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1

When you think benzene exposure, which condition do you think of MC?

Leukemia

2

How are we exposed to VOCs (3)?

dermal
inhalation
ingestion

3

What main systems are affected by VOC exposure (3)?

neurologic
immune
hematologic (thrombocytopenia, leukemia)

- these are oncogenic compounds, usually

4

Which compound are huffers after?

Toluene
- also known as methyl benzene
- smell of paint thinner

5

What compound is present in dry-cleaned clothing?

tetracholorethylene or PERCs

cause
-developmental
-neurological and
-respiratory effects

6

histology lab uses which compound for tissue processing? what effect does this compound cause and why is it concerning?

Xylene
- dimethylbenzene
- CNS depressant
- can penetrate most clothing

7

What compound is found commonly in chloroseptic and carmex?

phenol

8

Which condition is pathognomonic for asbestos?

Mesothelioma

9

What is the metabolite of nicotine?

cotinine

10

What is the major source of new car smell?

poly vinyl chloride

11

What does PAH stand for? And where does it come from?

Polycyclic aromatic hydrocarbon
- byproduct of burning

12

What are high and low molecular weight examples of PAH and where are they found?

LMW - naphthalene (found in mothballs)
HMW - benzo-a-pyrine (charred, grilled foods and tobacco smoke)

13

what compound is used a plasticizer and is easily leached?

phthalates

14

What compound can you find in metal cans, plastic or plastic wrap? It increases risk for (3)?

BPA
- xenoestrogen
- increases risk for diabetes, heart and liver problems

15

What are the 6 criteria for air pollutants?

- Carbon monoxide
- nitrogen oxide
- sulfur dioxide
- lead
- ground level ozone
- particulate matter

16

What is a xenobiotic?

anything that is foreign to the body

17

what are the primary routes of excreting environmental contaminants? (3)

Biliary
Urinary
Respiratory

18

What is the predominant CYP in the body?

3A4

19

Generally speaking, is fasting a good idea when considering environmental medicine? Why or why not?

No, biotransformation requires energy and it can only be spared at the expense of GLUCONEOGENESIS*

20

what is the definition of a fossil fuel?

when layers of buried plant and animal matter is exposed to heat and pressure over thousands of years

21

What heavy metal is common in shellfish and the reason we ask patients to avoid eating this food prior to testing.

arsenic

22

Which two pollutants combine to form ground level ozone?

VOC
Nitrogen oxide

23

What is the primary cause of acid rain? What is the pH of acid rain?

nitrogen and sulfur oxides combing with water
pH < 5.6 *

- caused by fossil fuel emissions

24

what is NOT included, when considering environmental medicine?

microbiology

otherwise, we consider: air pollution, heavy metal exposure, toxic chemical exposure and mold

25

What does ecology stand for?

the study of relationships between organisms and their environments

- for us to be healthy, the environment must be healthy

26

What are the common patient demographics (3) of multiple chemical sensitivity?

upper SES (85%)
caucasian
middle age female

-often found as co-morbidity to fatigue and mental health conditions

27

What are the three most common types of occupational cancers?

lung
bladder
mesothelioma

28

hair stylists are at high risk of exposure to this chemical marketed as "keratin-based" hair smoothing products?

formaldehyde
- some say formaldehyde free or dissolving formaldehyde (methylene glycol) or can be released during heating

29

At high levels, this compound can cause parkinsonism symptoms and is a higher exposure risk for welders

manganese
- parkinsonism sis called MANGANISM when at high levels

30

These release a small amount of mercury into the environment when broken

Compact Fluorescent Lightbulbs (CFL)

31

What should we be recommending to patients regarding their windows?

keep them open as much as possible

-maintains moderate humidity and temperature
-lets in some fresh air!

32

What does PTFE stand for and where can you find it?

polytetrafluoroethylene (PTFE)
- found in TEFLON cookware
- can cause PTFE toxicosis

when tested in birds with high respiratory efficiency, killed all 7 recently hatched chickens after heat lamp coated with PTFE exposure

33

How do organophosphates work in the body? What clinical picture do they create?

acetylcholinesterase inhibitors
- induce neurotoxicity

clinically:
- fatigue, HA, brain fog, slow response time, mm weakness

34

what can you replace mothballs with that work just as well?

cedar chips

35

is indoor air quality better or worse than outdoor air quality?

indoor air is 2-5x worse than outdoor

36

this compound has mostly resp. and mucous membrane health effects to the URT but not LRT because solubility prevents access to LRT - what compound is this?

Formaldehyde

37

What are the VOCs to be known? (6)

Benzene
Formaldehyde
Phenol
Toluene
Vinyl Chloride/PVC
Xylene

38

this compound is a byproduct of volcanoes, forest fires, carbon combustion as well as glues and paints?

benzene
- leukemia (cause cells not to work effectively)

39

this compound is 25x more reactive than benzene

methyl benzene otherwise known as:
TOLUENE

40

what is the primary target for toxicity in both acute and chronic toluene exposure?

CNS**

41

What is the Dx criteria for multiple chemical sensitivity

-Reproducible Sx
-Condition Persisted
-Low exposure leads to sx
-Sx improve when chemical removed
-Sx involve multiple organ systems

42

Difference between sick-building syndrome and building related illness

Sick building:
sx of ill health seem linked to a building but no specific cause is identified

Building related illness:
recognized diseases caused by being in a building

43

Main chemical in Brazilian Blow-Outs

Formaldehyde

44

What are the health effects of the natural gas exposure see on blood work?

High RBC, Hct, Hgb, and platelets
Low WBC.
(found after increased exposure to hydrogen sulfide in Iranian study)

Respiratory sx in people who use gas appliances

45

What can you potentially be exposed to if a Compact Fluorescent Bulb Breaks?

Mercury

46

What is found in Teflon Cookware?

Polytetrafluorethylene (PTFE)

47

What is a Maximum Residue Limit (MRL)? What is the MC agent?

the limit that the EPA has set for how much pesticide can remain on food
MC - organophosphates

48

What three chemicals are found in Fabric Softeners?

-Quaternary Ammonium Compounds
-Phthlates
-Synthetic Musks

49

What chemical is found in dry cleaned clothes?

-Tetrachloroethylene (PERC)
-a type of VOC

50

What is the concerning additive found in Child Vaccines?

Aluminum

51

What does OSHA stand for?

Occupational Safety and Health Administration

52

What does MSDS Stand for

Material Safety Data Sheet

53

What is the Fourth National Report on Human Exposure to Environmental Chemicals?

-CDC report using data from NHANES to assess levels of environmental chemicals in a U.S. subsample
-Utilizes blood and urinary markers

54

Main System Affected by VOC

-Hematological
-Nervous
-Immune System

55

What are phenols produced from

-Petroleum
-used in the conversion to precursors of plastics
-used in plywood, construction, automotive and appliance industries
-Precursor to many drugs
-Oral anesthetic in Chloraseptic and Carmex but considered to be quite toxic via oral exposure

56

Where do you find formaldehyde?

-Adhesives
-Glues and Dyes
-Pressed Wood Products
-Carpet
-Particle board

57

What is the main health effect of formaldehyde?

attacks respiratory tract and mucous membranes

58

Where do you find Vinyl Chloride?

-New car smell
-Pipes
-Insulation
-Siding
-Shower curtains

59

Which VOC causes hepatic angioscarcoma?

Vinyl Chloride

other diseases:
- raynaud's
- acroosteolysis
- Scleroderma-like skin changes

60

What are the two types of polycyclic aromatic hydrocarbons (PAH)

-LMW/Naphthalene
-HMW/Benzo(a)pyrene

61

What was the first carcinogen discovered

Benzo(a)pyrene

62

Heterocyclic Amines are formed by what?

burning at high temperatures
ex: Benzo(a)pyrene

63

What are some prevention strategies to protect against Polycyclic Aromatic Hydrocarbons (PAH)

-Tobacco cessation/non-grilled meat
-Brassicas
-Antioxidants
-Marinade in Acidic base

64

What metabolite can you test for to measure second hand smoke exposure?

Cotinine

65

Where is asbestos found?

WHAT IS IT?

-Fire proofing
-Insulation
-Friction products
-Tile

component of PM 10 and 2.5 (PARTICULATE MATTER)

66

What are 3 health effects of asbestos

-Asbestosis
-Mesothelioma
-Lung Cancer

67

What are the safest numbers of plastic

2
4
- no leeching, no detection in humans

68

What are the just ok plastics?

1
5
- some leeching, no detected health effects

69

What are the un-safe plastic?

3
6
7
- known leeching, known health effects*

70

Polyvinyl Chloride is what number plastic?

Is it safe? Where is it found, medically?

3

Not safe
- significantly increases risk of CV and nervous disease*

-found in IV bags and tubing

71

What number plastic is in trans-vaginal mesh and diapers?

5
polypropylene

72

3 facts about phthalates

-plasticizer
-leeches easily
-causes endocrine disruption

73

What are the health effects of Polystyrene: acute and chronic?

-acute - RESPIRATORY - effects mucous membranes and leads to irritation

-chronic - NEURAL TOXIC - dizziness, fatigue, n/v

74

2 facts about Bisphenol A (BPA)

-Used in food packaging, metal can coating

-Endocrine disruptor

75

What species is black mold?

Stachybotrys chartarum

76

What is the AQI?

Air Quality Index

77

What are 3 MAJOR sources of air pollution?

-power plants
-refineries
-transportation

78

What are 3 smaller sources of air pollution?

-Nail salons
-Dry cleaner
-Autobody shops

79

How is particulate matter classified?

PM10: all particles < or = 10 microns
-asbestos

PM2.5: fine fraction particles
-asbestos
-haze

PM 1.0-2.5: coarse fine fraction particles

Ultrafine: all particles <0.1 microns

80

What is smog and what is the main component?

Mixture of air pollutants and fine particles

Components:

-Ground level ozone (MAIN COMPONENT)
-Nitrogen oxide
-Volatile Organic Compounds
-Sulfur Dioxide
-particulate matter

81

What are the health effects and symptoms of carbon monoxide poisioning

-RBC pick up CO quicker than O2 > tissue necrosis > death


-SX: HA, dizziness, weakness, N/V, chest pain, confusion
At high levels - LOC and death

82

What is the main cause of haze?

PM 2.5, fine fraction particles

83

What is the primary cause of acid rain?

Sulfur dioxide

84

What are Chlorofluorcarbons (CFC)

-Compound consisting of chlorine, fluorine and carbon
-broken down by strong UV light in stratosphere; releasing Cl, which destroys ozone layer

85

What are 3 uses of Chlorofluorcarbons

-Refrigerants
-Solvents
-Foam Blowing Agents

(UV breaks down into Cl, destroying ozone)

86

These were commonly used in the past, but have been removed from the market because of health/environmental effects - what are they?

OrganoCHLORINE pesticides
- DDT
- Chlordane
- Dieldrin
- Heptochlor

87

Two types of acetylcholinesterase inhibitors

organophosphates (more toxic)
carbamates

88

What does the nitrate in fertilizers do?

alter the iron in hemoglobin (ferrous to ferric)
ultimately decreases oxygen carrying capacity of the blood

89

What are the exposure routes of heavy metals?

-Inhalation
-Ingestion
-Dermal Absorption

90

What is LD50?

-Median lethal dose; short term acute poisoning
-Dose given that causes death in 50% of test group

con - wide variability b/w species

91

What are mechanisms of heavy metal toxicity (5)?

-Enzyme/cofactor inhibition or potentiation

-Disruption of membrane and other transport processes

-Disrupt mitochondrial function and fatigue

-Decreased neuronal function and nerve conduction

-Bind sulfhydrl groups on proteins

92

What are potential sources of lead (4)

-Dust (directly correlated with child lead levels)
-Paint
-Soil
- Pre-1978 homes

93

Where is lead still found (7)

-Computers
-Solder
-Pewter
-Ceramic Glaze
-Jewlery
-Auto Batteries
-Imported or older pre-regulation products

94

Who are at most risk for lead exposure

Children and pregnant women's fetus

95

What are sx of lead toxicity

-Decreased learning and memory
-Paralysis
-Encephalopathy
-Fatigue
-Difficulty concentrating
-Irritability

96

What is the best test for lead toxicity screening?

Blood

97

Adult level of lead toxicity

>20mcg/dL

98

Child levels of lead toxicity

<5mcg/DL

99

What may imaging of lead toxicity reveal?

-Abdomen: lead items swallowed

-Long bones: Lead lines

100

What is the difference between elemental, organic and inorganic mercury.

What are their exposure sources

Elemental (inhaled)
- combustion of fossil fuels, solid waste, minning, smelting - source: thermometers, barometer, DENTAL AMALGAMS


Organic (methyl mercury) (GI ABS)
- bioaccumulates in fish; infant born with cerebral palsy
- ethyl mercury - Thimerisol*

Inorganic:
- mercuric chloride, mercuric sulfide,
- source: batteries, disinfectants, health remedies and skin lightening creams

101

What is bioaccumulation

accumulation of substances in an organism

102

What is biomagnification

As you move up the food chain, concentration increases

103

What does mercury bind to, in order to cross BBB - why?

Methylmercury binds to CYSTEINE molecule
-looks similar to methionine, replaces it in the membrane transport system

Not fat soluble must be transported into brain

104

What is contraindicated when you suspect mercury exposure?

NAC because it helps transport mercury into the brain, same mechanism methionine uses

105

What is the predominant use of Cadmium?
What are other sources (3)?

Battery Manufacturing (PREDOMINANT)
-Pigment products
-Coatings
-Plastic Stabilizers

106

What increases cadmium absorption?

Iron deficiency

107

Where does cadmium accumulate in the body

Why is this Concerning?

liver and kidneys

- irreversible proteinuria, progressive loss in GFR
concerning because if you chelate a person with elevated cadmium and try to mobilize for excretion, the key route is through the urine so you risk further damage

108

How does cadmium contribute to osteomalacia and/or osteoporosis


Other health effects?

Increased urinary excretion of
-calcium
-phosphorus
and decreased hydroxylation of Vit D*


Effects lung: pneumonititis, emphysema, lung ca

109

Where is arsenic found?

-Medicine
-Cosmetic lighteners
-Paint pigments
-Industrial wood preservation


110

Where is arsenic best absorbed in the body?

GI tract

111

What is the best test for acute exposure of arsenic

what is another source?

Blood is best

Hair - pros and cons

112

What are the PROs of hair testing for heavy metals

-Good for METHYLMERCURY
-cheap and easy
-Qualitative screening for exposure

NOT DIAGNOSTIC

113

What are cons for hair testing of heavy metals? Which metals are unreliable with this method (3)?

-Only a screen must be confirmed by blood
-No indication of net retention
-Highly vulnerable to external contamination
-No standard procedure

Not reliable for Hg, Cd, Pb

114

What is depuration

-Action or process of freeing something of impurities
-Removal of xenobiotics by the body

115

What is Detoxification

transforming a toxin into a non-toxic substance

116

What is nasal fatigue

you ever notice how when you walk into a room with a terrible smell and you stay there long enough you don't notice it anymore

well your in luck ;)

117

What are the effect of starvation on NADPH and why is starvation not a good idea for biotransformation?

NADPH: component of phase 1 detox

Not a good idea for biotransformation because it can only be produced at expense of gluconeogenesis

118

What is the main CYP in the liver

CYP-3A4

119

Are heavy metals inducers or inhibitors

INHIBITORS

120

What are major TYPES of absorption of biotransformation

-simple diffusion
-passage through pores
-specialized transport systems

121

What are major SITES of absorption of biotransformation

-ingestion
-inhalation
-dermal absorption

122

Major Storage sinks in the body (4)

-Adipose (pesticides)
-Bone (Al, Cd, Pb)
-Liver
-Kidney

123

What are a couple of our barriers?

-BBB
-Placenta

124

What is the MAJOR idea of biotransformation

Conversion of lipid soluble xenobiotic into polar water soluble for excretion

125

Difference between TH1 and TH2 response?

THI:
INFECTION (intracellular bacteria and some viruses)
- IL-2, INF gamma, TNF beta, activates macs

TH2:
WORMS (infestation by GI nematodes)
- IL-4,IL-5, Il-10, IL-14, antibody response and eosinophil activation

126

How do toxins cause immune deficits

-Hypersensitivity reaction (includes allergy)
-Autoimmunity

127

DES, DIOXINE and DDT - cause what?

Atrophy and/or death of the cells of the thymus gland

128

Polychlorinated Biphenols - PCB exposure make people more prone to what?

Allergic reponse

129

PAH exposure does what?

Decreases splenic and thymic activity

130

Lead and Mercury lead to an inability to do what?

kill candida

131

When may selenium supplementation be protective?

cadmium exposure
- can be protective of immune function

132

What is the main problem with Diethylstilbestrol (DES)?

reproductive problems in the offspring

133

What is an endocrine disruptor?

Xenoestrogen

-Phytoestrogen is specifically extracted from plants

134

What are problems with the ways we study xenoestrogens (2)?

-Mostly Animal Studies
-Differing half-lives

135

What environmental exposures can cause infertility in females? (5)

-PAH
-Chemotherapeutic agents
-Solvents
-BPA
-Particulate Matter

136

What causes infertility in males? (2)

-Organophosphates
-Heavy metals

137

What compound looks like thyroid?

-PCBS
polychlorinated biphenyls

138

What are two exposure history forms

-Crinnion
-ATSDR

139

What tests should be ran before doing any specialty heavy metal testing? (7)

-CBC
-CMP
-Lipids
-Complete UA
-Urine HCG
-G6PD
-TB test

140

Is there a good test to determine ACCURATE body burden of heavy metals?

NO

141

Who is a good candidate for stool testing?

Pediatric patients

142

Binding affinities for metals with chelating agents in order of greatest to least. Which is chelated best?

Hg>Ag>CH-Hg>Cu>Pb>Zn

best for mercury

143

is IV or oral administration of chelating agent best?

IV

144

What are the side effects of chelation (3)?

-Decrease in essential minerals
-Increase liver transaminases
-Allergic reaction occasionally

145

Why do you need to avoid seafood for a week prior to metal challenge testing?

Arsenic and Mercury bioaccumulation

146

How do you test for acetylcholinesterase pesticide exposure?

Whole blood AND plasma

Test both

147

What is the theory behind colon hydrotherapy as tx?

Increases bile dumping

148

Why low temp sauna

-Increases lipolysis
-Helpful for excretion of metals in adipose tissue, solvents, plastics and pesticides
-Tolerate longer times

149

Food and supplements that help increase glutathione (7)

-Cysteins (l-cysteine, NAC)
-Glutathione
-Cruciferous veggies
-Dietary Fiber
-Undenatured whey protein
-Dietary Fibers
-Onions and Garlic

150

List some of the basic supportive supplements (4)

-Vit. C
-Fiber
-Selenium
-Zinc

151

this occupation for mothers increases the risk of their children having cleft palate, what occupation is this?

preschool teacher

152

What is being used to replace CFCs (chlorofluorocarbons)?

HCFC (hydrochlorofluorocarbons)
- still break down ozone, but not AS extensively

153

what are heavy metal's main mechanism of detox from the body (i.e. - which phase II mechanism)?

glutathione conjugation

154

blood work for lead poisoning will show?

microcytic hypochromic anemia with basophilic stippling

155

What homeostasis is disrupted by mercury in the body?

calcium homeostasis

156

Whole blood levels for mercury should be?

< 5 mcg/dl