1
Q
When you think benzene exposure, which condition do you think of MC?
A
Leukemia
2
Q
How are we exposed to VOCs (3)?
A
dermal
inhalation
ingestion
3
Q
What main systems are affected by VOC exposure (3)?
A
neurologic
immune
hematologic (thrombocytopenia, leukemia)
- these are oncogenic compounds, usually
4
Q
Which compound are huffers after?
A
Toluene
- also known as methyl benzene
- smell of paint thinner
5
Q
What compound is present in dry-cleaned clothing?
A
tetracholorethylene or PERCs
cause
- developmental
- neurological and
- respiratory effects
6
Q
histology lab uses which compound for tissue processing? what effect does this compound cause and why is it concerning?
A
Xylene
- dimethylbenzene
- CNS depressant
- can penetrate most clothing
7
Q
What compound is found commonly in chloroseptic and carmex?
A
phenol
8
Q
Which condition is pathognomonic for asbestos?
A
Mesothelioma
9
Q
What is the metabolite of nicotine?
A
cotinine
10
Q
What is the major source of new car smell?
A
poly vinyl chloride
11
Q
What does PAH stand for? And where does it come from?
A
Polycyclic aromatic hydrocarbon
- byproduct of burning
12
Q
What are high and low molecular weight examples of PAH and where are they found?
A
LMW - naphthalene (found in mothballs)
HMW - benzo-a-pyrine (charred, grilled foods and tobacco smoke)
13
Q
what compound is used a plasticizer and is easily leached?
A
phthalates
14
Q
What compound can you find in metal cans, plastic or plastic wrap? It increases risk for (3)?
A
BPA
- xenoestrogen
- increases risk for diabetes, heart and liver problems
15
Q
What are the 6 criteria for air pollutants?
A
- Carbon monoxide
- nitrogen oxide
- sulfur dioxide
- lead
- ground level ozone
- particulate matter
16
Q
What is a xenobiotic?
A
anything that is foreign to the body
17
Q
what are the primary routes of excreting environmental contaminants? (3)
A
Biliary
Urinary
Respiratory
18
Q
What is the predominant CYP in the body?
A
3A4
19
Q
Generally speaking, is fasting a good idea when considering environmental medicine? Why or why not?
A
No, biotransformation requires energy and it can only be spared at the expense of GLUCONEOGENESIS*
20
Q
what is the definition of a fossil fuel?
A
when layers of buried plant and animal matter is exposed to heat and pressure over thousands of years
21
Q
What heavy metal is common in shellfish and the reason we ask patients to avoid eating this food prior to testing.
A
arsenic
22
Q
Which two pollutants combine to form ground level ozone?
A
VOC
Nitrogen oxide
23
Q
What is the primary cause of acid rain? What is the pH of acid rain?
A
nitrogen and sulfur oxides combing with water
pH < 5.6 *
- caused by fossil fuel emissions
24
Q
what is NOT included, when considering environmental medicine?
A
microbiology
otherwise, we consider: air pollution, heavy metal exposure, toxic chemical exposure and mold
25
What does ecology stand for?
the study of relationships between organisms and their environments
- for us to be healthy, the environment must be healthy
26
What are the common patient demographics (3) of multiple chemical sensitivity?
upper SES (85%)
caucasian
middle age female
-often found as co-morbidity to fatigue and mental health conditions
27
What are the three most common types of occupational cancers?
lung
bladder
mesothelioma
28
hair stylists are at high risk of exposure to this chemical marketed as "keratin-based" hair smoothing products?
formaldehyde
| - some say formaldehyde free or dissolving formaldehyde (methylene glycol) or can be released during heating
29
At high levels, this compound can cause parkinsonism symptoms and is a higher exposure risk for welders
manganese
| - parkinsonism sis called MANGANISM when at high levels
30
These release a small amount of mercury into the environment when broken
Compact Fluorescent Lightbulbs (CFL)
31
What should we be recommending to patients regarding their windows?
keep them open as much as possible
- maintains moderate humidity and temperature
- lets in some fresh air!
32
What does PTFE stand for and where can you find it?
polytetrafluoroethylene (PTFE)
- found in TEFLON cookware
- can cause PTFE toxicosis
when tested in birds with high respiratory efficiency, killed all 7 recently hatched chickens after heat lamp coated with PTFE exposure
33
How do organophosphates work in the body? What clinical picture do they create?
acetylcholinesterase inhibitors
- induce neurotoxicity
clinically:
- fatigue, HA, brain fog, slow response time, mm weakness
34
what can you replace mothballs with that work just as well?
cedar chips
35
is indoor air quality better or worse than outdoor air quality?
indoor air is 2-5x worse than outdoor
36
this compound has mostly resp. and mucous membrane health effects to the URT but not LRT because solubility prevents access to LRT - what compound is this?
Formaldehyde
37
What are the VOCs to be known? (6)
```
Benzene
Formaldehyde
Phenol
Toluene
Vinyl Chloride/PVC
Xylene
```
38
this compound is a byproduct of volcanoes, forest fires, carbon combustion as well as glues and paints?
benzene
| - leukemia (cause cells not to work effectively)
39
this compound is 25x more reactive than benzene
methyl benzene otherwise known as:
| TOLUENE
40
what is the primary target for toxicity in both acute and chronic toluene exposure?
CNS**
41
What is the Dx criteria for multiple chemical sensitivity
- Reproducible Sx
- Condition Persisted
- Low exposure leads to sx
- Sx improve when chemical removed
- Sx involve multiple organ systems
42
Difference between sick-building syndrome and building related illness
Sick building:
sx of ill health seem linked to a building but no specific cause is identified
Building related illness:
recognized diseases caused by being in a building
43
Main chemical in Brazilian Blow-Outs
Formaldehyde
44
What are the health effects of the natural gas exposure see on blood work?
High RBC, Hct, Hgb, and platelets
Low WBC.
(found after increased exposure to hydrogen sulfide in Iranian study)
Respiratory sx in people who use gas appliances
45
What can you potentially be exposed to if a Compact Fluorescent Bulb Breaks?
Mercury
46
What is found in Teflon Cookware?
Polytetrafluorethylene (PTFE)
47
What is a Maximum Residue Limit (MRL)? What is the MC agent?
the limit that the EPA has set for how much pesticide can remain on food
MC - organophosphates
48
What three chemicals are found in Fabric Softeners?
- Quaternary Ammonium Compounds
- Phthlates
- Synthetic Musks
49
What chemical is found in dry cleaned clothes?
- Tetrachloroethylene (PERC)
| - a type of VOC
50
What is the concerning additive found in Child Vaccines?
Aluminum
51
What does OSHA stand for?
Occupational Safety and Health Administration
52
What does MSDS Stand for
Material Safety Data Sheet
53
What is the Fourth National Report on Human Exposure to Environmental Chemicals?
- CDC report using data from NHANES to assess levels of environmental chemicals in a U.S. subsample
- Utilizes blood and urinary markers
54
Main System Affected by VOC
- Hematological
- Nervous
- Immune System
55
What are phenols produced from
- Petroleum
- used in the conversion to precursors of plastics
- used in plywood, construction, automotive and appliance industries
- Precursor to many drugs
- Oral anesthetic in Chloraseptic and Carmex but considered to be quite toxic via oral exposure
56
Where do you find formaldehyde?
- Adhesives
- Glues and Dyes
- Pressed Wood Products
- Carpet
- Particle board
57
What is the main health effect of formaldehyde?
attacks respiratory tract and mucous membranes
58
Where do you find Vinyl Chloride?
- New car smell
- Pipes
- Insulation
- Siding
- Shower curtains
59
Which VOC causes hepatic angioscarcoma?
Vinyl Chloride
other diseases:
- raynaud's
- acroosteolysis
- Scleroderma-like skin changes
60
What are the two types of polycyclic aromatic hydrocarbons (PAH)
- LMW/Naphthalene
| - HMW/Benzo(a)pyrene
61
What was the first carcinogen discovered
Benzo(a)pyrene
62
Heterocyclic Amines are formed by what?
burning at high temperatures
| ex: Benzo(a)pyrene
63
What are some prevention strategies to protect against Polycyclic Aromatic Hydrocarbons (PAH)
- Tobacco cessation/non-grilled meat
- Brassicas
- Antioxidants
- Marinade in Acidic base
64
What metabolite can you test for to measure second hand smoke exposure?
Cotinine
65
Where is asbestos found?
WHAT IS IT?
- Fire proofing
- Insulation
- Friction products
- Tile
component of PM 10 and 2.5 (PARTICULATE MATTER)
66
What are 3 health effects of asbestos
- Asbestosis
- Mesothelioma
- Lung Cancer
67
What are the safest numbers of plastic
2
4
- no leeching, no detection in humans
68
What are the just ok plastics?
1
5
- some leeching, no detected health effects
69
What are the un-safe plastic?
3
6
7
- known leeching, known health effects*
70
Polyvinyl Chloride is what number plastic?
Is it safe? Where is it found, medically?
3
Not safe
- significantly increases risk of CV and nervous disease*
-found in IV bags and tubing
71
What number plastic is in trans-vaginal mesh and diapers?
5
| polypropylene
72
3 facts about phthalates
- plasticizer
- leeches easily
- causes endocrine disruption
73
What are the health effects of Polystyrene: acute and chronic?
- acute - RESPIRATORY - effects mucous membranes and leads to irritation
- chronic - NEURAL TOXIC - dizziness, fatigue, n/v
74
2 facts about Bisphenol A (BPA)
- Used in food packaging, metal can coating
| - Endocrine disruptor
75
What species is black mold?
Stachybotrys chartarum
76
What is the AQI?
Air Quality Index
77
What are 3 MAJOR sources of air pollution?
- power plants
- refineries
- transportation
78
What are 3 smaller sources of air pollution?
- Nail salons
- Dry cleaner
- Autobody shops
79
How is particulate matter classified?
PM10: all particles < or = 10 microns
-asbestos
PM2.5: fine fraction particles
- asbestos
- haze
PM 1.0-2.5: coarse fine fraction particles
Ultrafine: all particles <0.1 microns
80
What is smog and what is the main component?
Mixture of air pollutants and fine particles
Components:
- Ground level ozone (MAIN COMPONENT)
- Nitrogen oxide
- Volatile Organic Compounds
- Sulfur Dioxide
- particulate matter
81
What are the health effects and symptoms of carbon monoxide poisioning
-RBC pick up CO quicker than O2 > tissue necrosis > death
-SX: HA, dizziness, weakness, N/V, chest pain, confusion
At high levels - LOC and death
82
What is the main cause of haze?
PM 2.5, fine fraction particles
83
What is the primary cause of acid rain?
Sulfur dioxide
84
What are Chlorofluorcarbons (CFC)
- Compound consisting of chlorine, fluorine and carbon
| - broken down by strong UV light in stratosphere; releasing Cl, which destroys ozone layer
85
What are 3 uses of Chlorofluorcarbons
- Refrigerants
- Solvents
- Foam Blowing Agents
(UV breaks down into Cl, destroying ozone)
86
These were commonly used in the past, but have been removed from the market because of health/environmental effects - what are they?
OrganoCHLORINE pesticides
- DDT
- Chlordane
- Dieldrin
- Heptochlor
87
Two types of acetylcholinesterase inhibitors
organophosphates (more toxic)
| carbamates
88
What does the nitrate in fertilizers do?
alter the iron in hemoglobin (ferrous to ferric)
| ultimately decreases oxygen carrying capacity of the blood
89
What are the exposure routes of heavy metals?
- Inhalation
- Ingestion
- Dermal Absorption
90
What is LD50?
- Median lethal dose; short term acute poisoning
- Dose given that causes death in 50% of test group
con - wide variability b/w species
91
What are mechanisms of heavy metal toxicity (5)?
- Enzyme/cofactor inhibition or potentiation
- Disruption of membrane and other transport processes
- Disrupt mitochondrial function and fatigue
- Decreased neuronal function and nerve conduction
- Bind sulfhydrl groups on proteins
92
What are potential sources of lead (4)
- Dust (directly correlated with child lead levels)
- Paint
- Soil
- Pre-1978 homes
93
Where is lead still found (7)
- Computers
- Solder
- Pewter
- Ceramic Glaze
- Jewlery
- Auto Batteries
- Imported or older pre-regulation products
94
Who are at most risk for lead exposure
Children and pregnant women's fetus
95
What are sx of lead toxicity
- Decreased learning and memory
- Paralysis
- Encephalopathy
- Fatigue
- Difficulty concentrating
- Irritability
96
What is the best test for lead toxicity screening?
Blood
97
Adult level of lead toxicity
>20mcg/dL
98
Child levels of lead toxicity
<5mcg/DL
99
What may imaging of lead toxicity reveal?
- Abdomen: lead items swallowed
| - Long bones: Lead lines
100
What is the difference between elemental, organic and inorganic mercury.
What are their exposure sources
Elemental (inhaled)
- combustion of fossil fuels, solid waste, minning, smelting - source: thermometers, barometer, DENTAL AMALGAMS
Organic (methyl mercury) (GI ABS)
- bioaccumulates in fish; infant born with cerebral palsy
- ethyl mercury - Thimerisol*
Inorganic:
- mercuric chloride, mercuric sulfide,
- source: batteries, disinfectants, health remedies and skin lightening creams
101
What is bioaccumulation
accumulation of substances in an organism
102
What is biomagnification
As you move up the food chain, concentration increases
103
What does mercury bind to, in order to cross BBB - why?
Methylmercury binds to CYSTEINE molecule
-looks similar to methionine, replaces it in the membrane transport system
Not fat soluble must be transported into brain
104
What is contraindicated when you suspect mercury exposure?
NAC because it helps transport mercury into the brain, same mechanism methionine uses
105
What is the predominant use of Cadmium?
| What are other sources (3)?
Battery Manufacturing (PREDOMINANT)
- Pigment products
- Coatings
- Plastic Stabilizers
106
What increases cadmium absorption?
Iron deficiency
107
Where does cadmium accumulate in the body
Why is this Concerning?
liver and kidneys
- irreversible proteinuria, progressive loss in GFR
concerning because if you chelate a person with elevated cadmium and try to mobilize for excretion, the key route is through the urine so you risk further damage
108
How does cadmium contribute to osteomalacia and/or osteoporosis
Other health effects?
Increased urinary excretion of
-calcium
-phosphorus
and decreased hydroxylation of Vit D*
Effects lung: pneumonititis, emphysema, lung ca
109
Where is arsenic found?
- Medicine
- Cosmetic lighteners
- Paint pigments
- Industrial wood preservation
110
Where is arsenic best absorbed in the body?
GI tract
111
What is the best test for acute exposure of arsenic
what is another source?
Blood is best
Hair - pros and cons
112
What are the PROs of hair testing for heavy metals
- Good for METHYLMERCURY
- cheap and easy
- Qualitative screening for exposure
NOT DIAGNOSTIC
113
What are cons for hair testing of heavy metals? Which metals are unreliable with this method (3)?
- Only a screen must be confirmed by blood
- No indication of net retention
- Highly vulnerable to external contamination
- No standard procedure
Not reliable for Hg, Cd, Pb
114
What is depuration
- Action or process of freeing something of impurities
| - Removal of xenobiotics by the body
115
What is Detoxification
transforming a toxin into a non-toxic substance
116
What is nasal fatigue
you ever notice how when you walk into a room with a terrible smell and you stay there long enough you don't notice it anymore
well your in luck ;)
117
What are the effect of starvation on NADPH and why is starvation not a good idea for biotransformation?
NADPH: component of phase 1 detox
Not a good idea for biotransformation because it can only be produced at expense of gluconeogenesis
118
What is the main CYP in the liver
CYP-3A4
119
Are heavy metals inducers or inhibitors
INHIBITORS
120
What are major TYPES of absorption of biotransformation
- simple diffusion
- passage through pores
- specialized transport systems
121
What are major SITES of absorption of biotransformation
- ingestion
- inhalation
- dermal absorption
122
Major Storage sinks in the body (4)
- Adipose (pesticides)
- Bone (Al, Cd, Pb)
- Liver
- Kidney
123
What are a couple of our barriers?
- BBB
| - Placenta
124
What is the MAJOR idea of biotransformation
Conversion of lipid soluble xenobiotic into polar water soluble for excretion
125
Difference between TH1 and TH2 response?
THI:
INFECTION (intracellular bacteria and some viruses)
- IL-2, INF gamma, TNF beta, activates macs
TH2:
WORMS (infestation by GI nematodes)
- IL-4,IL-5, Il-10, IL-14, antibody response and eosinophil activation
126
How do toxins cause immune deficits
- Hypersensitivity reaction (includes allergy)
| - Autoimmunity
127
DES, DIOXINE and DDT - cause what?
Atrophy and/or death of the cells of the thymus gland
128
Polychlorinated Biphenols - PCB exposure make people more prone to what?
Allergic reponse
129
PAH exposure does what?
Decreases splenic and thymic activity
130
Lead and Mercury lead to an inability to do what?
kill candida
131
When may selenium supplementation be protective?
cadmium exposure
| - can be protective of immune function
132
What is the main problem with Diethylstilbestrol (DES)?
reproductive problems in the offspring
133
What is an endocrine disruptor?
Xenoestrogen
-Phytoestrogen is specifically extracted from plants
134
What are problems with the ways we study xenoestrogens (2)?
- Mostly Animal Studies
| - Differing half-lives
135
What environmental exposures can cause infertility in females? (5)
- PAH
- Chemotherapeutic agents
- Solvents
- BPA
- Particulate Matter
136
What causes infertility in males? (2)
- Organophosphates
| - Heavy metals
137
What compound looks like thyroid?
-PCBS
| polychlorinated biphenyls
138
What are two exposure history forms
- Crinnion
| - ATSDR
139
What tests should be ran before doing any specialty heavy metal testing? (7)
- CBC
- CMP
- Lipids
- Complete UA
- Urine HCG
- G6PD
- TB test
140
Is there a good test to determine ACCURATE body burden of heavy metals?
NO
141
Who is a good candidate for stool testing?
Pediatric patients
142
Binding affinities for metals with chelating agents in order of greatest to least. Which is chelated best?
Hg>Ag>CH-Hg>Cu>Pb>Zn
best for mercury
143
is IV or oral administration of chelating agent best?
IV
144
What are the side effects of chelation (3)?
- Decrease in essential minerals
- Increase liver transaminases
- Allergic reaction occasionally
145
Why do you need to avoid seafood for a week prior to metal challenge testing?
Arsenic and Mercury bioaccumulation
146
How do you test for acetylcholinesterase pesticide exposure?
Whole blood AND plasma
Test both
147
What is the theory behind colon hydrotherapy as tx?
Increases bile dumping
148
Why low temp sauna
- Increases lipolysis
- Helpful for excretion of metals in adipose tissue, solvents, plastics and pesticides
- Tolerate longer times
149
Food and supplements that help increase glutathione (7)
- Cysteins (l-cysteine, NAC)
- Glutathione
- Cruciferous veggies
- Dietary Fiber
- Undenatured whey protein
- Dietary Fibers
- Onions and Garlic
150
List some of the basic supportive supplements (4)
- Vit. C
- Fiber
- Selenium
- Zinc
151
this occupation for mothers increases the risk of their children having cleft palate, what occupation is this?
preschool teacher
152
What is being used to replace CFCs (chlorofluorocarbons)?
HCFC (hydrochlorofluorocarbons)
| - still break down ozone, but not AS extensively
153
what are heavy metal's main mechanism of detox from the body (i.e. - which phase II mechanism)?
glutathione conjugation
154
blood work for lead poisoning will show?
microcytic hypochromic anemia with basophilic stippling
155
What homeostasis is disrupted by mercury in the body?
calcium homeostasis
156
Whole blood levels for mercury should be?
< 5 mcg/dl
Environmental Medicine
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