Public Health Basics Flashcards

Question

# Public Health What are live-attenuated vaccinations?

Answer 1

Vaccinations in which the pathogen in question has been weakened but not fully killed before being introduced to the patient (E.g. the Sabin polio or MMR vaccine)

Answer 2

Vaccinations in which the pathogen in question has been killed before being introduced to the patient (E.g. the Salk polio vaccine)

Answer 3

Vaccinations in which the only a component of the pathogen in question is introduced to the patient (E.g. the pertussis portion of the DTaP vaccine)

Answer 4

The resistance of a group to a disease due to the overall immunity of the group (A certain percentage of the population must be vaccinated to prevent infectious disease spread. This percentage depends on the disease in question)

Answer 5

The number of people one sick individual will infect (On average)

Answer 6

Nonspecific mechanisms that protect the body against disease. Examples: Skin, hair, mucus, macrophages, neutrophils, lysozyme secretions, stomach acidity, etc.

Answer 7

Mechanisms that protect the body against specific, previously encountered antigens. Examples: B-lymphocytes, T-lymphocytes, immunoglobulins

Answer 8

False Many large, well-designed studies have found no link between MMR and autism. Autism usually becomes apparent around the same time MMR is given—no evidence of causality. Autism probably has multiple components, including genetics (e.g., one study found that if one identical twin had autism, the chance that the second twin had autism was greater than 90%, but with fraternal twins the chance was less than 10%).

Answer 9

False Vaccines use only a tiny proportion of a baby’s immune system’s ability to respond; though children receive more vaccines than in the past, today’s vaccines contain fewer antigens (e.g., sugars and proteins) than previous vaccines. Smallpox vaccine alone contained 200 proteins; the 11 currently recommended routine vaccines contain fewer than 130 immunologic components. Delaying vaccines increases the time children will be susceptible to diseases. There is no evidence that spreading out the schedule decreases the risk of adverse reactions.

Answer 10

An odds ratio (OR) is a measure of association between an exposure and an outcome. The OR represents the odds that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure.

Answer 11

A case-control study

Answer 12

An epidemic is a period of time with a higher than expected incidence rate but over a broader geographic region.

Answer 13

The term endemic refers to a region where there is a persistent baseline incidence and prevalence rate.

Answer 14

A pandemic is an epidemic where the disease is being actively transmitted on multiple continents.

Answer 15

An outbreak is defined as a higher than expected incidence rate tied to a geographic focal point.

Answer 16

Airborne water-borne fecal-oral vector-borne fomite perinatal food-borne animal bites sexual transmission

Answer 17

The time between being infected with a pathogen and showing symptoms (Actively dividing pathogen)

Answer 18

The time between being infected with a pathogen and showing symptoms (Non-actively dividing pathogen)

Answer 19

In an incubation period, the pathogen is actively dividing. In a latency period, it is not.

Answer 20

The number of a certain type of pathogenic microb needed in order to cause disease in an infected individual.

Answer 21

Eradication refers to the complete removal of a disease from the world (E.g. smallpox). Elimination refers to the complete removal of a disease from a specific geographic region (E.g. polio).

Answer 22

A microorganism that can cause disease.

Answer 23

No (Think botulism or tetanus). They are infectious but not widely transmissible from person to person.

Answer 24

Touching surface, object or person

Answer 25

Respiratory drops in the air (Due to sneezing, coughing, breathing)

Answer 26

Carried by non-host species to host (Typically insects)

Answer 27

Ingesting microscopic amounts of contaminated fecal matter

Answer 28

Water-borne Perinatal (mother to child) Food-borne Animal bites (Zoonotic) Sexual transmission

Answer 29

Anti-parasitic drugs

Answer 30

Drugs that kill bacteria or interfere with bacterial growth

Answer 31

Non-drug related treatments. E.g. hand washing, exercise, isolation of infected individuals

Answer 32

Prokaryotic cells that can both be helpful and harmful to humans. They reproduce on their own (Unlike viruses). Helpful bacteria work as our microbiome and protect us and help us with digestion.

Answer 33

They are not alive. They are protein shells (Capsids made of protomers) that contain genetic material (Single- or double-stranded DNA or RNA) and require a host cell in order to replicate themselves. They hijack the host cell's enzymes and other machinery. Viral glycoproteins allow the cell to interact with host cells in order to inject their genetic material or to be completely endocytosed. More complex viruses sometimes have a lipid coat around their capsid.

Answer 34

Multicellular (Usually) eukaryotic organisms (Like us). Things like malaria, leishmaniasis, hookworm, guinea worm, etc.

Answer 35

How we describe infectious disease movements, patterns, and behaviors over time and geography

Answer 36

Any group of interacting parts that form a whole

Answer 37

Has many interacting parts that need to work correctly in a sequence to reach the desired result. However, each step of the process is completely predictable based on the step before it

Answer 38

No, the results brought about by the interacting parts of a complex system are not directly predictable

Answer 39

Behaviors or outputs of a system that arise from two or more interacting components that cannot be explained by either of them on their own

Answer 40

A graph of the number of cases or incidence rate of cases versus time.

Answer 41

How humans interact with and are impacted by their surrounding environment and each other

Answer 42

An individual entity in the network, like a person or a hospital

Answer 43

What connects two nodes

Answer 44

A lot of people/things randomly connected to each other with no rhyme or reason

Answer 45

A network where some nodes are more highly connected than others

Answer 46

Nodes that are more connected than others

Answer 47

The timing of an epidemic overlapping in multiple locations

Answer 48

Individuals having multiple partners at the same time

Answer 49

We are essentially coming up with a fake scenario in which people flow from one “compartment” or stage to another

Answer 50

The model does not worry about random effects, like individual differences in susceptibility. Everyone follows the same rules of probability about what compartment they are in at any given time.

Answer 51

“Susceptible, Infectious, and Recovered.” Each person is either in the S, I or R compartment at any given time. The simplest version of the SIR model doesn’t take into account birth and death.

Answer 52

Susceptible individuals (May become sick)

Answer 53

Infectious individuals (Are sick and may infect others)

Answer 54

Recovered individuals (Are no longer in danger of becoming sick again)

Answer 55

A model that takes individuality into account. They are very commonly used and based off of the same mathematical principles as deterministic models. They just use more complicated probability formulas describing whether someone will move into the next compartment, and are not deterministic.

Answer 56

Helpful to study diseases that are very difficult to trace through a network to a particular infecting person (like respiratory diseases). They use computer simulations to estimate the behaviors of a real-world city, region or country. The simulations can help predict what emergent properties might occur as an infectious disease travels.

Answer 57

The number of infected individuals one person is expected to infect while they are infectious

Answer 58

The proportion of people that need to be immunized in order to eradicate a disease, or prevent an outbreak (Varies from disease to disease)

Answer 59

A change in status. ex. a new emerging disease can cause an epidemic, and if not eliminated, reach a new stable equilibrium where it is now endemic

Answer 60

cBSI/n ``` c = contacts Beta = P(Infected/contacted) S = susceptible I = infected n = population ```

Answer 61

1/DI ``` D = duration I = Infectious ```

Answer 62

Real-time or effective reproduction. Our goal when trying to prevent infectious diseases is to push Rt below 1, so that the epidemic will die out. In essence, you want to “remove” susceptible or infectious individuals from the population faster than the disease spreads. Vaccines do this very effectively

Answer 63

cB/y ``` c = contact B = P(Infected/contacted) y = rate of recovery ```

Answer 64

R0 \< 1 (The disease is not actively propagating)

Answer 65

Predictions

Answer 66

Sexual networks

Answer 67

The study of factors influencing the abundance and distribution of organisms

Answer 68

Competition - Driving force of natural selection (Remember viruses damaging each other and competing for resources) Cooperation - Differing species working together to benefit all species involved (Remember biofilms)

Answer 69

A biofilm is a collection of bacteria cooperating and working together. Biofilms often form on hospital catheters / instruments and are responsible for many nosocomial infections Quorum sensing is the cell-to-cell communication that regulates the density of bacteria growth so they can share resources.

Answer 70

The physical area a species inhabits

Answer 71

The habitat + behaviors of a particular species

Answer 72

Only 1. Either one species will evolve to separate the niches, or one will out-compete the other, resulting in its extinction.

Answer 73

1) Warming can cause a shift in timing, where epidemic peak may occur at a different time of year than it did in the past 2) Warming can cause more epidemic “cycles”, meaning that there may be two epidemic peaks in the same year 3) Warming can cause overall epidemic intensity to either increase or decrease, depending on whether the pathogen can well-tolerate the new climate.

Answer 74

A zoonotic disease is a disease that has its origins in a species other than humans (This includes vector-borne diseases as well as direct zoonotic diseases)

Answer 75

Transmission rates increase with the number of infectious people, but it doesn’t matter how geographically dense they are. (I.e. STDs and some vector-borne diseases)

Answer 76

Transmission rates increase with population density of the host. (E.g. influenza)

Answer 77

A silent zone

Answer 78

There will be an epidemic

Answer 79

Perinatal Airborne Animal bites Water-borne Sexual Fecal-oral Fomite Food-borne

Answer 80

Direct human-to-human (E.g. influenza)

Answer 81

Direct zoonosis (E.g. rabies)

Answer 82

Vector-borne (E.g. malaria)

Answer 83

Vectored zoonosis (E.g. encephalitis)

Answer 84

Anthropo-zoonosis (E.g. yellow fever)

Answer 85

A host species for a viral disease that does not usually become seriously ill from the disease

Answer 86

Bats, mice, and birds

Answer 87

A spillover event

Answer 88

The greater the number of species in a given area, the fewer interactions humans are likely to have with a particular disease-carrying species (Remember the Lyme disease example). This is called the dilution effect.

Answer 89

The process by which a disease gains strength in the general population following a spillover event

Answer 90

No. Usually, they get Lyme disease from their first blood meal (If the meal is infected, as white-footed mice often are).

Answer 91

Uninfected larva hatch in late Summer --\> The feed on a (possibly) infected small animal --\> They molt and become nymphs till the end of Winter --\> In Spring/Summer/Fall they feed on vertebrates --\> Ticks that feed on deer mate and lay eggs

Answer 92

The International Health Regulations (IHR)

Answer 93

Field surveillance --\> National focal point (E.g. CDC) --\> Regional contact point (E.g. The Pan-American Health Organization) --\> WHO

Answer 94

Morbidity and Mortality Weekly Report (MMWR)

Answer 95

These are examples of reportable diseases . (AIDS, chickenpox, gonorrhea, hepatitis A and B, measles, mumps, rubella, salmonella, shigella, syphilis, and TB

Answer 96

Catchment areas Case-report forms (CRFs)

Answer 97

A catchment area is the defined geographic region in which the surveillance will be operated. The catchment area designation is the first step in the surveillance program design.

Answer 98

Data collection tool (Basically a survey) where information on sick -or suspected to be sick- individuals can be recorded.

Answer 99

1. System design (Catchment area designation, disease identification protocols, reporting process set up, etc.) 2. Data collection (CRFs, contact tracing, etc.) 3. Collation (Data aggregation, standardization, and organization)

Answer 100

4. Analysis (Statistical / epidemiological measures) 5. Interpretation (Rates, vulnerable / geographic areas, morbidity / mortality, etc.)

Answer 101

6. Dissemination / Communication (Radio, social media, television, health departments, scientific journals, etc.) 7. Program change (Target vulnerable populations, modify program procedures)

Answer 102

Uses non-diagnostic health data (E.g. Google searches or ambulance records) to determine how many people are symptomatic of a disease. Remember GPHIN from the TED video shown in class. They prevented a SARS epidemic.

Answer 103

Very useful in the detection of emerging diseases, disease outbreaks, or bioterrorist threats.

Answer 104

CDC catchment zones scattered across the U.S. monitoring antibiotic-resistant bacteria, foodborne outbreaks, influenza, and nosocomial infections.

Answer 105

An EIP program responsible for collecting data surrounding bacterial disease trends.

Answer 106

Early detection, early response

Answer 107

When there are high morbidity and mortality due to a bacteria that has become resistant, it is often referred to as a superbug. Extra info: Resistance to pharmacotherapy is not only an issue for bacteria, but it can arise in cancer cells, parasites, fungi, and other infections. Bacteria with acquired resistance include TB, S. aureus, Acinetobacter, E. coli, and V. cholera.

Answer 108

Microscopic organisms have been battling one another for millions of years by producing chemicals that can limit the growth of other organisms. Resistance to these chemicals has evolved in synchronization with them. Mechanisms for resistance are therefore not new to human populations. They have been in development long before we ever started using antibiotics therapeutically. In fact, a large portion of your microbiome is already resistant to antibiotics you have never been exposed to. (Example: Penicillinase was discovered in the natural bacterial population in samples that pre-date the use of therapeutic penicillin.)

Answer 109

When a bacteria takes up DNA from another source, it is called horizontal (or lateral) gene transfer (HGT)

Answer 110

The part of a bacteria’s genome resulting from HGT is called a genomic island, or a genetic cassette. Genomic islands can confer resistance in the new bacteria.

Answer 111

If a gene is inherited directly from a “parent” bacteria during reproduction, it is called vertical gene transfer (VGT).

Answer 112

In the case of intrinsic resistance, no mutation is necessary to confer resistance. The bacteria simply overcomes the antibiotic by making more copies of the protein that the antibiotic targets.

Answer 113

It is important to note that resistance genes exist in bacteria with or without selection (does not “cost” them anything). There are many different biological mechanisms by which they work. These include: 1. changing the shape of the antibiotics target protein, 2. developing the ability to metabolize the antibiotic, 3. developing the ability to recognize and actively pump out the antibiotic

Answer 114

Transfer of genetic material from bacteria to bacteria through a sex pilus connection

Answer 115

Transfer of genetic material from bacteria to bacteria via a bacteriophage (Virus that infects bacteria)

Answer 116

Direct uptake of 'spilled' DNA from outside the bacterial cell into the bacteria

Answer 117

1. Less than ½ of the therapeutic antibiotics in existence are for human use. 2. There is a dramatic overprescription of antibiotics in the U.S. and internationally (Often for viral infections). 3. In agriculture, antibiotics are often used prophylactically because it was thought that they improve weight gain of animals (not to treat or prevent infection).

Answer 118

Identifying resistant bacteria earlier, and developing new methods for identifying antibiotics or other antimicrobial therapies. For example, genotyping of strains in clinics to test for resistance is on its way to becoming common practice. Another common strategy is to use combinations of antibiotics, so that the bacteria is not able to acquire resistance. This is a method used often in the treatment of drug-resistant TB.

Answer 119

Diseases that are transmitted between hosts by another species (The vector is typically not infected, but that is not true in cases such as malaria)

Answer 120

How do we eliminate/control the vector without wide-ranging ecological effects? How will climate change affect vector and host distributions?

Answer 121

Indoor residual spraying Bednets / window screens Genetic modifications Larvae extermination

Answer 122

Malaria Dengue fever Zika Chikungunya virus Etc.

Answer 123

Mosquito-borne Central / Southeast Asia and Sub-Saharan Africa 1 - 12 days Rash, fever, polyarthralgia, vomiting, headache Anti-inflammatories

Answer 124

The *Aedes aegypti* mosquito More than 100 countries in both hemispheres Crushing bone pain (It is often called 'bone break fever'), fever, lethargy, can be hemorrhagic

Answer 125

The *Aedes Agypti* mosquito Microindonesia, Brazil, several other locations Usually, mild symptoms lasting a few days to a week Causes microcephaly and Guillan-Barre Syndrome among infants of affected mothers

Answer 126

6 months 2 months

Answer 127

It is a zoonotic disease that originated in non-human primates as SIV.

Answer 128

Intravenous drug users Homosexual men (44x higher risk than heterosexual men) Impoverished women (Especially those that have little sexual control in their relationships) Prostitutes Healthcare workers (Due to needle sticks and accidental fluid exchange) African-Americans, Asian-Americans, and Pacific Islanders also experience higher rates of HIV in the US than is found in other ethnic groups (Likely from a socioeconomic or stigma-related disparity).

Answer 129

It means that, upon infection, the virus (RNA) is transcribed (By reverse transcriptase) to DNA and inserted into the host genome after infection. This makes it very hard to treat as it becomes part of our own DNA!

Answer 130

It replicates slowly. There can be long incubation and latency periods between infection and symptoms

Answer 131

HIV spreads via bodily fluids such as blood, blood products, semen, rectal or vaginal fluids, or breast milk. Seroconversion is when the immune system first begins producing antibodies against HIV. This usually happens a few weeks after the initial infection.

Answer 132

The virus preferentially infects CD4+ Helper T-cells (A type of white blood cell). Upon initial infection, there are acute symptoms which are typically flu-like.

Answer 133

When CD4+ Helper T-cell count below 200/ml (normal counts are 500-1500 per ml).

Answer 134

- Pneumocystic (fungal) pneumonias - Pneumonia due to cytomegalovirus, toxoplasmosis, herpes simplex, or gastrointestinal protozoa - Some patients develop a rare form of cancer called Kaposi’s sarcoma. The cancer is caused by Kaposi sarcoma herpesvirus (KSHV) that inserts its genes into the host (Kaposi’s sarcoma is 20,000 times more common in AIDS patients than in the general public).

Answer 135

Antiretroviral Therapy They do not fully cure the disease; they only keep the viral load down.

Answer 136

When an HIV-infected patient on ARV becomes infected with an additional strain of HIV (Double HIV infection).

Answer 137

Transmission from an infected mother to her child. Transmission can occur in utero, during delivery, or through breastfeeding. Breastfeeding is the most common type of transmission from mother to child.

Answer 138

More recurring opportunistic bacterial and viral infections, (but they are less likely to develop Kaposi’s sarcoma) more rapid disease progression as well

Answer 139

A special ARV regimen (Highly effective). The Pediatric AIDS Clinical Trials Group (PACTG) 076 AZT regimen is a series of ARV drugs given in different amounts during pregnancy, delivery and just after birth to prevent transmission of HIV to a child.

Answer 140

Condom distribution Education Prophylactic ARV treatment (reduces transmission by 60-80%) Needle exchange programs Male circumcision

Answer 141

No. About 20% of HIV+ persons in the United States are unaware of their infection.

Answer 142

## Footnote *Mycobacterium tuberculosis*

Answer 143

Respiratory droplets (Airborne transmission) Respiratory system Yes, TB can disseminate to organs other than the lungs

Answer 144

Many small areas of local TB spread throughout an organ

Answer 145

Alveolar macrophages

Answer 146

Immune cells surround the area, promote inflammation, and accumulate as dead cells (This forms nodules called granulomas)

Answer 147

No, the immune system usually only manages to keep the bacterium at bay (This is called latent TB and is true for 90% of infected individuals)

Answer 148

Reactivation

Answer 149

The Mantoux Tuberculin test (TB antigen injected under the skin) and chest x-rays

Answer 150

A TB granuloma large enough to be seen on x-ray

Answer 151

This is a Gohn complex

Answer 152

Primary infection is the initial host encounter with TB bacterium. A secondary infection refers to EITHER being infected with TB after being cured OR reactivation of latent TB

Answer 153

Fever, cough, bloody sputum, weakness, and chest pain.

Answer 154

- 2 initial months of chemotherapy (antibiotics) and varying amounts of continuing treatment (No need to memorize drug names, but know it’s a drug cocktail given for months). - Patients may be asked to take a complex regimen of drugs including: Isoniazid (an anti-metabolite) Rifampin (inhibits RNA polymerase) Ethambutol (inhibits cell wall formation) Pyrazinamide (converts to an acid and accumulates, killing the cell).

Answer 155

Vaccination (18-30% efficacy) Prophylactic antibiotics Isolation of infected individuals DOTS program (Involves much closer patient-physician interaction and follow-up than usual)

Answer 156

Multi-drug resistant TB In all countries

Answer 157

Extremely-resistant TB Totally resistant TB

Answer 158

A protozoan parasite that exists in many different animals

Answer 159

* Plasmodium* *malariae* --\> * Plasmodium vivax* --\> * Plasmodium falciparum*

Answer 160

*Plasmodium vivax* enters human erythrocytes via the Duffy receptor (An RBC glycoprotein). Being 'Duffy-less' is now a dominant human mutation in most Africans, and so *P.* *vivax* is more prevalent in Europe and Asia

Answer 161

Hemoglobin disorders confer some immunity to *P. falciparum*, and so now 1/14 of humans carry genetic mutations related to thalassemia, sickle-cell anemia, ovalocytosis, and other hemoglobin disorders.

Answer 162

Inside the mosquito --\> Inside the human liver --\> Inside the human bloodstream --\>

Answer 163

Fever, chills, nausea, and sweating

Answer 164

Hypnozoites

Answer 165

Insecticide-treated bed nets Indoor residual spraying Prophylactic medication (E.g. Doxycycline and primaquine) Possible vaccines in the pipeline

Answer 166

Quinine and artemisinin (Resistant strains of malaria are developing to both these drugs)

Answer 167

A naturally occurring compound that can kill a microbial organism (Usually bacteria or parasites)

Answer 168

Antibiotics as well as synthetic compounds Multiple mechanisms of action including interfering with the building of cell wall and stopping nucleic acid synthesis

Answer 169

Basically drug treatment Antibiotics are a different form of pharmacotherapy (Treatment) than drugs used to treat chronic diseases, in that they target bacterial receptors/proteins instead of patient’s proteins. This makes each patient’s treatment unique as organisms fight back, hide, etc.

Answer 170

Nonspecific treatment When a bacterial infection is suspected but isn’t identified yet, a doctor can prescribe a general antibiotic until it is identified. This is called empiric therapy

Answer 171

Specific treatment Once the bacteria is identified by laboratory tests, they are supposed to describe an antibiotic that is specifically tailored to that pathogen, which is called definitive therapy. Doctors don’t always transition from empiric to definitive therapy the way they should, which can be a driver of antibiotic resistance.

Answer 172

How antibiotics interact with both the bacteria and the patient Can impact a lot of how effective an antibiotic is going to be. Some antibiotics may inhibit bacterial growth (bacteriostatic), while others kill the organism (bacteriocidal). For example, if the antibiotic interferes with DNA replication it is likely bacteriostatic. If it causes cell lysis, it is bacteriocidal. Usually both are effective, but some infections (like meningitis) require bacteriocidal antibiotics.

Answer 173

The minimum amount of antibiotic for inhibiting bacterial growth (If it is bacteriostatic)

Answer 174

The minimum amount of antibiotic needed to kill a bacteria (if it is bacteriocidal)

Answer 175

Pharmacokinetics is how the patient impacts the concentration of the antibiotic in the body. When an antibiotic is administered, it goes through three stages: absorption, distribution (concentrated differently throughout the body), and metabolism/excretion (most excreted in same form). How quickly the antibiotic goes through each stage depends on a variety of factors. For example, it matters whether an antibiotic is hydrophobic or hydrophilic, how large the antibiotic is, and how it is administered.

Answer 176

Alexander Fleming formally discovered in 1928 Mold Penicillum notatum on petri dish Purified by Florey and Chain (British researchers) and disseminated during WWII

Answer 177

How quickly the antibiotic goes through each stage depends on a variety of factors. For example, it matters whether an antibiotic is hydrophobic or hydrophilic, how large the antibiotic is, and how it is administered.

Answer 178

Antibiotics can alter microbiome composition and allow for opportunistic pathogen infection.

Answer 179

Beta-lactams are a type of antibiotic (E.g. penicillin and cephalosporin) that have a double-ring structure and work by interfering with the enzyme that constructs bacteria cell walls. They are effective against many types of bacteria, but not against certain atypical organisms such as MRSA.

Answer 180

Tetracyclines are 4 ring structures that work by physically preventing binding of tRNA to the ribosome, thus inhibiting translation and protein synthesis.

Answer 181

Anti-metabolites function by mimicking something that the bacteria needs to metabolize to survive and starving the bacteria by inhibiting its enzymes.

Answer 182

They mimic natural infection to 'trick' the body into building up an immunity to a specific pathogen.

Answer 183

Anything that produces an immune response in the body (Usually the pathogenic components like glycoproteins that act as antigens to our bodies)

Answer 184

Proteins produced by our bodies (By B Cells) that will stick to pathogen antigens. Immunoglobulins.

Answer 185

The second. The first can take anywhere from a few days to two weeks, but the second often takes less than a day.

Answer 186

Vaccines that are made with a pathogen that is alive but weakened. The pathogen can still reproduce a little bit, but not cause disease (e.g. the MMR vaccine or the Sabin polio vaccine)

Answer 187

An inactivated or killed vaccine is what it sounds like. The pathogen is completely dead, but the antigen still promotes an immune response (E.g. the Salk polio vaccine or the flu vaccine)

Answer 188

Vaccines made up of an inactivated toxin that the pathogen normally secretes. Mostly used for bacterial infections (E.g. the DTaP vaccine)

Answer 189

If only a part of the pathogen is used to make the vaccine, it is referred to as a subunit vaccine (E.g. the Pertussis portion of the DTaP vaccine).

Answer 190

Gene-based vaccines use the injection of a small amount of the pathogen’s genetic material rather than an antigen. The person’s cells uptake the genetic material and produce the antigen themselves, promoting an immune response.

Answer 191

Virus-like particles are a technology where the capsid or envelope of the virus is made in a laboratory but without any genetic material inside. This way, the antigens can be presented to the immune system intact without any risk of the virus causing infection. The HPV vaccine uses this method.

Answer 192

T-Cells, B-Cells, and macrophages

Answer 193

CD4+ - Helper T-Cells that support the other immune cells CD8+ - Killer T-Cells that kill our own infected cells

Answer 194

Plasma cells - Produce antibodies Memory B-Cells - Retain immunogenic memory of past antigens the body has seen

Answer 195

Ingest foreign materials and enemy cells to present their antigens to T- and B-Cells (They also clean up any debris in the human body).

Answer 196

Adjuvants are chemical additives to vaccines that are able to boost immune response through various mechanisms. These include possibly clumping vaccine particles at the injection site (which recruits more APCs) or directly stimulating immune cells.

Answer 197

Thimerosol is a preservative (not an adjuvant) containing trace amounts of mercury. It was used in some vaccines to prolong shelf life. It has been taken out of all vaccines given to children under 6, and is only now included in some multi-dose flu vaccine vials. It is often discussed as one of the possible reasons for the (disproven) hypothesis that vaccines are associated with autism. Some anti-vaccine literature suggests it was used in the MMR shot, however, it never was. Thimerosol was removed as a precaution and other preservatives were used.

Answer 198

Only aluminum-based compounds

Answer 199

A method of epitope prediction. In reverse vaccinology, researchers compare the genetic sequences of many different strains of the pathogen, looking for regions of the genome that are always consistent. These are areas that don’t mutate much, likely because the virus needs that very specific protein for survival. When they identify a region, it becomes a good antigen to potentially include in a vaccine.

Answer 200

An epitope is the specific chemical site on an antigen to which an antibody binds. It can be helpful to try to identify good epitopes for antibody binding in advance, instead of having to try many different antigens (This is very difficult for diseases like HIV which mutate very quickly).

Answer 201

Adjuvants boost immune responses. Preservatives prevent contamination (Typically fungal).

Answer 202

Intramuscular injection (IM) ``` Oral vaccines (Usually for live vaccines) Nasal sprays (Usually for live vaccines) Vaccine patches ```

Answer 203

You have far more immune cells right under the surface of your skin (to respond to scratches and cuts) than you do deep in your muscles. So delivering vaccine directly under the skin can increase the number of immune cells exposed, and thus the immune response. It also lowers the risk of accidental needle-sticks for healthcare providers.

Answer 204

Booster shots are used in some cases to reinforce immunity as immunity can fade over time. Ex: It is recommended that a DTaP booster be given to all caregivers for newborns and young children.

Answer 205

Covers Bordatella Pertussis infection (Whooping cough), diphtheria and tetanus (Toxoid vaccine)

Answer 206

Measles, Mumps, Rubella (German measles), Varicella (chicken pox) (Live-attenuated)

Answer 207

Pneumococcal disease caused by S. pneumonia (Live-attenuated vaccine)

Answer 208

A killed vaccine, unless it's the nasal spray, which is live-attenuated The vaccine is incubated in chicken eggs (Although we are shifting over to human cell cultures for incubation)

Answer 209

The MMR vaccine

Answer 210

250 children

Answer 211

No, it is a settled issue on both sides of the vaccination argument.

Answer 212

No. Even a baby's body is rapidly acquiring immunity to all sort of bacteria and viruses all the time. Vaccines only use a tiny portion of the baby's immune system.

Answer 213

Don't be dismissive or condescending. Build common ground. Validate their real, lived experience.

Answer 214

Genetic and environmental exposures (Maybe environmental effects on the microbiome)

Answer 215

Exposure (Yes or No) and Outcome (Yes or No). 'Total' columns are often added to this table.

Answer 216

Divide the risk of the outcome in the exposed (a / (a + b)) by the risk of the outcome in the unexposed (c / (c + d)). (a / (a + b)) / (c / (c + d)) = RR

Answer 217

Subtracting the risk of the outcome in the unexposed (c / d) from the risk of the outcome in the exposed (a / b). (a / (a + b)) - (c / (c + d)) = RD

Answer 218

Risk difference Risk ratio Odds ratio

Answer 219

A rate is an observed number of cases per unit time. A risk is just a proportion.

Answer 220

Odds ratios are more useful for case-control studies and/or rare diseases. This is more useful when we don't have totals that represent the population (I.e. we've matched 500 cases for 500 controls). Risk ratios are based on the total percentage in the group, and so we need somewhat representative groups to utilize RRs. Useful link: https://www.mdedge.com/jfponline/article/65515/relative-risks-and-odds-ratios-whats-difference

Answer 221

(a / b) / (c / d) OR (a / c) / (b / d) OR (ad) / (bc) Basically, the odds of your having the outcome if exposed over the odds of your having the outcome if not exposed.

Answer 222

Lack of knowledge as to where future meals will come from.

Answer 223

An area where healthy foods are not available or accessible.

Answer 224

Plant-based compounds (Usually non-essential to human diet) with some health benefit

Answer 225

Carbohydrates, proteins, and lipids

Answer 226

A phytonutrient - Aids in healthy vision

Answer 227

A phytonutrient - May aid in intestinal immune cells

Answer 228

A phytonutrient - Aids in vitamin A absorption

Answer 229

A phytonutrient - May help to prevent CVD

Answer 230

A phytonutrient - Possible antioxidant

Answer 231

A phytonutrient - May aid in intestinal immune cells

Answer 232

An antihypertensive diet cetnered around salt-reduction and an increase in fruits and vegetables

Answer 233

A combination of the Mediterranean and DASH diets designed to increase cognitive health and functioning

Answer 234

WIC (Women, Infants, and Children) SNAP (Supplemental Nutrition Assistance Program) School breakfast program Farm Bill

Answer 235

Kilograms / meters^2 (Or) lbs. / inches^2 x 703

Answer 236

≤ 18.4 18.5 - 24.9 25 - 29.9

Answer 237

30 - 34.9 35 - 39.9 ≥ 40

Answer 238

Not quite. We use a percentile chart to standardize the BMIs for all the variation in child growth rates.

Answer 239

\< 5th percentile \> 85th percentile \> 95th percentile

Answer 240

Higher rates among the middle-aged and older. Slightly more women than men Blacks \> Hispanics \> Whites \> Asians

Answer 241

CVD Obstructive Sleep Apnea GERD GI issues Cancer Stroke Diabetes Heart failure Hypertension Dyslipidemia Osteoarthritis Atherosclerosis Atrial fibrillation Alzheimer’s Disease Non-alcoholic fatty liver disease (NAFLD) Polycystic Ovarian Syndrome (PCOS) Surgical and anesthetic complications Psychosocial disorders etc...

Answer 242

1. Increased body mass leads to increased systemic blood pressure. → Increased BP leads to chronic cardiac overload → Overload leads to cardiac hypertrophy and strain. 2. Lower HDL and higher LDL levels lead to atherosclerotic blood vessels and increased systemic blood pressure.

Answer 243

1. Excess weight and body mass disrupt normal metabolic processes’ ability to regulate blood sugar levels → Hyperglycemia and diabetes often result. 2. Obesity is generally related to excessive and long-term carbohydrate intake, very directly leading to chronic hyperglycemic conditions.

Answer 244

1. Increased levels of insulin and insulin growth factor (IGF-1) lead to excess growth. 2. Excess adipose tissue increases estrogen levels (Affecting breast and endometrial cancer rates). 3. Fat cells are suspected to also affect cancer cell growth regulation in a yet unknown way.

Answer 245

Visceral fat is the fat that sits between and compresses the organs of themselves (Usually gives rise to an apple-shaped torso). Subcutaneous fat is the less harmful fat that sits just below the skin (Usually gives rise to a pear-shaped torso).

Answer 246

Blood pressure, triglycerides, HDL cholesterol, plasma glucose, and abdominal obesity. 3/5

Answer 247

BMI (Principal method) DEXA scanning underwater weighing

Answer 248

Blood pressure (High) ≥ 130 / 85 mmHg Plasma triglycerides (High) ≥ 150 mg/dl Fasting plasma glucose (High) ≥ 100 mg/dl Abdominal obesity (High) ≥ 35" (women); ≥ 40" (men) HDL cholesterol (Low) ≤ 40 mg/dl

Answer 249

Gastric bypass surgery

Answer 250

HDL LDL and VLDL

Answer 251

Gastric sleeve bypass Gastric roux-en-y bypass Gastric banding

Answer 252

A condition in which blood sugar is highly elevated.

Answer 253

Type 1 and type 2 Type 2 (90-95% of cases)

Answer 254

Insulin and glucagon secretion Islets of Langerhans

Answer 255

Beta cells Alpha cells

Answer 256

Decrease blood glucose by: Increasing glucose transport into adipose and skeletal muscle tissues through GLUT-4 transporters Increasing glycogenesis Decreasing gluconeogenesis Decreasing lipolysis

Answer 257

Increase blood glucose by: Increasing glycogenolysis (Glycogen breakdown) Increasing gluconeogenesis (Protein breakdown) Increasing lipolysis (Fat breakdown)

Answer 258

Insulin deficiency due to autoimmune destruction of pancreatic beta cells

Answer 259

Insulin insensitivity

Answer 260

A measure of how much glucose has gotten 'stuck' on hemoglobin for the past 120 days (The lifespan of an RBC). Used as a measure of long-term blood glucose control.

Answer 261

Normal \< 5.7% Pre-Diabetic 5.7 - 6.4% Diabetic \> 6.4%

Answer 262

Elevated blood sugar

Answer 263

A measurement of an individual's blood glucose levels during a fasting state

Answer 264

Normal \< 100 mg/dl Pre-Diabetic 100 - 125 mg/dl Diabetic \> 125 mg/dl

Answer 265

Early. Often between 12 and 18 Later in life Usually after 35 or 40

Answer 266

Polyphagia (Excessive hunger) Polydipsia (Excessive thirst) Polyuria (Excessive urine production)

Answer 267

There are many systemic effects, including, but not limited to: Peripheral neuropathy Diabetic retinopathy Infection and gangrene Acanthosis nigricans Weight loss (Mainly in T1DM) Renal damage

Answer 268

Diabetic ketoacidosis (DKA)

Answer 269

Hyperosmolar Hyperglycemic Non-Ketotic Coma (HHNC)

Answer 270

Insulin administration and diet adjustment

Answer 271

Diet and weight loss; oral hypoglycemic medications as needed (E.g. metformin)

Answer 272

Renal failure

Answer 273

Heart failure

Answer 274

The Southeastern United States (The obesity/stroke/diabetes belt) African-Americans are at increased risk over other racial groups

Answer 275

Obesity, metabolic syndrome, high-sugar and high-fat diet, family history

Answer 276

A complete cure of some patients' T2DM (As well as an average of 2/3 excess weight lost)

Answer 277

Usually seen only in T1DM, glucose is unable to make it into the cells, the cells begin to starve, and lipids are broken down at a quick rate for energy production. Lipid breakdown leads to the production of ketone bodies that are acidic to normal blood pH. Blood pH drops and the individual enters a coma.

Answer 278

Beta-hydroxybutyrate and acetoacetate

Answer 279

Low blood sugar (\< 70 mg/dl) Brain damage

Answer 280

**A1c** \< 7% **Blood pressure** \< 130 / 85 **Cholesterol** LDL \< 100 mg/dl HDL \> 50 mg/dl (Women) \> 40 mg/dl (Men)

Answer 281

BMI ≥ 25 (Overweight) ≥ 45 years of age Family history of T2DM History of gestational DM

Answer 282

23 (*Screen at 23*)

Answer 283

Gluconeogenesis (glucose-new-production) (Promoted by glucagon; inhibited by insulin)

Answer 284

Lipolysis (Promoted by glucagon; inhibited by insulin)

Answer 285

Glycolysis (Inhibited by glucagon; promoted by insulin)

Answer 286

Glycogen Liver and skeletal muscle tissue

Answer 287

Glycogenesis (Inhibited by glucagon; promoted by insulin)

Answer 288

Glycogenolysis (Promoted by glucagon; inhibited by insulin)

Answer 289

An idiopathic form of HTN (cause unknown) 90%

Answer 290

HTN due to some underlying disease

Answer 291

\< 120 / 80 mmHg

Answer 292

Systolic BP = BP while the ventricles are contracting - Top number (e.g. **120** / 80) Diastolic BP = BP while the ventricles are relaxing - Bottom number (e.g. 120 / **80**)

Answer 293

Elevated BP (No longer known as pre-HTN)

Answer 294

130 to 139 / 80 to 89 mmHg

Answer 295

≥ 140 / ≥ 90 mmHg

Answer 296

≥ 180 / ≥ 120 mmHg

Answer 297

Stroke Atherosclerosis Thrombosis Aneurysm formation Organ damage (Not a comprehensive list)

Answer 298

An antihypertensive diet focusing on the reduction of salt and lipid intake

Answer 299

Weight loss Salt intake reduction Physical activity increase Meditation

Answer 300

the REasons for Geographic And Racial Differences in Stroke

Answer 301

Lack of oxygen delivery to tissues

Answer 302

Cell damage and death due to loss of blood flow

Answer 303

A 'mini-stroke' that results in signs and symptoms that have completely resolved 24 hours after the insult

Answer 304

Cerebrovascular attack (CVA)

Answer 305

Ischemic (thrombotic; loss of blood supply) and hemorrhagic (rupture leads to blood entering cranial space) Ischemic is more common (85-90% of cases) Hemorrhagic is more deadly

Answer 306

The core zone refers to the infarcted tissues following complete loss of blood supply The penumbra refers to the affected area of tissue that is often still viable tissue but will die if perfusion is not reestablished; there is usually some collateral circulation supplying the tissues with some blood flow

Answer 307

A weakening or outpouching in the blood vessel wall (a ballooning that is more likely to rupture than surrounding tissue)

Answer 308

Hypertension (Most important factor) Metabolic syndrome Atherosclerosis Atrial fibrillation Aneurysms Race (African-Americans more at risk) Medical history of thrombotic events

Answer 309

Headache, weakness, paralysis, dizziness, vision changes, balance changes, drooping facial features, slurred speech, disorganized speech or thoughts (Physical signs often unilateral)

Answer 310

The left side (and vice-versa for a left-sided stroke) Contralateral

Answer 311

Clinical presentation, MRI, CT scans, angiography

Answer 312

Aspirin and/or heparin TPA (tissue plasminogen activator)

Answer 313

CVD is #1 (for the U.S. and the world)

Answer 314

Thrombus = *stationary* blood clot Embolus = *moving* blood clot (or other clumped substance such as bacteria, fat, air, tumors, amniotic fluid, etc.)

Answer 315

Ischemia refers to reduced blood flow to tissues Infarct refers to tissue necrosis secondary to reduced blood flow

Answer 316

Atherosclerosis - Arterial hardening due to fatty plaque buildup Angina - Chest pain Acute Myocardial Infarction - Infarction of heart tissue

Answer 317

Right coronary artery - Acute marginal artery (Anterior right ventricle) - Posterior descending artery (Posterior right ventricle) Left main coronary artery - Left anterior descending (Anterior left ventricle and interventricular septum) - Lateral and posterior left ventricle

Answer 318

The left anterior descending artery

Answer 319

This is awesome: https://millionhearts.hhs.gov/files/MH-meaningful-progress.pdf

Answer 320

Physical activity Weight reduction Diet Don't smoke

Answer 321

Blood pressure Plasma cholesterol Plasma glucose

Answer 322

Physical activity Weight reduction Diet Stop smoking Blood pressure Plasma cholesterol Plasma glucose

Answer 323

Lipoproteins

Answer 324

**H**igh-density lipoprotein (HDL) Protective **(H**appy cholesterol) **(H**ealthy cholesterol) (**H**elpful cholesterol)

Answer 325

**L**ow-density lipoprotein (LDL) (**L**ousy cholesterol) (**L**ame cholesterol) (**L**oser cholesterol)

Answer 326

Chest pain caused by ischemia in the heart tissues. This is not necessarily an infarction and so cells are not always dying at this point.

Answer 327

Ischemic chest pain that begins on physical and/or emotional exertion and subsides on rest and/or intake of nitrates

Answer 328

Ischemic chest pain that begins at rest and/or exertion and does not subside after rest and/or intake of medication. Often called crescendo angina as it tends to worsen over time.

Answer 329

Ischemic chest pain due to atypical contraction and spasm of the coronary arteries. Occurs most often in young women Not related to atherosclerosis

Answer 330

Unstable (crescendo) angina

Answer 331

Cocaine (Vasoactive - causes arterial constriction) (Also nicotine)

Answer 332

**Women:** Typically characterized by flu-like symptoms, fatigue, aches, chest tightness or pain, nausea, dyspnea **Men:** More classically associated symptoms such as crushing chest tightness, pain that radiates into the neck and left arm, and dyspnea

Answer 333

Through decreased production of thromboxane A₂ (A clotting activator) from arachidonic acid

Answer 334

Subendocardial infarction involves only the innermost layer of the heart. Transmural infarction involves all three layers of the heart (leads to ST-elevation).

Answer 335

Men are characterized by macrovascular atherosclerotic plaque buildup (Fat buildup in clumps in the bigger arteries) Women are characterized by inflammatory processes which lead to microvascular dysfunction and widespread, even occlusion of the smaller arteries On angiography, this difference often manifests as women's arteries being clearer than men's (even though there may be similar amounts of plaque buildup overall)

Answer 336

Electrocardiogram (ECG), coronary angiography, stress test, cardiac enzymes present in blood (high-sensitivity C-Reactive protein (hsCRP) specifically in women)

Answer 337

Troponin I

Answer 338

Tunica intima (Endothelium) Tunica media (Smooth muscle) Tunica externa (Connective tissue)

Answer 339

Hypertension

Answer 340

1. The endothelium is damaged 2. Cholesterol is deposited in the ruptured space 3. Macrophages enter the site, die, and become fat-laden foamy macrophages 4. The vessel lumen continues to narrow, pressure increases, and the risk of full occlusion or vessel rupture increase

Answer 341

An umbrella term for the effects of diseases resulting in a syndrome of effects including some mix of the following symptoms and behavioral changes: memory loss, aphasia, agnosia, apraxia, executive function decline. Also, agitation, mood swings, aggression, depression, sundowning, perseveration, hallucination, apathy, confusion, wandering, etc.

Answer 342

Inability to speak (a-phrase-ia)

Answer 343

Inability to recognize faces and symbols (a-nose-ia)

Answer 344

Loss of fine motor skills and ability to perform practical motor tasks (e.g. buttoning shirt, tying shoes, brushing teeth) (a-practical-ia)

Answer 345

The worsening of dementia symptoms as night falls

Answer 346

Alzheimer's Disease (60 - 80% of dementia cases)

Answer 347

Age Gender (women make up 2/3 of cases) Family history Social isolation Low educational attainment Metabolic syndrome

Answer 348

Only by death after autopsy All other diagnoses made by exclusion

Answer 349

65 and older (Although it is important to remember that AD is NOT a part of the normal aging process)

Answer 350

Younger than 65 years of age

Answer 351

Sensory interpretation and organization

Answer 352

Frontal Parietal Temporal Occipital

Answer 353

Executive function, planning, reasoning, planned motor functions

Answer 354

Memory organization, auditory function

Answer 355

Visual processing

Answer 356

APOE-E4 (Apolipoprotein-E4) Yes, APOE-E2

Answer 357

APP (Amyloid protein precursor) PSEN1 (Presenilin-1) PSEN2 (Presenilin-2) Autosomal dominant (50% chance for offspring)

Answer 358

Beta-amyloid plaques (extracellular) Tau-protein tangles (intracellular) - also known as neurofibrillary tangles

Answer 359

There is no definitive treatment available yet

Answer 360

Reduce metabolic syndrome factors Learn as much as you can (Cognitive reserve hypothesis)

Answer 361

The more social interaction, education, and other activities that stimulate the brain, the more protected an individual is against the effects of Alzheimer's Disease. AKA more brain usage = more neural connections = more of a buffer against neuronal damage or loss

Answer 362

Yes, the mini-cognitive test (mini-cog) and the mini-mental-state exam (MMSE)

Answer 363

Mild - Person still functions independently; mild cognitive decline; may be noticed by family and friends Moderate - Longest stage; level of care required; sociobehavioral changes; increased cognitive impairment Severe - Loss of ability to respond to environment; personality changes; comprehensive care-giving required; loss of awareness and physical abilities

Answer 364

Mild cognitive impairment and loss of short-term memory (This leads to difficulty in separating AD from the normal cognitive decline associated with the aging process)

Answer 365

4-8 years (although this number can stretch out to up to 20 years)

Answer 366

Pneumonia or other respiratory issues associated with loss of proper swallowing ability

Answer 367

Lewy body dementia Note: In our review, I said vascular dementia was 2nd. There is some debate around this topic, and for the purposes of our class, Lewy body dementia is 2nd MC. However, vascular dementia is commonly cited as 2nd MC and Lewy body as 3rd MC.

Answer 368

Abnormal protein deposits (alpha-synuclein) in the brain, somewhat similar to AD These deposits lead to a deficiency of dopamine and can cause some Parkinsonian symptoms

Answer 369

Vascular damage or defects lead to loss of sufficient blood flow to the brain and subsequent brain damage (Basically, stroke or other vascular insults damage the brain)

Answer 370

An infectious disease caused by prions (misfolded proteins) that accumulate in the brain and cause neuronal degeneration

Answer 371

An autoimmune attack on the myelin sheath that leads to scanning speech, incontinence, decreased motor ability, fatigue, nystagmus, etc. (Remember, **M**ultiple **S**clerosis affects the **M**yelin **S**heath)

Answer 372

Not characterized by dementia until the disease has severely progressed Loss of dopamine-producing region of the brain (substantia nigra pars compacta in basal ganglia) Characterized by rigidity, tremor, akinesia, shuffling walk

Answer 373

A hereditary, autosomal dominant genetic mutation with an onset between 20 and 50 years of age Characterized by loss of motor inhibition, dementia, and depression

Answer 374

A combination of the DASH (antihypertensive) and Mediterranean diets; it is thought to decrease inflammatory and metabolic processes and thus improve cognitive function

Answer 375

Lung cancer

Answer 376

Breast cancer

Answer 377

Prostate cancer

Answer 378

No, 85% have no family history of the disease

Answer 379

- nipple or another part of breast pulling inwards - dimpling or puckering - sudden discharge from a nipple - itchy, scaly sore or rash on the nipple - localized pain that doesn't go away - thickening, redness or darkening of the skin on the breast or underarm area - "peau d'orange" orange peel effect - unusual swelling and warmth, or a change in breast size or shape.

Answer 380

False. They are not even recommended.

Answer 381

~40% A larger presence of fibroglandular tissue (lactiferous lobules and ducts); as opposed to adipose tissue Younger women (as their breasts are preparing for lactation)

Answer 382

Mammography (x-ray of the breast)

Answer 383

Dense breast tissue 'shields' the tumor from detection. No, there is no relation.

Answer 384

Gender - much more common in females Age - more common as age increases Genetics - BRCA1 and BRCA2 (**BR**east **CA**ncer genes) genes Any increase in estrogen exposure - Nulliparous, no breastfeeding, early menarche, late menopause (Estrogen stimulates breast growth)

Answer 385

A cyst - fluid-filled space Fat necrosis - usually due to trauma A benign tumor - fibroadenoma A malignant tumor (cancer) - adenocarcinomas (much more common) and fibrosarcomas

Answer 386

Upper outer quadrant (armpit area) The ducts

Answer 387

Caucasian women African-American women

Answer 388

Breast, ovarian, and uterine cancers

Answer 389

Mainly breast cancer

Answer 390

The breast cancer cells have no receptors for estrogen (E), progesterone (P), or human epidermal growth factor (HER-2) This type of cancer is not responsive to hormone therapy and thus more dangerous

Answer 391

The axillary lymph nodes

Answer 392

The Sentinel node

Answer 393

Annual screening for women from 45-54 years of age Biennial screening for women ≥ 55 years of age

Answer 394

Biennial screening after 50 years of age

Answer 395

When she has a higher risk - Personal or family history - Genetic susceptibility - History of chest radiation (e.g. past TB patients)

Answer 396

Most frequent breast lesion. Painful, multiple bilateral masses that worsen in pain and increase in size during premenstrual cycle Most common in women aged 30-50

Answer 397

Depends on the extent of the disease growth. Lymph node dissection Lumpectomy Mastectomy - Simple - Partial - Total - Radical Halsted - Modified-radical

Answer 398

Human rating Demands Catastrophizing

Answer 399

1. Work to persuade people to change thinking that upsets them 2. All emotion, thought, behavior, and perception are intricately connected

Answer 400

82% are in low- and middle-income countries

Answer 401

Diet Physical activity Alcohol use Tobacco use

Answer 402

Lung cancer

Answer 403

Prostate cancer

Answer 404

Breast cancer

Answer 405

Hypertension and arthritis

Answer 406

Hypertension, arthritis, and diabetes mellitus