes
were better than his old ones, both for use and to look at.
[173] Ep. 120, to Arno.
[174] The account which follows is taken from the
contemporary annals of Eginhart.
[175] Under the year 800.
[176] The actual words are given by Baronius, but with a vague
reference to his authority. They are given at length by Milman,
Hist. of Lat. Christianity, ii. 205.
[177] The ordinary word for the crypt or other receptacle of the
body of a saint.
[178] Stephen I was Pope 252 to 257. Another Stephen was
elected on March 14, 752, but died before his consecration. On
March 26, 752, the Stephen here spoken of was elected. He is
thus more properly called Stephen II than Stephen III; and
Stephen IV, who appears in Karl’s time, should be called Stephen
III. Many writers, however, call them Stephen III and Stephen IV.
[179] Labbe, Concil. xii. 539.
[180] Labbe, Concil. xii. 543.
[181] See p. 26.
[182] The district was rich in wine, fruit, flowers, and honey.
[183] Archbishop Albert of York; see p. 84.
[184] Solomon’s Song, iv. 12—v. 2.
[185] Isaiah, lv. 1.
 [186] But see p. 209.
[187] There are great difficulties in the way of accepting this
statement of a mission by Karl in 773. The passage calls Albinus
deliciosus ipsius regis, and is quoted by Ducange as an evidence
of the use of the word. It appears to imply a more intimate
acquaintance than at that early date there can have been.
[188] In modern times, better wine is grown near Tours than
near Orleans. The wines of Vouvray, for example, beyond
Marmoutier, are much esteemed. A waiter at Tours concedes that
wine is still grown at Orleans, mais pas de spécialité comme ici.
[189] The spellings of ordinary names are varied in those times
almost at will, and it is interesting to note how often the letter h
plays a part in the variation.
[190] 1 Chron. xxvii. 27.
[191] Song of Songs, ii. 4. Alcuin takes on the whole the
Vulgate version. It will be seen by reference to the text and
margin of the Authorised and the Revised Versions that there is
much variety in the rendering of the Hebrew, especially as
regards the word here rendered “flowers”. The Septuagint gives a
sixth meaning, “perfumes” or “unguents”.
[192] 1 Chron. xxvii. 32. Alcuin makes here an unusually bold
use of Scripture, first in taking to himself the description of David’s
uncle, Jonathan, and then in putting into his mouth a cento of
phrases from Judges xvi. 4, Jer. xlviii. 33, Prov. v. 16.
[193] This song is built up from Song of Solomon vii. 12, v. 1, 2,
vii. 9, vi. 3, and Isa lv. 1.
[194] Song of Songs v. 3.
[195] Luke xi. 5, 7.
[196] 2 Sam. xxi. 1, 2.
[197] This appears to be going beyond a joke.
[198] Prov. xxv. 24.
[199] This is of course not the usually assigned derivation; but it
sounds the more reasonable of the two.
[200] Plate II.
[201] Plate III.
[202] Plate IV.
 [203] Multitudo paganorum idolatriis dedita. Per cryptas et
latibula cum paucis Christianis per eumdem conversis, mysterium
solemnitatis diei Dominici clanculo celebrabat.
[204] See p. 221.
[205] For further extracts from Hadrian’s decree, see p. 228.
[206] His last testament is printed by Migne in the Appendix to
the works of Gregory of Tours, columns 1148-51. “Simul et omnes
libros meos praeter Evangeliorum librum quem scripsit Hilarius
quondam Pictavensis sacerdos quem tibi Eufronio fratri et
consacerdoti dilectissimo cum prefata theca do lego volo statuo.”
This theca was one of silver, containing relics of saints, which he
used to carry about with him. Another theca, gilt, was in his chest,
with two chalices of gold and a gold cross made by Mabuin; these
he left to his church.
[207] Gesta Regum, i. 3.
[208] See p. 203.
[209] But see p. 50.
[210] See p. 217.
[211] Printed in Gallia Christiana under Tours. See p. 228.
[212] See p. 217.
[213] It may be helpful to remember that the abbey was
originally outside the ancient Roman city, and its district was
called Martinopolis. The ancient Gallican bishoprics were
bishoprics of cities rather than of dioceses in our wide sense of
the word. This may conceivably have a bearing on the curious
question raised by Hadrian.
[214] See my Constitution of French Chapters, Proceedings of
St. Paul’s Ecclesiological Society, Vol. III, 1895.
[215] Micah v. 5, 6.
[216] James ii. 13.
[217] We know from other sources that this “&c.” meant Most
Serene Augustus, crowned by God, great peace-making
Emperor, Governor of the Roman Empire, by the mercy of God
King of the Franks and of the Lombards.
[218] The emperor irresistibly reminds us of the Eton master
and the boy who complained that his name was not that called for
punishment:—

Sive tu mavis Bōsănquet vocari

Sive Bōsănquet,
Te vapulabo.

[219] That is, Theodulfus, the Bishop of Orleans.

[220] Romans xiv. 4.
[221] 1 Kings xx. 42.
[222] This refers, no doubt, to the immunity of St. Martin’s from
the intervention of the Archbishop.
[223] Eulogias. Wattenbach and Dümmler gloss this cibos.
From its original meaning of the consecrated wafer it came to
mean the pain benit, then any present, and then a salutation.
There is no clue to its special meaning here.
[224] The character of the Latin verse may be gathered from
the closing words of this hexameter, est non laudabile cui nil.
[225] In another poem Theodulf begs Queen Luitgard to send
him some oil of balsam, to enable him to compose and
consecrate cream for chrism. We must suppose that Luitgard had
some special connexion with ports to which balsams were
brought.

Balsameum regina mihi transmitte liquorem,

Quo bene per populos chrismatis unguen eat.
Inde seges crescet tibimet mercedis opimae
Christicolum nomen cum dabit unguen idem.

[226] See p. 33.

[227] That is, a summary, epitome; not as yet a service-book.
[228] Ps. lxx. 14. The Vulgate, which Alcuin quotes, has more
point for his present purpose, adiiciam super omnem laudem
tuam, “I will add Thy praise above all praise.”
[229] Exod. xxiii. 8. Alcuin reads corda sapientium where the
Vulgate has prudentes.
[230] The letter was written in Lent. Easter day in 800 was April
19.
[231] These were Gisla, Charlemagne’s sister, and Rodtruda,
his daughter; see also p. 253.
 [232] Adapted from chapters i and ii of Solomon’s Song.
[233]

Nomine pandecten proprio vocitare memento

Hoc corpus sacrum, lector, in ore tuo.
Quid nunc a multis constat bibliotheca dictum
Nomine non proprio, ut lingua pelasga probat.

A pandect was the whole Bible, Old and New Testament, as its
name, “containing everything,” implies. A bibliotheca, like our
word “library,” meant both a room or case where books were
stored, and also the collection of books in the place; hence it
might be used for the pandect, on the ground that it was a
collection of all the books of the Bible.
[234] Wattenbach and Dümmler, 223-4.
[235] See on this point pp. 86-9.
[236] See my Anglo-Saxon Coronation Forms, and the use of
the word Protestant in the Coronation Oath, S. P. C. K.
[237] That is, if the Pope has recovered from the attempt to
blind him and cut out his tongue.
[238] Presumably, if new charges are made against the Pope.
[239] A reference to Pliny’s Natural History, where wolves are
credited with this power; see also Virgil, Ecl. ix. 53, 54.
[240] A reference to Leo’s denial of the charges against him at
Paderborn, and also to St. Peter’s denial. We must credit Alcuin
with having seen that he would be taken to mean that one was as
true as the other. The denial was renewed at Rome, see p. 189.
[241] See p. 208.
[242] St. Martin’s at Tours.
[243] His pupils.
[244] See p. 72.
[245] It is a curious coincidence that the ivory comb found in St.
Cuthbert’s coffin, provided by Westone after the Norman
Conquest, had—as nearly as we can count—sixty teeth, sixteen
large and forty-four small. Alcuin’s comb may have had the same
double row of teeth, with a knob in the shape of a lion’s head
projecting from the ends of the central ivory.
 [246] Monumenta Alcuiniana, Wattenbach and Dümmler, p. 63.
[247] Italian Alps, Longmans, 1875, Appendix D, pp. 371-3.
[248] Kemble, Cod. Dipl. ii. 208-62. Coolidge, Swiss Travel,
160. “Perpessus sit gelidis glacierum (and glaciarum) flatibus, et
pennino exercitu malignorum spirituum.”
[249] Gesta Pontificum, Rolls series, pp. 25, 26, 265.
[250] See my Lessons from Early English Church History, pp.
45, 46.
[251] Written from Rome; not preserved.
[252] Leo III.
[253] See p. 281 note.
[254] Leo III, see p. 188.
[255] There were two monasteries with this dedication. One of
these, Iuvavense, was at Salzburg, and probably it is the one to
which reference is made.
[256] See p. 168.
[257] It is probable that he was called Cuckoo from the refrain
of some favourite song of his. The Teutonic name for the “bird of
spring” was not a likely personal name, any more than cuckoo is
with us.
[258] See also Epistle 186 in Appendix A.
[259] Here, and in Ep. 108, to Arno, Alcuin combines two
phrases from the Song of Solomon, v. 7 and 8: “The watchmen
have wounded me,” “I am sick of love.” In the letter to Arno he
appears to quote the actual words of a text in his possession:
vulnerata karitate ego sum; in the present letter he writes caritatis
calamo vulneratus sum. The Vulgate has vulneraverunt me—
amore langueo. See p. 275.
[260] Eginhart in his life of Karl (ch. 25) states that the king
studied grammar under Peter of Pisa, an aged deacon.
[261] This was Angilbertus.
[262] That is, Eginhart, the man skilled in many arts, as was
Bezaleel, the chief architect of the Tabernacle.
[263] See p. 33.
[264] The Wends.
 [265] Eginhard tells us under this year 789 that Karl crossed the
Rhine at Cologne with a great army, pushed through Saxony as
far as the Elbe, and brought the Wiltzi to terms. That, he says, is
their name in the Frank tongue. In their own tongue they are
Welatabi.
[266] The Huns, or Avars, had in the previous year invaded Italy
and Bavaria.
[267] See p. 151.
[268] “Amice carissime.”
[269] See my Aldhelm, S.P.C.K., p. 129.
[270] Mansi, Concilia, xiii. 937.
[271] Vienna, 1904.
[272] Cummings, History of Architecture in Italy, ii. 71.
[273] Pertz, Monumenta (Scriptores), ii. 665, 6.
[274] de ista die.
[275] savoir et pouvoir me donne.
[276] chacune.
[277] comme homme.
[278] droit.
[279] faciet.
[280] secundum meum velle.
[281] Concilium Liptinense.
[282] A photograph of this inscription is reproduced at p. 209 of
my Conversion of the Heptarchy.
[283] This must have come very near to being an umbrella.
[284] Dan. xiv. 35, Vulgate.
[285] Bonefatii. This was, of course, the great English
missionary Archbishop of Maintz, martyred at Dorkum in 755.
[286] 1 Cor. xv. 58.
[287] Rom. xii. 2.
[288] Based on 1 Pet. ii. 1.
[289] He was Abbat of Fulda from 780 to 802, when he
resigned the office.
 [290] This, no doubt, is the origin of the tradition that Alcuin
wrote the Office for Trinity Sunday. See pp. 20, 173.
[291] Rom. xiv. 5.
[292] It will be observed that no mention is made of a king of
Kent. See p. 91.
[293] See the list on the next pages.
[294] This would indicate that the aula at which they had met
the king and held the council was one of Offa’s outlying manors,
and not his central royal residence.
[295] Supposed, on slight reasoning, to have been held at
Corbridge, see p. 216.
[296] Besides those in the Pope’s list.
[297] Sacerdos. It is uncertain to how late a date sacerdos is to
be rendered bishop.
[298] Wattenbach and Dümmler give only the headings of the
chapters, as here. The chapters themselves will be found in
Haddan and Stubbs, iii. 448-58.
[299] There are many injunctions that priests and others
serving at the altar must wear drawers. There is quite a large
literature on the subject of these garments (femoralia), in which
such of the early fathers as are given to symbolism find symbolic
meanings. They were an essential part of the dress of the
Levitical priesthood (Exod. xxviii. 42, 43).
[300] Probably referring to the practice of tattooing.
[301] Prudentius (Dipt. i. 3) has “Adam” not “humum”.
[302] This was Tilbert, Bishop of Hexham (Augustald) 781-789.
There is no reason of seniority or priority that should make him
sign above the Archbishop. If, as is probable, the Council was
held at Corbridge, in his diocese, he might sign first as bishop of
the place.
[303] Praesul. In the other signatures episcopus is used.
[304] Candens-casa, usually Candida-casa, so named from its
being the first church built of white stone in that region.
[305] Myensis. see p. 156. Aldulf was consecrated in 786, the
year of this Council, by Eanbald, Tilberht, and Hygbald, at
Corbridge. It is on this account that the Germans think the Council
was held at Corbridge. Hexham would equally meet the case, and
better meets the suggestion of a previous note.
[306] Not as yet identified.
[307] It is rather quaint that Sigha should have chosen placido
mente as the phrase to describe his manner of assent to No. 12
above, for two years later he killed King Aelfwald, and he
eventually died by his own hand.
[308] Of Ripon, 786-787.
[309] Some read Alquinum here, and make Alcuin one of the
two lectores.
[310] The text has two forms of this variously spelled name.
[311] Higbert of Lichfield 779-802.
[312] Lindsey 767-796. The Lindisfaras had nothing to do with
Lindisfarne.
[313] Leicester 781-802.
[314] Elmham 786-811, see p. 159.
[315] London 794-801.
[316] Kinbert of Winchester 785-801.
[317] Hendred of Dunwich, 781-789.
[318] Esne of Hereford 781-789.
[319] Tolta of Selsey 781-789.
[320] Rochester 785-803.
[321] Sherborn 766-793.
[322] Worcester 781-798.
[323] “Aimoini monachi, qui antea Annonii nomine editus est,
Historiae Francorum” Lib. V. Parisiis. 1567.
[324] Omitted in the quotation.
 INDEX

A
Abrenuntiatio diaboli, 295.
Abulabaz, 289, 324.
Acca, 137.
Adalbert, 2, 27.
Adoptionism, 24, 174.
Adoration of Charlemagne, 190, 191.
Aigulf, 32.
Aimoin, 322.
Albert (York), 16, 53, 80.
Albinus (Alcuin), 15.
Alchfrith, 8.
Alchred, 122.
Alcuin, called Flaccus, 1;
Albinus, 15;
studies Virgil, 2, 11;
conversion, 11;
trained by Ecgbert, 12,
by Albert, 16;
a vision, 18;
ordained deacon, 19;
master of the School of York, 20;
joins Karl, 22;
revisits England, 24;
returns to France, 24;
 refutes Felix, 25, 176, 299;
wishes to retire to Fulda, 26;
manner of life, 26;
knowledge of secrets, 2, 29, 30, 33, 34, 223;
extinguishes fire, 37;
writings, 42, 51-3,
poem on York, ch. iv,
lesser poems, 268, 277, 298,
a riddle, 268;
drinks wine, 45,
beer (not English, 267), 45 n.;
interview with the devil, 43;
death, 46, 303;
miracles, 49;
alms for his soul, 224;
his chief dates, 52, 85, 172;
the pallium, 77;
inherits the library of York, 84;
a fisherman, 268;
liturgical work, 260, 308;
singing, 260;
interest in missions, 285-9;
Bibles, 257;
advises reference to Hadrian, 177-9;
settles at Tours, 202;
his styles, 264-9;
mentions Eginhart, 283;
is mentioned by Eginhart, 284;
praised by William of Malmesbury, 52;
described by Theodulf, 45 n., 245.
Alcuin’s letters to:—
Abbat, an, 285.
Adalhard, 264.
Arno, 170, 235, 268, 270, 271, 273-6, 287, 289, 298, 299,
300.
Athilhard, 94, 115, 116, 117.
Beornwin, 98.
Bishop, a, (sanctuary), 234.
Britain, the pontiffs of, 157.
Candida Casa, 301.
Candidus and Nathanael, 231.
Charles (Karl’s son), 248, 250.
Colcu, 150, 286.
Cuckoo, the, 168, 169.
Dunwich and Elmham, 159, 301.
Eanbald I, 161.
Eanbald II, 164, 166, 167.
Eardulf, 141.
Elmham and Dunwich, 159, 301.
Etheldryth, 146, 148.
Fulda, 305.
Gisla and Rotruda, 253.
Hexham, 137.
Hibernia, 153.
Higbald, 132, 170, 287.
Jarrow, 135.
Joseph, 267.
Karl, 117, 191, 202, 208, 238, 247 (?), 254, 287, 300, 301,
302.
Kenulf, 109.
Leo III, 77.
Lindisfarne, 132, 135.
Mayo, 154.
Megenfrid, 288.
Mercian, a, 107.
Offa, 93, 103.
Osbald, 143.
Paulinus, 270.
Pepin, 252.
Peter of Milan, 270.
Pontiffs of Britain, 157.
Remedius, 270.
Rotruda, 253.
Theodulf, 206.
 Uulfhard, 205.
Wearmouth, 135.
York, 162.
Aldhelm, 52, 107.
Aldric, 2.
Alfwold, 123.
Alps, 269-72.
Amalgarius, 242.
Anglo-Saxon, Coronation Forms, 261-3.
Anglo-Saxon, Earliest Examples of, 296, 297.
Archpresbyters, 230.
Areida, 151.
Arno, 47, 276.
Aust, 114.

B
Baldhuninga, 151.
Balther, 79.
Bede, letter to Ecgbert, ch. iii.
Bede, Story of, 70.
Beer, 45 n.
Beer, acid in Northumbria, 267.
Benedict of Aniane, 30.
Beornrad, 7.
Bewcastle Cross, 9, 57, 296.
Bibles, Alcuin’s, 257.
Billfrith, 125.
Biscop, 127.
Bishops, their conduct, 55.
Bishops, dioceses too large, 57.
Bishops, election of, 163.
Boniface, 26, 285, 305.
Boniface, his abrenuntiatio diaboli, 295.
Bouulf, 307.
Bremen, 285.
British Museum, Alcuin’s Bible, 257.

C
Ceolfrith, 78.
Charlemagne, see Karl.
Chur, 269.
Coire, 269.
Colcu, 150-3.
Cold in the Alps, 271-3.
Columba, see Rotruda.
Comb, riddle of, 269.
Constantine Copronymus, 201.
Constantine the Great, Donation by, 195, 320.
Constantine VI, 193.
Cormery, 31, 223-8.
Coronation Forms, Anglo-Saxon, 261-3.
Cuckoo, the (Cuculus), Arno’s letter to, 276.
Cuckoo, Alcuin’s lament on, 277.
 D
Danes, 126.
Devil, interview of Alcuin with, 43;
of St. Martin, 44.
Dictated letters, &c., 7.
Donation of Constantine, 195, 320, 321.
Drithelme, vision of, 273.
Dunwich, 159, 301.

E
Eadbert, 76, 122.
Eadfrith, 125.
Eanbald I (York), 21, 161.
Eanbald II, 163-9.
Eanred, 124.
Eardulf, 123.
Eata, 79.
Ecgbert (Ireland), 8.
Ecgbert (York), 12, 13, 53, 54, 76.
Ecgfrith, 106.
Eginhard (Bezaleel), 33, 283, 284.
Elephants, 289-92.
Elfwald, 124.
Elmham, 159, 301.
Epternach, 6.
Ethelred I, 123.
Ethelred II, 124.
Ethelwald, 122, 125.

F
Felix, 174-9, 298.
Ferrières, 1, 28.
Frankfort, Council of, 183.
Fredegisus (Fridugisus), 27, 226, 227, 256.
Fulda, 26, Appendix A.

G
George, legate, 310.
Gisla (Lucia), 253;
letter to Alcuin, 254, 256.
Graduale, 260.
Gregory, Pope, the Pastoral Care, 169-71.

H
Hadrian I, 21;
raises Lichfield to an Archbishopric, ch. v;
fears Offa, 92;
to be consulted on a treatise of Felix, 177;
letter to Karl, 323.
Harun al Raschid, 324.
Hereditary descent, 5-7.
Hexham, 137.
Higbald, 132.
Huguenots, 210.
 I
Image-worship, 181-3.
Irene, 193.
Itherius, 217, 224-6.

J
Jaenbert of Canterbury, despoiled, ch. v.
Jarrow, 127, 135.
Joseph, Archbishop of Tours, ch. xiv.

K
Karl, 21, 22;
visits Alcuin at Tours, 31;
loved foreigners, 33;
invites Alcuin, 54;
quarrels with Offa, 98;
letters to Offa, 99, 119;
letter to Athelhard, 120;
his visits to Rome, 186-91;
grants to Cormery, 225;
blames the brethren of St. Martin’s, ch. xiv;
letter to Alcuin (sanctuary), 235;
described by Theodulf, 245;
questions to Alcuin, 280-4;
described by Eginhart, 284.
Kenulf, 93, 111.

L
Languages of Carolingian times, 292-6.
Lectores, 317.