HARK CASE STUDY Q's - MASTER

Question 1

The CDC states that lead poisoning, which causes learning and behavioral problems and organ damage affects______ young children.

a. 1:10
b. 1:38
c. 1:76

Answer 1

b. 1:38
* While there is NO SAFE or acceptable blood level of lead, more than half a million American children between 1-5 yo have BLLs more than 5 micrograms/dL.

Question 2

True or false? The largest contributor of lead contamination in the environment is from leaded fuel.

Answer 2

True.

• Current major sources of lead emissions are ore and metal processing and aircraft engines operating on leaded aviation fuel.
  https: //www.scientificamerican.com/article/lead-in-aviation-fuel/#:~:text=While%20jets%2C%20which%20comprise%20the,a%20real%20air%20quality%20issue.

Question 3

The primary sources of pediatric lead poisoning in the U.S are (select all that apply):

a. chipped paint
b. leaded fuel
c. contaminated soil and dust from chipped paint
d. pencils

Answer 3

a and c

*1972 - lead in house paint was banned (1% lead content or higher). 1997 that threshold was changed to 0.06%. It is estimated that about 2/3 of homes built in the 1960’s and 1970’s used lead containing paint.

Question 4

Other sources of lead include (select all that apply):

a. well water
b. occupational
c. artist paint
d. ammunition
e. food
f. toys

Answer 4

all (a-f).

• In the past lead was used for plumbing so could come into contact if older plumbing systems erode. 1991 EPA regulated lead (and copper) in public sector, however private wells that serve less than 25 people are not regulated thus still at risk.
• Occupational - lead miners, refiners, smelters, construction workers
• Shooting range, gunsmiths, police officers at risk - can come home on police officers clothes, putting family at risk.
• Lead in soil, air, and water can contaminate food. Moonshine really high in lead due to using automobile radiators for the distillation process. Dinnerware, lead from glaze and paints on servingware. Lead from imported medications, herbs, cosmetics, ayurvedic remedies.
• 1978 lead paint on childrens toys banned in U.S, however not banned for toys imported from other countries.

Question 5

For children, a blood lead level over ____micrograms/dL is considered an “area of concern”

a. 3
b. 5
c. 10
d. 1

Answer 5

b. 5 (though it should be anything)

Question 6

Lead is absorbed primarily through the _____ and the _____.

a. Skin, GI tract
b. GI tract, lungs
c. lungs, mucous membranes
d. skin, lungs

Answer 6

b. GI tract (40-45%) - ingested particles, and lungs (30-40% inhaled particles.
* iron, calcium, and zinc deficiencies can exacerbate lead absorption in the GI tract

Question 7

Children store _____% of lead burden in their bone.

a. 30
b. 50
c. 70
d. 100

Answer 7

c. 70, while adults store 90% of lead burden in their bone.
* this is why new bone formation is impaired in lead toxicity, also “lead lines” -https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(03)13946-3/fulltext

Question 8

Lead depletes _____ due to its affects on renal biogenesis of the vitamin.

a. vitamin C
b. vitamin B6
c. vitamin D
d. vitamin E

Answer 8

c. vitamin D
* Lead inhibits the mitochondrial P450 1-hydroxylase enzyme needed to synthesize vitamin D. This leads to lack of D for adequate calcium homeostasis, thus bone formation negative impacts.

Question 9

The biologically active form of vitamin D is:

a. calcitriol
b. ergocalciferol (D2)
c. cholecalciferol (D3)

Answer 9

a. calcitriol - 1,25{OH}2D3
* Calcitriol: 1. promotes cell differentiation. 2. Intestinal absorption of calcium and phosphorous. 3. stimulates osteoclast - mediated bone resorption.

Question 10

Vitamin D deficiency in kids can cause _________ (condition that begins with R), and in adults can cause ____________- (condition that begins with O).

Answer 10

Rickets, osteomalacia.

*Most common signs of osteomalacia - bone and muscle weakness, tingling in extremities (calcium deficiency), bone fractures.

Question 11

Burning chest pain and stomach pain relived by antacids are symptoms in a young female athlete that may trigger a clinician to consider:

a. Riboflavin deficiency
b. an eating disorder
c. heartburn
d. overexercise

Answer 11

b. an eating disorder - c/b purging type.

* Laboratory hypokalemia and alkalosis can also suggest vomiting.

Question 12

A young adult with an eating disorder is at risk for ______ deficiency:

a. calcium
b. biotin
c. vitamin C
d. niacin

Answer 12

a. calcium
* Infants and adolescents have higher calcium requirements. Hormonal changes in puberty and growth increase the need (1,300mg/day), however only 20% (of non-vomiting) girls meet the RDA for calcium.

Question 13

Obstructive sleep apnea (OSA) is a medical condition characterized by intermittent airway closure during sleep. These airway closures lead to intermittent drops in oxyhemoglobin saturation, which triggers a surge in sympathetic activity and an arousal from sleep.

Answer 13

The three largest risk factors for sleep apnea include obesity, male gender, and middle-age.

Question 14

True/False: The diagnostic gold standard for sleep apnea is an in-laboratory polysomnography (PSG)

Answer 14

aka - or an overnight “sleep study”

A large prospective study found that persons with apnea experience increased risk of future development of hypertension.

Question 15

The solution for OSA is
A. B12 injections
B. Vitamin D 10,000 IU
C. CPAP
D. All of the above

Answer 15

C. CPAP
Randomized, controlled trials show that CPAP therapy reduces blood pressure and insulin resist- ance and improves neuro-cognitive function

Question 16

According to the NCEP ATP III definition, metabolic syndrome is present if three or more of the following five criteria are met:

• waist circumference over 40 inches (men) or 35 inches (women)
• blood pressure over 130/85 mmHg
• fasting triglyceride (TG) level over 150 mg/dl
• fasting high-density lipoprotein (HDL) cholesterol level less than 40 mg/dl (men) or 50 mg/dl (women)
• fasting blood sugar over 100 mg/dl.

Answer 16

:(

Question 17

Those with CF are at risk of developing (most commonly) deficiencies of:
A. The B vitamins
B. Fat soluble vitamins
C. amino acids
D. all of the above

Answer 17

Patients with CF are at risk for developing multiple fat-soluble vitamin deficiencies with their associated clinical manifestations.

Deficiencies of water-soluble vitamins are less common; however, vitamin B12 deficiency pro- duces macrocytic anemia and neuropathy.

Fat malabsorption, which occurs when CF patients are not receiving (or are not complying with) pancreatic enzyme replacement therapy, impairs the digestion of the glycoproteins known as R binders, which are necessary for the transfer of vitamin B12 to intrinsic factor (IF).

Osteopenia is also commonly seen in CF patients, which may be due to malabsorption, decreased calcium intake, vitamin D deficiency, delayed puberty, reduced physical activity, medications (e.g., corticosteroids), and high circulating levels of inflammatory cytokins related to lung infections.

Question 18

MNT for CF:

Even with appropriate pancreatic enzyme therapy, fat malabsorption and associated fat-soluble vitamin deficiencies may still persist in patients with CF. A daily multivitamin supplement, enriched in fat-soluble vitamins A, D, E, and K that are in a water-miscible form to improve absorption, is indicated. Since vitamin K is produced by gut micro-organisms, antibiotic therapy significantly decreases gut bacteria and, as a result, diminishes vitamin K production. Therefore, vitamin K supplements are often given to patients with CF, especially those receiving chronic antibiotic therapy (at least 2.5 to 5 mg per week).

Answer 18

Vitamin D deficiency is also common in patients with CF. Based on updated guidelines, vitamin D deficiency should be treated by doubling the amount of vitamin D3 (cholecalciferol) in their current supplements and re-checking the 25-hydroxy vitamin D level 3 months after supplementation is increased. Serum vitamin A, E, 25-hydroxy vitamin D, and PIVKA-II levels should be checked annually in all patients with CF and deficiencies should subsequently be treated.

Question 19

There is a significant association between _______ and nutritional deficit in the elderly even after adjusting for variables such as low educational and socioeconomic level, and smoking.

a. lower lifespan
b. depression
c. heart attack

Answer 19

b. depression

* A study by Cabrera et al. found depression in 24.3% of elderly subjects (Hark, pg. 217).

Question 20

Elderly are at risk for _______ deficiency, especially if they are homebound.

a. vitamin C
b. zinc
c. vitamin D
d. copper

Answer 20

c. vitamin D
* Depression can increase the likelihood of an elderly individual being homebound, thus less sun exposure and increase risk of vitamin D deficiency.

Question 21

The following would be prudent to implement with an elderly individual:

a. multimineral supplement with 100% RDA for calcium for older adults (600mg).
b. multivitamin supplement with at least 1000 IU vitamin D3 daily.
c. both a and b

Answer 21

c. a multivitamin/multimineral supplement with 600mg calcium and at least 1000 IU vitamin D3.

Question 22

Focus for constipation in older adults should be on:

a. fiber
b. hydration
c. exercise
d. all of the above

Answer 22

d. all of the above

Question 23

The number one cause of blindness in developing countries and the third leading cause of blindness internationally is ________.

a. cataracts
b. glaucoma
c. macular degeneration

Answer 23

c. age related macular degeneration
* the macula contains the most densely packed area of photoreceptors, which allows from the majority of functional vision.

Question 24

The two major forms of AMD are non-neovascular (“dry/atrophic”) and neovascular (“wet”). Non-neovascular AMD accounts for _____% of cases, while neovascular accounts for _____%.

a. 10, 90
b. 90, 10
c. 20, 80
d. 80, 20

Answer 24

b.

Non-neovascular (dry) AMD accounts for 90% of AMD cases, and is characterized by yellowish deposits of extracellular material called drusen in the retina and degeneration of the photoreceptors. This version progresses slowly over many years and seldom causes severe vision loss. (less severe, more common).

Neovascular (wet) AMD accounts for 10% of AMD cases, and is characterized by abnormal blood vessels in the retina which leads to leakage of blood, fluid, and lipids, causing fibrous scars to form. More than 80% of severe vision loss is due to this form of the disease (more severe, more rare).

Question 25

The greatest modifiable risk for Age-Related Macular Degeneration is:

a. vitamin D levels
b. smoking
c. obesity
d. vitamin A levels

Answer 25

b. smoking

* First priority should be to encourage someone at risk to quit smoking.

Question 26

Someone with advanced AMD should be prescribed the age-related eye disease study 2 (AREDS-2) formulation of (select all that apply):

a. 500mg vitamin C
b. 400IU vitamin E
c. 80mg zinc oxide
d. 2mg copper
e. 10mg lutein, and 2mg zeaxanthin

Answer 26

a-e

*The original AREDS study used beta carotene in place of lutein and zeaxanthin, however the beta carotene was found to significanly increase lung cancer risk, particularly amongst smokers, thus antioxidants lutein and zexanthin were trialled and successfully substituted for beta carotene.

Question 27

Menopause is defined as cessation of menses for ___ year, brought about by normal, progressive reduction in ______ and ______ production.

a. 1, estrogen, testosterone
b. 2, estrogen, progesterone
c. 1, estrogen, progesterone
d. 1.5, estrogen, testosterone

Answer 27

c. Menopause = cessation of menses for 1 year brought about by normal, progressive reduction in estrogen and progesterone production.

Question 28

Failure to produce estrogen may begin as early as age 30 but remains asymptomatic until a woman makes the transition from ____________ by age 50-55.

a. high levels of progesterone to little progesterone
b. less ovarian function to ovarian failure
c. high sex drive to low sex drive

Answer 28

b. Failure to produce estrogen may begin as early as age 30 but remains asymptomatic until a woman makes the transition from less ovarian function to ovarian failure by age 50-55.
* Normal physiologic cessation of menses in menopause is thought to be due to the depletion of follicle units within the ovary, mainly via apoptosis of oocytes. This process begins before birth and continues until all oocytes are exhausted, depleting a much greater number of follicles than those lost to ovulation alone.
a. k.a - apoptosis rids more oocytes than ovulation. Darn you apoptosis.

Question 29

The average range of onset of menopause is approximately ____ years.

a. 44-56
b. 35-55
c. 40-50

Answer 29

a. 44-56, with the average age of onset being 51.

• Many women remain asymptomatic even after the loss of menstrual bleeding for over 1 year.
  a. k.a - don’t think your in the clear unless you don’t get symptoms for well over a year!

Question 30

Up to 85% of women in menopause experience (select all that apply):

a. vaginal dryness and discomfort
b. hot flashes
c. sweating
d. insomnia

Answer 30

a-d

*For most women, symptoms resolve after approximately 5 years.

Fun fact - while lack of menstruation, loss of fertility, and symptoms are aspects of menopause, true diagnosis is based on failure to produce hormones. When serum follicle stimulation hormone (FSH) is measured, levels greater than 30mIU/ml, combined with symptoms, confirm a woman is experiencing menopause.

Question 31

Conditions associated with menopause include (select all that apply):

a. vaginal atrophy
b. uroepithelial atrophy
c. hot flashes
d. coronary artery disease
e. osteoporosis
f. mental health issues

Answer 31

a-f.

Vaginal atrophy - vaginal dryness, itching, pain with intercourse.

Uroepithelial atrophy - cystitis, urethritis, urinary frequency, urgency, and incontinence

hot flashes - Occur in 50-80% of women

CAD - risk doubles after menopause. Estrogen is cardioprotective but safety of hormone replacement therapy during or after is seriously questioned.

Osteoporosis - Estrogen plays a role in the intestinal absorption of calcium and bone remodeling (unknown exactly how). 75% of bone loss in women occurs within the first 15 years after menopause.

Mental health - headaches, brain fog, memory loss, confusion. Changes in mood from sleep and hormonal shifts.

Question 32

True or false - perimenopause occurs in the mid to late 40’s but can start in the 30’s as well.

Answer 32

True.

• Perimenopause is the transition period into menopause where irregularity of menstrual cycle occurs, longer time between cycles, skipped periods may occur. This can last a few months to several years, but 4 years is avg.

Question 33

Recommendations for women in menopause include (select all that apply):

a. regular exercise including weight bearing exercise
b. healthy fats
c. quality protein, increased consumption
d. vitamin D supplementation

Answer 33

a-d

*HRT increases risk of cancer thus should be avoided if possible. SSRI’s have been used successfully to treat hot flashes. Black cohosh, red clover, wild yam, evening primrose oil, maca, dong quai, vitamin E (400IU/day), flax seed, and whole soy foods have also been recommended. Valerian, ginsing, and magnesium recommended for sleep.

Question 34

What physical examination findings should one look for in a patient suspected of having disorders of lipid metabolism?

a. Examination of the pulses
b. Thyroid palpation
c. Eye examination
d. Tendon and skin examination
e. all of the above

Answer 34

e. all of the above
* Palpation of the pulses, and auscultation for bruits in the carotid and femoral arteries
* Hypothyroidism is a possible secondary cause of hypercholesterolemia
* eye examination for corneal arcussenilis
* Tendon and skin examination for xanthelasmas or xanthomas.

Question 35

To rule out secondary or contributory causes of dyslipidemia ______ should be measured:

a. fasting serum glucose
b. TSH
c. a and b

Answer 35

c. a and b
* Fasting serum glucose should be measured to rule our impaired glucose tolerance, prediabetes, or diabetes mellitus. *Thyroid stimulating hormone should be measured to rule out hypothyroidism.

Hark, pg 260

Question 36

True or false?

Metabolic syndrome is diagnosed if a patient has three or more of the following:

a. waist circumference in men over 40”, or 35” in women
b. triglycerides over 150
c. HDL less than 40 in men and 50 in women
d. fasting glucose over 100
e. Systolic BP over 130 and/or diastolic 85 or higher

Answer 36

True.

Question 37

Non-statin therapies to lower triglycerides have included:

a. Nicotinic acid ( Niacin)
b. Fibric Acid Derivatives
c. Omega-3 fatty acids
d. all of the above

Answer 37

d. all of the above
* Niacin - lowers LDL-C and triglyceride levels and raises HDL-C. It can also increase insulin resistance however if the individual is overweight.
* Fibric Acid Derivatives lower triglycerides and raise HDL-C; can have a modest (6%) LDL-C lowering effect.
* n-3 at doses of 2-4g/day lower triglycerides without significant effects on LDL-C or HDL-C.

All of the above have mixed evidence.