ISBN Flashcards

Question

The Haddon matrix is used for assessing interventions for the prevention of a. Water pollution b. Air pollution c. Radiation exposure d. Injury e. Toxic substance exposure

Answer 1

d. Injury This is a systematic approach to injury prevention developed by William Haddon Jr. of the New York State Department. The matrix categorizes interventions as modifying the host, agent, and environment either before, at the time of, or after the event.

Answer 2

c. Prohibiting feeding garbage to hogs Infection of hogs with nematodes of the genus Trichinella can be prevented by ensuring that all garbage and offal fed to the hogs are heat-treated to destroy the cysts or, preferably, by using feed devoid of animal meat, such as grain. Prohibition of marketing of garbage-fed hogs is easier to enforce than inspection to ensure that all garbage is properly cooked. The disease is transmitted by ingestion of larvae in hog skeletal muscle, not by hog feces. Thorough cooking of pork and pork products so that all the meat reaches at least 71°C (160°F) destroys the encysted larvae. Freezing pork also destroys the larvae if adequate time-temperature schedules are followed. In order to be effective, freezing must be done at −15°C (−5°F) for 30 days if the piece of meat is 15cm in thickness or less.

Answer 3

e. Filtration Slow sand, rapid granular, or membrane filtration is the most effective water treatment method to remove Cryptosporidium cysts, as they are not destroyed by disinfection. Flocculation is used to help form large floc particles from particulate matter including bacteria which can then can be more easily removed. Sedimentation, through gravity, makes particulates including bacteria settle to the bottom of a tank. Flocculation and sedimentation do not effectively remove cysts. It is important to note that high water turbidity may affect the ability of filtration to remove the parasite, and that filtration may not always afford absolute protection. Boiling is not an engineered water sanitation process, but it is the simplest effective method to prevent Cryptosporidium parvum infections if drinking water is contaminated or has not been treated adequately. The water intended for drinking should be boiled for 1 min. Immunosuppressed persons, such as those with HIV, are particularly at risk of severe infections.

Answer 4

a. Air Although most lead intake in humans is from ingestion of lead-contaminated food (about 0.1 mg of lead is ingested daily per person), the amount of lead that is absorbed after inhalation of lead-contaminated air is of greater significance because up to 50% of inhaled lead, compared with only as much as 10% of ingested lead, is absorbed and circulated through the blood. Because modern building codes require the replacement of lead domestic water-supply pipes with those made of copper or galvanized iron, drinking water has become a decreasing source of lead poisoning. The intake of lead through ingestion of lead-based paint is mainly a problem with children. GI absorption of lead appears to be more efficient in children, while pulmonary absorption is more efficient in adults.

Answer 5

b. A hearing conservation program Exposures of 85 dB or more for 8 hrs/day or more require the implementation of a hearing conservation program (HCP) under OSHA (Occupational Safety and Health Administration) regulation. This program includes noise monitoring, engineering controls, administrative control, worker education, selection and use of hearing protection devices (HPD), and periodic audiometric evaluations. Engineering controls where possible are always the preferred method of controlling sound levels. Administrative controls include reducing the amount of time the worker is exposed to high levels of sound. This is often difficult to achieve and requires constant oversight to ensure implementation. Hearing devices must be able to bring the level of sound to 90 dB or less, the permissable exposure level for sound. However, workers may not always wear these devices. At levels of sound below 90 dB, OSHA requires that HPD be made available to workers. At level 90 or above, HPD must be provided and proper use must be enforced by the employer.

Answer 6

e. Cadmium Acute exposure to mercury results in cough, inflammation of the oral cavity, and GI symptoms. Renal injury is of particular concern. Neurological symptoms can later occur. Mercury is often used in the manufacturing of control instruments (such as thermometers). Dimercaprol is used for treatment. Copper toxicity (in the US) is primarily due to accidental ingestion or suicide attempts and leads to intravascular hemolysis and methemoglobinemia. No specific treatment exists. The initial symptoms associated with acute exposure (ingestion or inhalation) of lead are primarily gastrointestinal (abdominal cramps). Encephalopathy can follow. Lead is used intensively in the production of storage batteries. Chromium is used in plating. Acute exposure results in irritation of eyes, nose, and throat with epistaxis.

Answer 7

a. EDTA Chromium is a known carcinogen (lung cancer). Dermatologic conditions are common among chromium workers (ulcerations with delayed healing on fingers, knuckles, and forearms) and are treated with 10% CaNa2 EDTA ointment. Atropine and pralidoxime are used in the treatment of pesticide exposure. Acetylcysteine is used for acetaminophen poisoning.

Answer 8

c. Adenocarcinoma Substances causing adverse biological effects in humans can be classified as reproductive, renal, and respiratory toxins; neurotoxins, dermatotoxins, and hepatotox- ins. It is assumed that there may be some form of dose-response relationship and that there is a minimal exposure below which a toxic effect will not occur (the threshold). The absence of threshold is assumed for any substance that is carcinogenic, mutagenic, and/or teratogenic. There is no safe exposure below which no effect exists. In other words, a nonthreshold effect exists when there is no safe level of exposure to humans.

Answer 9

e. 90% Most cancers are caused by one or a combination of exposure(s) due to the environment or lifestyle such as tobacco smoke, radon, chemicals, asbestos, toxins, and ultraviolet light.

Answer 10

c. Heat exhaustion Heat stroke is characterized by the presence of mental status changes and a core body temperature of more than 39° C. *Cardiovascular collapse will occur if not treated immediately as the body temperature may reach up to 41.1° C. This is a medical emergency requiring IV hydra- tion and rapid cooling: cool water or isopropyl alcohol 70% on the body with fanning, sponge baths, ice packs on the groin/axilla/neck, and/or iced gastric lavage until the core body temperature drops to 39° C. Patients should be advised to avoid heat exposure for at least 4 wks because hypersensitivity to heat may persist for a long period of time after an episode of heat stroke. Heat cramps are characterized by painful muscle cramps along with some nausea and vomiting. The core body temperature is normal. This is caused by sodium depletion due to sweating: the patient should be placed in a cool environment and hydrated with a balanced salt solution. Rest for at least 1 to 3 days is recommended. Heat syncope is a sudden loss of consciousness due to vasodilation secondary to heat.

Answer 11

e. Cool and shaded environment She should be placed in a cool and shaded environment. This patient should also receive hydration and salt replenishment with IV fluids. Milder cases can be treated with oral hydration.

Answer 12

a. 1 day At least 1 day of rest is recommended after heat exhaustion. Heat index guidelines are developed by the National Weather Service and predict risk of heat-related disorders based on ambient heat and humidity.

Answer 13

a. Ames test All the tests listed can be used to screen substances for mutagenesis and carcinogenesis, that is, their ability to interact with genetic material and DNA. The Ames test is the most commonly used rapid screening test and is a bacterial mutation assay. It tests for the reversion of a histidine-requiring Salmonella typhimurium mutant to the wild type. It is very sensitive to DNA damage. The other tests are more sophisticated, take more time, and are more expensive.

Answer 14

c. Atropine The clinical signs are not consistent with heat-related illness, but rather poisoning with the commonly used pesticide carbamate. Symptoms are related to the inhibition of cholinesterase. Mild symptoms are characterized by muscarinic signs and symptoms. Atropine blocks the effect of acetylcholine at the muscarinic receptors.

Answer 15

a. Waste minimization Minimizing waste is the best approach to controlling the problem by reducing the amount of waste generated. Recycling, when possible, is the next best method, followed by incineration when appropriate (organic compounds can be reduced to water, CO2, and heat). Physical treatment is most commonly used for water treatment (sedimentation, filtration, flocculation). Chemical treatment can be used to transform hazardous substances into less-toxic ones. Biological treatment can be used to treat industrial wastewater, a major source of waste.

Answer 16

d. Cosmic rays Natural background radia- tion (terrestrial and cosmic radiation, naturally occurring radionuclides) is the most important source of radiation exposure for all humans. Radiation from manufactured origins accounts for only 20% of all radiation exposure. Terrestrial radiation, consisting of gamma rays (average exposure: 4050 mr em per year), varies with geography, and cosmic radiation due to cosmic rays (average exposure: 4050 mr em per year) increases with altitude. Air travel increases exposure and aircrews have five times greater exposure than the general population. Alpha radiation * very limited penetration because of the large size of the particles and is completely absorbed by the outer layer of the skin; * hazard occurs when these particles enter the body and irradiate living tissue (radon daughters that are inhaled); Beta particles are all internal hazards, but external exposure can be stopped by one inch of water. Cosmic rays are more penetrating than gamma rays. X-rays are indistinguishable from gamma rays, except for their origin (synthetic versus natural terrestrial).

Answer 17

c. Landfill * used to dispose of nonliquid waste only; * is the only method of disposing of radioactive waste safely; Other methods are used to dispose of nonradioactive waste.

Answer 18

d. Toilet flushing ``` Flushing: 40% Bathing: 30% Laundry: 15% Drinking/Cooking: 5% Dishwashing: 5% ```

Answer 19

b. Ozone The major air pollutants are particulates, sulfur oxides, carbon monoxide, oxides of nitrogen, hydrocarbons, lead, and ozone. The latter is formed by sunlight irradiating an atmosphere containing hydrocarbons and oxides of nitrogen, and has been associated with Southern California smog. It has primarily been linked to an exacerbation of asthma. Hydrocarbons are precursors of smog. Carcinogenicity is debated. Oxides of nitrogen are also precursors of smog: important sources are automobiles and airplanes. They are primarily mucosal irritants and studies on respiratory effects are conflicting. CO, although a plentiful pollutant, is quickly transformed into CO2. Increases will aggravate coronary artery disease, precipitate MI, and reduce exercise tolerance. Particulate matter will most severely affect persons with COPD. Sulfur oxide is the most important air pollutant.

Answer 20

e. Ultraviolet radiation B Ultraviolet radiation covers the spectrum between visible radiation (light) and ionizing radiation (100400 nm). Ultraviolet radiation B * ranges fr om 280 to 315 nm, the range to which the eye is particularly sensitive &where most injuries occur; * Acute exposure to UV of less than 315 nm results in photokeratoconjunctivitis, with symptoms appearing 6 to 12 hours after exposure; * Prolonged exposures to UV between 295 and 320 nm can result in cataract formation; Ultraviolet A * ranges from 315 to 400 nm. Injuries caused by visible radiation (light); * covers the spectrum between infrared & UV radiation (400750 nm); * affect primarily the retina, which is most sensitive to blue light (eclipse blindness); Infrared light * covers the spectrum between visible light and radiofrequency (750 to 3 million nm); * is given off by any material of a temperature greater than absolute zero; * Thermal injury can occur with intense exposure to infrared light of less than 2000 nm and has been associated with cataract formation.

Answer 21

c. Turbidity * is a major impediment to disinfection. Major steps in potable water treatment are sedimentation, coagulation (often alum is added to facilitate floc formation that will settle more readily) and flocculation, which get rid of 90% of the bacterial load and reduce color and turbidity (see question 239). Filtration eliminates particles which cannot be destroyed by other methods, such a cysts from Cryptosporidium, Entamoeba hystolitica, and Giardia lamblia. Finally, the water is disinfected generally with chlorine whose power is greater at lower pH. Residual levels remain in the water as it is distributed to consumers, a major advantage over ozone.

Answer 22

c. Asbestos Tobacco is still a leading cause of lung cancer. Radon has also been associated with lung cancer, and the combination of radon and tobacco smoke can be synergistic. Lung cancer is responsible for 20% of all asbestos-related deaths. Formaldehyde has been associated with nasopharyngeal cancers. Sulfur oxide is primarily an outdoor pollutant

Answer 23

e. Manganese So-called hard water is primarily due to high concentrations of calcium or manganese. Soft water can be corrosive and leach metals from pipes, especially lead.

Answer 24

c. Proper hand washing by food handlers The short IP and symptoms are characteristic of food poisoning due to the toxin produced by Staphylococcus aureus. Organisms and toxin are not destroyed by freezing. Although the organisms can be killed by heating food to 66° C (150° F), the preformed toxin generally survives. Optimum growth of the bacteria occurs at 59° to 99° F (growth is inhibited at below 39° F), with toxin production optimal after 4-6 hrs. The source is human skin, mouth, and nose. Proper hand washing by food handlers and excluding those with skin infections is the best way to prevent contamination.

Answer 25

e. A urinalysis Dye workers are susceptible to bladder cancer due to exposure to β-Naphtylamine and benzidine. The most common presenting symptom will be gross hematuria or microscopic hematuria. Liver cancer has been associated with exposure to vinyl chloride while hematologic cancers are associated with radiation and benzene exposure. Occupational causes of brain cancer have not been well identified at this time.

Answer 26

a. Rest, fluid, and antipyretics These symptoms are typical of hypersensitivity pneumonitis, which can often be confused with infectious causes such as influenza or Mycoplasma pneumoniae. CXR may be completely normal even in symptomatic individuals. However, typically, the CXR may show bilateral reticulonodular infiltrates. The acute form is characterized by the appearance of symptoms a few hours after short-term high exposure, and resolves after a few hours or days. Treatment should primarily consist of avoiding the causative agent or wearing respiratory protective equipment. Acute episodes resolve on their own without glucocorticosteroids. Prednisone is the treatment for severe or progressive hypersensitivity pneumonitis. Psittacosis has an incubation period of 7-14 days, can be associated with splenomegaly (10 to 70% of cases), and the x-ray generally shows diffuse patchy infiltrates.

Answer 27

c. Treated sewage Biological oxygen demand is a measure of organic content in water. The greater the demand, the greater the load of organic content that can be broken down, reflecting a high bacterial load. (in mg/L BOD) Untreated freshwater: 25; Treated sewage: 1020; Domestic sewage: 200500; Industrial sewage: >2000

Answer 28

c. Barometric pressure Lower barometric pressure associated with air travel will lower the tension of oxygen in the inspired air, the alveolar oxygen tension, and arterial oxygen saturation, which could lead to an exacerbation of coronary artery disease deficiency. Immobilization for long periods of time can increase the risk of thromboembolic disease, which may be more of an issue for pregnant women. Getting up periodically to walk up and down the aisles may help alleviate this problem. The circadian rhythm will be changed due to the change in time zones and peaks of cortisol production will also vary. This can potentially affect the pathophysiology and timing of cardiac events. Cabin air quality studies have shown that the CO, CO2, and respirable particulate levels are below OSHA standards, and that ozone levels are below the Federal Aviation Administration (FAA) standards.

Answer 29

a. An asbestos worker The effect of asbestos and smoking are synergistic for the development of lung cancer. Uranium workers, due to exposure to radon, will also be at greater risk, particularly if they are exposed to higher levels of radiation (a dose response relationship).

Answer 30

a. Headache, nausea, and sleep disturbances (Acute mountain sickness) Acute mountain sickness, as described, is the most common altitude illness and usually occurs in altitudes above 8000 feet (2500 m). Symptoms occur about 3-12 hrs after reaching that level. It will resolve spontaneously after 5-7 days at altitude. High-altitude pulmonary edema can occur (1 to 2% of individuals) at altitudes of over 10,000 feet. Symptoms of tachyp- nea and dyspnea with rales start 2 to 4 days before reaching that altitude. They can be rapidly fatal if not treated. High-altitude cerebral edema occurs occasionally (less than 1% of persons) at altitudes above 15,000 feet, but may occur as low as 9,000 feet in susceptible individuals. Symptoms are describedHeadache, ataxia, and altered mental status. Rapid descent and dexamethasone is the required treatment. Persons may also experience abdominal bloating due to the expansion of gas in the bowel, but it is not associated with diarrhea.

Answer 31

c. Acetazolamide Acetazolamide 125 to 250 mg every 8-12 hrs starting 24 hrs before the ascent and to be continued for 2 days at altitude or 500 mg SR tablet every q24hrs and continued for 2 days at altitude may alleviate symptoms. Dexamethasone 4 mg every 6 to 12 hours is reserved for those intolerant/allergic to Acetazolamide or for treatment of more serious altitude sickness. High-altitude pulmonary edema can be rapidly fatal if not treated. Treatment consists of rapid descent and nifedipine.

Answer 32

e. Alcohol ingestion At least 2/5 of all motor vehicle deaths are alcohol-related. Some statistics report 50%. A motor vehicle crash related death is most likely to occur with a young male, at night, on a rural road in a single-vehicle crash. Most crashes occur in the summer. Use of a larger, more crashworthy vehicle and use of restraints such as seatbelts reduce the incidence of death related to the accident.

Answer 33

c. Pleural mesothelioma Asbestos has been linked to Lung CA, the most common neoplasia associated with this exposure, colon CA, and kidney CA. Pleural and peritoneal mesotheliomas are particular to asbestos exposure. Lung cancers have also been linked to arsenic, beryllium, cadmium, chromium, and mustard gas.

Answer 34

c. Mining and quarrying Mining and quarrying is the most dangerous industry in the United States. Construction is next, followed by agriculture. A shift toward a service industry and away from manufacturing jobs, which involve equipment and machinery, and safer work environments have resulted in overall declines in occupational injury and deaths.

Answer 35

b. Thermal conductivity Conduction is the principal source of heat loss during cold-water immersion. Thermal conductivity of water is 25 times that of air. Alcohol can precipitate heat loss in both air or water immersion due to the vasodilation it produces. Exhaustion may also be a contributing factor to heat loss in water versus air.

Answer 36

a. Nitrogen narcosis * is due to increased partial pressure of nitrogen in the nervous system and symptoms are analogous to alcohol intoxication. Barotrauma (barosinusitis, middle ear or barotitis media) is due to the mechanical effects of expansion and contraction of gases when pressure differences exist between the body cavities and the environment. These two syndromes are manifestations of compression sickness occurring during descent. The bends (so called because the person can be stooped because of severe joint pain) are a form of decompression sickness (also called caisson disease) due to inadequate elimination of dissolved gas after a dive, affecting the skin and joints. Decompression sickness can occur either after a too rapid ascent from a dive below 9 meters or a sudden pressure loss at altitudes above 7000 ft.

Answer 37

d. Dust particles Pneumoconiosis, a fibrosing disease of the lungs, usually occurs as a result of occupational exposure to air that contains particulate matter, especially mineral dust. Anthracosis, silicosis, asbestosis, and berylliosis are among the more than 30 forms of pneumoconioses that have been described in the literature. Sulfur oxides, nitrogen oxides, oil fumes, and cigarette smoke are likely to cause acute bronchospasm or to exacerbate preexisting diseases such as chronic bronchitis and emphysema.

Answer 38

a. 3 to 16 weeks Susceptibility of the central nervous system extends beyond 8 weeks, contrary to most other organ development. The eyes and the ears are usually not susceptible to teratogens. Enhanced susceptibility of the external genitalia starts at a later period than most other organs (about 7 weeks) and extends to 9 weeks. The heart is more susceptible between 3 to 6 weeks.

Answer 39

c. Lead Carbon disulfide, chloroprene, estrogens, excessive heat, lead, and ionizing radiation have all been strongly linked to oligospermia. Exposure to lead can occur during the manufacturing of storage batteries. Chromium, nickel, and antimony levels are measured in urine, but are not associated with oligospermia.

Answer 40

a. A study examining an association with early spontaneous abortion Early spontaneous abortion (SAB) is particularly difficult to evaluate. If the study is prospective, women exposed to a particular substance who may be worried about it may seek earlier medical care, and the pregnancy will be detected earlier. Thus, more losses will be detected compared to women who present at a later time in pregnancy, as early spontaneous abortion is a relatively frequent event. Therefore, it is important to define when and how the pregnancy is diagnosed (chemical versus clinical). If a case-control study is undertaken based on medical records, some early SABs that are due to the exposure may be missed. The other outcomes mentioned can be better defined and are less subject to bias. Cohort studies are particularly well suited to examine pregnancy outcomes given the short follow-up period. However, since some of the outcomes in question can be very rare (such as congenital anomalies), case-control studies may sometimes be more appropriate.

Answer 41

b. Temporary conductive hearing loss Acute exposures to sound pressure levels above 180dB will result in a traumatic rupture of the tympanic membrane and conductive hearing loss. The rupture should repair spontaneously unless infection occurs. If the loss persists for more than three months, surgical repair is possible. Sensorineural loss is generally due to fractures or trauma to the inner ear. Mixed hearing loss can occur secondary to fractures of the temporal bone, when both the middle and the inner ear are traumatized.

Answer 42

c. Eliminating the waist motion Static body and holding positions should be avoided. For instance, persons working at a computer terminal should be reminded to do a short walking task every 20 minutes. Objects can be placed on a supporting surface instead of handheld. Eliminating the waist motion such that everything needed is within arms reach will reduce stress on back, neck, and shoulders. The less torso movement, the better.

Answer 43

b. Repairing cracks in the foundation Radon diffuses from rocks and soil containing uranium during radioactive decay. It can also be found in water. Since 1988, the EPA has recommended that homes below the 3rd flr be tested for radon, which is recognized as the 2nd leading cause of Lung CA after tobacco smoke. Homes that are sealed carry a greater risk of higher concentrations. Keeping the basement free of cracks and holes, aeration, and venting radon-laden air from beneath the foundation can all be helpful. Keeping windows open may not be a very practical solution, but can be effective.

Answer 44

a. Decrease in cardiovascular disease Hard water requires more soap for bathing and laundering. There have been some studies that have demonstrated an inverse relationship between the hardness of water and cardiovascular mortality rates, making an argument against water softening.

Answer 45

b. Beryllium Beryllium causes a syndrome similar to sarcoidosis. Only individuals who are sensitized to the metal will develop the disease. It can also cause granulomas of the skin. Tantalum is increasingly used in alloys for the aerospace industry, but has caused few health problems. Uranium causes exposure to radon, a known carcinogen of the lung. The Kveim-Siltzbach consists of an intradermal injection of a heat-treated suspension of sarcoidosis spleen extract. A biopsy is taken at the site 4-6 wks later. Patients with sarcoidosis will develop sarcoidosis-like lesions in the skin.

Answer 46

d. Meat-packing plants Much of the work requires cutting up carcasses on an assembly with a heavy saw and in a bent position. All of this is done in a refrigerated environment, which predisposes workers to repetitive motion disorders (RMD). The occupation has therefore all of the risk factors for developing RMD: force, repetition, cold temperature, vibration, and bad posture.

Answer 47

b. Escherichia coli The Environmental Protection Agency (EPA) produced guidelines in 1986 recommending that states adopt the enterococcus or E. coli criterion for freshwater and the enterococcus criteria for saltwater, based on the observation that there existed a linear relationship between enterococcus and E. coli (but not coliforms) concentrations and swimming-associated GI symptoms.

Answer 48

Arsenic | chronic exposure

Answer 49

Cadmium Chronic exposure to cadmium can cause Fanconis syndrome (only metal to cause this).

Answer 50

Zinc (acute exposure)

Answer 51

Mercury Exposure to mercury can cause ataxia, spasticity, parethesias, and visual disturbances.

Answer 52

Alcohols Chronic toxicity (which can occur through inhalation) produces optic neuropathy (particular to this type of alcohol; not seen with other solvents)

Answer 53

Acute exposure to PHENOLS causes the tissue destruction. Although all solvents can potentially cause some form of hepatotoxicity if exposure is high and long enough, halogen and nitro group are particularly toxic to the liver.

Answer 54

Formaldehyde (chronic exposure)

Answer 55

Pralidoxine Parathion is an organophosphate pesticide. Pralidoxine can be given for the treatment of organophosphate (but not carbamate) poisoning.

Answer 56

Dimercaprol

Answer 57

Brucellosis Packing and slaughterhouse employees, livestock producers, veterinarians, and hunters are at risk of developing brucellosis caused by a gram negative coccobacillus. Occupational infection usually results from inoculation through abraded skin or mucous membranes: gloves and goggles can prevent this form of spread.

Answer 58

Legionella pneumophila *from contaminated aerosol can be disseminated in the ventilation systems through cooling towers, air-conditioning systems, humidifiers, and decorative fountains. Outbreaks can occur and air conditioner workers and others exposed can be at risk.

Answer 59

Hepatitis B Health care workers are at risk for hepatitis B and should be vaccinated.

Answer 60

Hematopoietic systems (Blood)

Answer 61

b. 0.25 mg per day No supplements are necessary before 6 months of age. <0.3ppm * 6 months to 3 years: 0.25 mg/day; * 3 to 6 years: 0.50 mg/day; * 6 to 16 years: 1.00 mg/day 0. 3 to 0.6 ppm * <3 yrs: not needed; * 3 to 6 years: 0.25 mg/day; * 6 to 16 years: 0.50 mg/day; No supplement is necessary if the level is 0.6 ppm or higher. Fluorosis, a white or brown discoloration of the teeth, can occur if ingestion of fluoride exceeds 4 to 8 mg/day.

Answer 62

a. Decreased intelligence test scores Even low lead levels can be detrimental to the intellectual performance of a child. The single most important intervention in reducing elevated blood lead levels in children is the elimination of lead in their environment, regardless of the level.

Answer 63

d. Elimination of lead in the child's environment Treatments: not considered Chelation therapy: recommended for all children with blood levels above 45 μg/dL. There is considerable debate about the use of chelation therapy when blood levels are between 20 and 45 μg/dL. The CDC recommends that an EDTA mobilization test be considered for children with blood levels between 25 and 44 μg/dL. If the test is positive, which, according to one study, can occur in up to 35% of children with venous lead levels between 25 and 35 μg/dL, then chelation therapy should be administered. Chelation agents include BAL, EDTA (edetate calcium disodium), DMSA, and d-penicillamine. Iron supplements are recommended if the child with elevated blood levels has iron deficiency anemia. Supplements also decrease the absorption of lead and may be considered even in the absence of iron deficiency.

Answer 64

d. 21 It takes a 3500 deficit in calories to lose 1 pound of fat. If exercise only is used to produce the deficit of 1000 calories per week, it will take her 21 weeks to lose 6 pounds of fat. This will probably take her much longer than she thought. This is why dieting is often needed for weight-loss programs.

Answer 65

e. Give clear, personalized advice to quit and readdress the issue at the next visit For patients in a precontemplative stage of change, advising them to quit and personalizing the message to their risk factor is the best approach. It is important to continuously assess smoking status and advise to quit at every encounter to help motivate patients until they are ready for action.

Answer 66

c. Recommend dietary therapy According to the National Cholesterol Education Program (NCEP) guidelines, persons with borderline-high cholesterol 200 to 239 mg/dL with two or more risk factors for coronary heart disease (CHD), in this case, smoking and male = 45 years of age, should have a lipoprotein analysis performed, even if the HDL is 35 mg/dL. Dietary therapy would be the recommendation (no CHD, two or more risk factors) if the LDL is ≥130 mg/dL.

Answer 67

a. Fecal occult blood testing (FOBT) Screening for colon cancer is recommended for all persons age 50 and over. *Fecal occult blood testing (FOBT) has been shown to be effective in reducing mortality from colon cancer by a randomized trial. Influenza vaccine is recommended for persons over the age of 65. None of the other measures are recommended for screening by the U.S. Preventive Services Task Force.

Answer 68

d. Engineering Engineering methods have been the most effective to control injuries, particularly passive methods, such as automobile seatbelts and airbags. Education appears to be the least successful, in general, although it has resulted in behavioral change in some instances. The effectiveness of laws depends on their degree of enforcement. Emergency response will impact the damage resulting from injury, but not its prevention. It has less impact on morbidity than other methods.

Answer 69

e. Using a standardized questionnaire The most effective method to detect early alcohol abuse is to use a structured questionnaire such as the CAGE or MAST. Abnormal serum gamma-glutamyltransferase (GGT) is neither sensitive nor specific enough to use for detection of early alcohol abuse. Blood alcohol levels are used to evaluate acute situations. Although asking the patient seems like a reasonable approach, reliability is variable. Finally, discussion with family members may be indicated if a problem is suspected.

Answer 70

d. Access to firearms The proportion of firearms-related suicides has been increasing in recent years among youth and the elderly. Contrary to other methods, it is highly effective. The more difficult the access to a lethal method, the less likely someone will commit suicide. Limiting access to alcohol and drugs and compliance with therapy and medication will all be helpful to prevent a bad outcome. Social isolation contributes to a depressive state.

Answer 71

d. Injuries Unintentional injury is the leading cause of death for all persons aged 1-24, making it the leading cause of years of potential life lost because of the young age of those most affected. Cardiovascular disease is still the overall leading cause of death in the United States, followed by cancer. HIV infection is the leading cause of death among persons aged 25 to 44.

Answer 72

c. 80-100 mg/dL Behavioral, psychomotor, and cognitive changes can occur with blood alcohol levels of only 20 to 30 mg/dL. However, the legal limit of blood alcohol content (BAC) in most states is 80 to 100 mg/dL (0.1%), although there is a push toward lowering it further in some states. Levels of more than 300 to 400 mg/dL can be lethal. Ethanol either alone or with other intoxicants causes more toxic-overdose deaths than any other agent.

Answer 73

b. Domestic violence It is estimated that between 20 and 25% of pregnant women suffer from domestic violence, and pregnancy is a particularly high-risk period for abuse. Battered women are much more likely to be injured on the chest, breasts, and abdomen than nonabused women. Over half of women who are battered eventually abuse alcohol.

Answer 74

a. Improvements in medical care Improvements in medical care are largely responsible for the decreases in IMR.

Answer 75

c. 100% higher

Answer 76

d. Age Bone loss increases with age, particularly in women after menopause, when lack of estrogen accelerates the process. To a lesser extent, smoking, lack of physical activity, and alcohol abuse can also increase the risk of osteoporosis. Obesity, presumably because it is accompanied by an increase in estrogen production, does not increase the risk of osteoporosis.

Answer 77

d. Venous blood lead Venipuncture is the best way to accurately measure blood lead levels. Capillary blood: is often contaminated and results in falsely elevated levels; more cost-effective to collect venous blood initially than to do so only if the capillary blood level is high. Although many infants with lead poisoning will also have iron deficiency anemia, the CBC will not identify all cases of lead poisoning. The erythrocyte protoporphyrin is no longer recommended for screening as it will not identify lead levels below 25 μg/dL. It may be used for the detection of iron deficiency. Ferritin is used to estimate iron body stores.

Answer 78

a. Ovarian Over 2/3 of cases of ovarian cancer are detected when they are at an advanced stage. Ovarian cancer is responsible for 55% of all gynecologic cancers deaths, while endometrial and cervical cancers are responsible for 23 and 18%, respectively. Invasive cervical cancer is in theory 100% preventable because an effective screening test is available. A significant decrease has occurred in the last 45 years with the introduction of the Pap smear. Cancers of the vulva are less frequent, are more indolent, and account for only about 500 deaths annually. Vaginal cancer is rare.

Answer 79

a. Heart disease, CA, stroke, and COPD ``` Heart disease : 31.4%; Cancer: 23.3%; Stroke: 6.9%; COPD: 4.7%; Unintentional injuries: 4.1%. ```

Answer 80

c. Non-insulin-dependent diabetes T2DM is almost nonexistent in individuals with a BMI below 22kg/m2. Prevention of obesity prevents diabetes. Even modest weight reduction (5 to 10 kg) decreases insulin resistance and the resulting hyperinsulinemia. Increased mortality from obesity results from cardiovascular disease, HPN, diabetes, and some types of cancer.

Answer 81

b. Endometrium, breast, and colon Obesity is associated with hypertriglyceridemia, decreased HDL, and increased LDL. Obesity is a risk factor particularly for endometrial cancer, although it may also increase the risk of postmenopausal breast cancer and colon cancer.

Answer 82

d. Diet with less than 25% of total calories from fat Diet is the first step in reducing weight. Reducing or eliminating alcohol intake and taking frequent small meals helps to reduce food intake. Exer- cise helps maintains weight loss, but is not a primary strategy. Medication is reserved for women with a BMI above 30 or 27 kg/m2 if comorbidity is present, and surgery for above 35 kg/m2.

Answer 83

a. <15 years Abortion ratio= # of abortions per 100 live births Abortion rate= # of abortions per 1000 women 15 to 44 years of age. Abortion ratios tend to be higher at the extremes of reproductive age (<15 and >40 years). The percentage of women who obtained late abortions are highest among women less than age 15.

Answer 84

e. 90% The great majority of abortions are performed at less than 12 weeks of gestation.

Answer 85

c. A 30y/o with a history of familial polyposis As much as 25% of patients with colorectal cancer have a family history of the disease. Off-springs of persons with familial polyposis have a 50% probability of developing the disease, and annual flexible colonoscopy is recommended until age 35. It will usually be identified by age 25. Almost all patients who are not treated for these colonic polyps will develop cancer by age 40. There has been an association described between diets high in animal fat and colon cancer, but the data is less convincing for high-fiber diets decreasing the risk. The risk of developing colon cancer in patients with inflammatory bowel disease ranges from 8 to 30% after 25 years of the disease. Irritable bowel syndrome is not a risk factor for developing colon cancer. Obesity can also increase the risk of colon cancer, but to a lesser degree than the other factors.

Answer 86

d. Asphyxiation Asphyxiation occurs mainly in older adults age 75 and over and young children age 4 and younger. Falls are a common cause of injury in children under the age of 5, but they rarely result in death. Drowning occurs mainly in older children.

Answer 87

c. HIV infection The leading cause of death for men between the ages of 25 and 44 is now HIV infection, followed by unintentional injuries, heart disease, cancer, and homicide. Homicide is the leading cause of death for African American men between the ages of 15 and 24.

Answer 88

b. A male with hypertension Hypertension is a major risk factor for hemorrhagic (through elevated arterial pressure and microaneurysm) and ischemic stroke. Treatment of high blood pressure is the most efficacious way to prevent stroke, including in the elderly. Other risk factors for strokes include smoking, vascular disease, and diabetes mellitus. In individuals with cerebral vascular disease, the risk of developing a stroke within one year for a patient with an asymptomatic carotid disease is 1.3% and with a transient ischemic attack is 3.5%; the great- est risk is for the patient with ≥70% symptomatic carotid stenosis (15%).

Answer 89

d. Thiamine The patient has Charcots triad of ataxia, confusion, and ophthalmoplegia, which occurs in malnourished individuals. Parenteral thiamine may reverse the disease if given within a few days of the occurrence of symptoms. Prolonged untreated deficiencies can result in permanent damage.

Answer 90

a. Vitamin A Chronic toxicity (25,000 units or more for a protracted period) symptoms include bone pain, hyperostosis, hair loss, dryness and fissures of the lips, and weight loss. High doses of vitamin C for long periods can cause an increase in the risk of oxalate kidney stones and cause uricosuria. Vitamin E excess is present in persons receiving anticoagulants and in premature infants and can prolong prothrombin time. Vitamin D excess will result in hypercalcemia. Vitamin K excess will result in blocking the effect of anticoagulants. Excess most frequently occurs in fat-soluble vitamins (A, D, K, E).

Answer 91

a. All men, women, and children The USPS Task Force recommends that blood pressure be taken routinely at all ages.

Answer 92

e. Cocaine Chronic cocaine use can occasionally cause paranoid behavior. Hallucinations and acute psychosis with extreme violent behavior is associated with LSD. Chronic use of LSD may lead to similarities with mentally ill persons reporting profound religious experiences. Chronic use of marijuana can lead to disinterest in desirable social goals. Major issues about chronic opiate intake is related to acquiring HIV and other infectious diseases.

Answer 93

d. 6 to 12 months According to the Treatment Outcome Prospective Study, the most important predictor of success of drug treatment was length of time in the program, regardless of type of drugs used. Being in a program for at least 6 to 12 months was associated with abstinence, reduction of crime, and full-time employment.

Answer 94

c. Marriage Older age at initiation of drug use, employment, and marriage are factors associated with decreased drug use in young adults. Parental drug use and educational level, peer drug use, early drug use, sensation seeking, deviance, poor school grades, depression, agression, and low socioeconomic status are all risk factors associated with drug use.

Answer 95

a. Ovarian OCP * reduce the risk of ovarian cancer, the leading cause of death from gynecological cancer, by up to 80%; * can also reduce the risk of endometrial cancer; * no effect on the risk of developing vulvar cancer The issue of whether they increase the risk of breast cancer and cervical cancer is debatable. Any potential increase in the risk of breast cancer is likely to be very small and to occur only in a certain subgroup of women: the benefits of using OCs far outweigh any risks.

Answer 96

d. Asthma Estimated annual morbidity in non-smokers exposed to ETS is 400,000 to 1 million children affected by exacerbation of their asthma.

Answer 97

b. Folic acid supplements Folic acid use during the first trimester of pregnancy has been shown to decrease the incidence of neural tube defect, which is often associated with hydrocephalia, which in turn may be associated with intellectual disability that can be severe. In fact, folic acid supplements are recommended beginning one month prior to conception, so for all women capable of becoming pregnant. It is advisable to counsel women to avoid alcohol during pregnancy, although the risk of fetal alcohol syndrome is increased with 14 drinks per week or more. The effect of lower levels of drinking has been inconsistent.

Answer 98

c. Endometrial carcinoma Endometrial cancer most often presents with vaginal bleeding (80%) and is the most common postmenopausal gynecological cancer. Atrophic vaginitis does not present as spontaneous vaginal bleeding. A blood coagulation disorder would most likely present with other signs (petechia, bleeding gums) and symptoms. An endometrial biopsy should be performed in this situation.

Answer 99

c. Diabetes

Answer 100

Vitamin C deficiency Scurvy due to vitamin C deficiency is characterized by pain and tenderness of the extremities, irritability, and hemorrhagic phenomena, all the result of defective formation of collagen.

Answer 101

Niacin deficiency Pellagra (4Ds) * Diarrhea: disturbances of the GIT; * Dermatitis: disturbances of the skin; * Delirium & Dementia: disturbances of nervous system

Answer 102

Thiamine deficiency leads to beriberi in which either myocardial disease, edema, and cardiac failure or neurological signs predominate.

Answer 103

Vitamin A deficiency Hyperkeratosis: defects in epithelial cells of skin Xerosis & Keratomalacia: eye disorders Night blindness

Answer 104

Battery *involves touching another per- son in a socially unacceptable way without the persons consent; When informed consent is not obtained for medical procedures—diagnostic or therapeutic. The fact that the act may have improved the patients health is legally irrelevant.

Answer 105

Abandonment Abandonment is the unilateral termination of a doctor-patient rela- tionship by the physician. It occurs when a physician terminates medical care prematurely (such as failing to follow up after an acute illness), fails to provide adequate cross-coverage, or refuses to see an established patient without notifying the patient and making arrangements to transfer care. The doctor-patient relationship may be ended by mutual consent of both parties, dismissal of the physician by the patient, absence of a requirement for con- tinued medical care, or withdrawal of the physician with notification of the patient. This notification should be written and provide a reasonable transition period.

Answer 106

False imprisonment False imprisonment is the illegal confinement or restraint of a person or the illegal restraint of a person s liberty. A competent person who is not allowed to sign out against medical advice or who endures excessive use of physical restraints could sue for false imprisonment. Separate laws govern the involuntary hospitalization of the mentally ill.