A4M Written Exam Questions and Answers: A Comprehensive Guide to Medical Knowledge, Exams of Social Sciences

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A4M WRITTEN EXAM QUESTIONS AND ANSWERS

Mechanism of action of curcumin Supplement whose mechanism includes decreasing tau phosphorylation and reducing COX-2 expression. - Answers-Curcumin is an inhibitor of phosphorylase kinase. It decreases tau phosphorylation; reduces COX-2 expression; inhibits NF-kB. Stimulates neutrophils and macrophages to kill microorganism. Nontoxic and does not cause microbial resistance. Useful for treatment of intracellular organisms. - Answers- Olive leaf extract Rate of secretion of PSA from prostate / day? - Answers-0.07 ng / mL Mineral responsible for increasing renal intra-glomerular pressure and decreasing arterial compliance - Answers-Sodium How much does potassium decrease BP? - Answers-Supplementing potassium 60- 120 mEG day may decrease SBP / DBP by 4/2.5 mm HG Actions of Magnesium on BP: are - Answers-- Acts as a calcium channel blocker

• Regulates insulin sensitivity
• Regulates pH
• Increases arterial compliance via endothelial vasodilatation T or F: omega-6 fatty acids decrease blood pressure - Answers-False (although may indirectly affect BP through effects on saturated fatty acids) Recommended intake of calcium to reduce HTN - Answers-> 800 mg / day may reduce incidence of HTN T or F: soy protein decreases blood pressure and increases arterial compliance - Answers-True; recommended in fermented form; 30-40 gm / day for hypertensive individuals T or F: omega-9 fatty acids found in olive oil have beneficial effects on both blood pressure and cholesterol - Answers-True Effects of garlic on HTN - Answers-garlic acts as a natural ACE-I, CCB and increases arterial compliance via increase of NO production T or F: The gamma isomer of Vitamin E is more potent than the alpha isomer in lipid lowering effects - Answers-True

Most potent B vitamin; lowers blood pressure via multiple mechanisms - Answers- Vitamin B6. Increases bioavailability of coA and decreases cholesterol synthesis. Also reduces oxLDL. Increases HDL, reduces LDL and triglycerides. T or F: There is strong evidence for Guggul in treatment of cholesterol - Answers-False T or F: Niacin is the most effective currently known agent for increasing HDL - Answers- True Which infectious agents have been linked to development of MS plaques in brain? - Answers-Mycoplasma pneumoniae and EBV T or F: 20% of MS patients have been shown to have gluten sensitivity - Answers-True pharmaceutical / nutriceutical agents have been shown to be helpful in treatment of MS? - Answers-Alpha lipoic acid; minocycline; doxycycline; memantine; NAC; Vitamin What B12; phosphatidyl serine; Coenzyme Q10; HRT with estrogen / estriol; hyperbaric oxygen therapy Which areas of the brain are affected in a SPECT scan of a patient with Alzheimer's disease? - Answers-Posterior cingulate gyrus; parietal and temporal lobes What area of the brain is affected in a SPECT scan of a patient with Lewy Body dementia? - Answers-Occipital lobe T or F: IGG to periodontal bacteria is elevated in patients with dementia - Answers-True What abnormalities are found in the brain on autopsy of patients with Alzheimer's disease? - Answers-Beta-amyloid plaque and neuro-fibrillary tangles. Neurofibrillary tangles are formed from mutations on tau protein. Beta-amyloid plaques are formed from breakdown of APP (amyloid precursor protein). Beta amyloid causes destruction in brain parenchyma by combining with salt and water in the brain. It also causes influx of calcium into neurons, leading to apoptosis. Type of dementia associated with protein deposits known as alpha-synuclein; visual hallucinations; low dopamine levels - Answers-Lewy body dementia What is mechanism for brain injury from concussion? - Answers-- Excitotoxic reaction mediated by increased extracellular glutamate / aspartate and increased intracellular calcium

• Microglia (normally dormant) become activated and release ROS; inflammatory prostaglandins; cytokines and chemokines
• High levels of extracellular glutamate reduce astrocytic glutathione

Type of dementia most commonly caused by abnormalities on tau protein. Characterized by uninhibited behavior, primary aphasia, lack of insight - Answers- Frontal Lobe Dementia What area of the adrenal gland are the sex hormones produced? - Answers-Zona reticularis Where is aldosterone produced in adrenal gland? - Answers-Zona granulosa (outer layer) What are the risk factors for sub-arachnoid hemorrhage (rupture of cerebral aneurysm)?

• Answers-Hypertension; smoking; oral contraceptive usage; usage of stimulants What is the mechanism of action of migraine headache? - Answers-Extreme cerebral vasoconstriction followed by vaso-dilatation Which neuro-transmitter deficiencies have been implicated in the development of migraine headaches? - Answers-GABA and serotonin T or F: thymectomy is recommended for treatment of myasthenia gravis - Answers- False; current evidence does not support thymus removal due to risks of surgery and lack of evidence; however, 70% of patients with myasthenia gravis have thymus hypertrophy and 10 - 15% have thymomas. IVIG may be helpful for management of myasthenia gravis. T or F: many of the pharmacologic treatment options for demential increase homocysteine levels, which may directly contribute to cognitive decline - Answers-T T or F: consumption of milk > 16 oz / day over a 30 year time period leads to a 230% increased risk of Alzheimer's disease - Answers-T T or F: both Curcumin and Resveratrol cross the BBB and are helpful in treatment of both TBI and dementia - Answers-True. Resveratrol improves beta amyloid clearance from brain. How many genes do humans have? - Answers-Humans have 23,000 genes - only 1.5% of which code for proteins Which estrogen metabolite is protective against breast and ovarian cancer? - Answers- 2 methoxy estrone T or F: High blood insulin levels inhibit the conversion of saturated fatty acids to MUFA's, leading to elevated blood triglycerides - Answers-True What is the first sign of pancreatic insufficiency? - Answers-Deficiency in pancreatic lipase or elastase.

How do nutrients such as carnosine and vitamin B1 help to reduce HA1c? - Answers- Interferes with glycosylation of proteins What is Type 2 hypothyroidism? - Answers-Reduction in thyroid hormone receptor sensitivity - associated with normal serum levels of all thyroid hormones but sx of hypothyroidism. Receptor sensitivity can be affected by iron levels and Vitamin D. Which nutrients impact T4 to T3 conversion? - Answers-Selenium, zinc T or F: serum calcium levels are an accurate predictor of bodily calcium stores - Answers-False. Serum calcium is tightly regulated by PTH, calcitonin, Vitamin D. If serum calcium is low, bone will be resorbed to replete levels. Which element is present in highest amount in the human body? - Answers-calcium (total body calcium = 1000 grams) What is the second most abundant mineral in the body? - Answers-Phosphorous What are the 9 essential amino acids? - Answers-histidine, isoleucine, leucine, lycine, methionine, phenylalanine, threonine, tryptophan, valine What amino acids are "conditionally" essential? - Answers-Arginine, glutamine, glycine, and taurine What is the best method for determining amino acid status? - Answers-Plasma levels In what disease states is low homocysteine seen? - Answers-Autism & ADHD. Methionine can be supplemented in these instances. What are the primary lymphoid tissues? - Answers-Thymus, fetal liver, and bone marrow What is the prevalence of Hashimoto's disease in the US population? - Answers-13% What are the secondary lymphoid tissues? - Answers-Spleen, lymph nodes, tonsils, Peyer's patches (gut) What are signs / symptoms of low T3 in cardiovascular disease? - Answers- Bradycardia, narrowed pulse pressure, diastolic hypertension, elevated CRP, inflammatory markers and homocysteine T or F: T3 therapy is antiarrhythmic - Answers-T What is the strongest independent predictor of death in cardiac patients - Answers-Low fT

What enzyme(s) does progesterone act on in hormonal pathway? - Answers- Progesterone has actions as both an aromatase inhibitor as well as a 5-alpha-reductase inhibitor Mechanisms of action of melatonin on inflammation - Answers-- Inhibits COX-2 & Nuclar Factor Kappa Beta

• Reduces expression of inflammatory cytokines
• Most effective scavenger of hydroxyl radical
• Endogenously protects mitochondria and nuclear DNA from injury and oxidation
• Stimulates superoxide dismutase, glutathione peroxidase
• Increases free radical scavenging and antioxidant efficacy of glutathione, Vit E, Vit C
• Protects against cellular and DNA damage from ionizing radiation and reperfusion injury T or F: growth hormone peaks at puberty and starts to decline at age 21 - Answers-True Main estrogen produced in the post-menpausal woman - Answers-Estrone T or F: obese women have higher estrone: estradiol ratio than non-obese women - Answers-True Strongest estrogen in body - Answers-Estradiol T or F: 16-hydroxyestrone does not stimulate cells to divide - Answers-False. 16-OHE bind strongly to special receptors inside of cells and increase rate of DNA synthesis How much of a female's total testosterone level is free? - Answers-1% What conditions are associated with high levels of 16-OHE? - Answers-Obesity, hypothyroidism, pesticide exposure, omega-6 FA excess, inflammatory cytokines T or F: Testosterone, when given without estradiol in a woman, increases the risk of MI by increasing plaque formation in heart vessels - Answers-T What is the central killing mechanism of neutrophils? - Answers-NADPH oxidase, which generates high levels of superoxide, a ROS. Superoxide combines with NO to form peroxynitrite and hydrogen peroxide. How do activated macrophages contribute to tissue damage during prolonged immune activation? - Answers-Macrophages contain surface glutamate receptors that, when activated, cause tissue damage. Macrophages readily enter the brain and spinal cord, transform into microglia, and release cytokines, chemokines, interferons and other ecitotoxic molecules. T or F: mast cells can enter the brain from the blood during brain injury - Answers-T

What cell line constitutes the first line of defense against invading organisms? - Answers-Macrophages T or F: plasma cells are highly present in circulation - Answers-False. Plasma cells reside in secondary lymphoid organs. They will accumulate in areas of high antigen presence. what is the purpose of T-regulatory cells? - Answers-T-regulatory cells reduce inflammatory responses and are connected to IL-4 and IL-10, the anti-inflammatory cytokines. What are the 5 R's of gut rebalancing? - Answers-Remove, Replace, Reinoculate, Repair, Rebalance T or F: LDL can become oxidized from pathogen exposure - Answers-T. This is due to LPS activating foam cells (inflammatory response) T or F: High plasma renin activity (PRA) will respond more effectively to ACE-I and CCB

• Answers-T. High PRA > 0.65 will respond to ACE-I BMI definition of obesity - Answers-BMI > or equal to 30 T or F: Administering pregnenolone to a person in sympathetic overdrive may increase cortisol production - Answers-T What can be done to mitigate oxidation of fatty acids when administering omega-3 FA to a person with an APOE4/4 genotype? - Answers-Add 50% GLA to omega-3 FA dose + 1/10 dosage mixed tocopherols + 200 mg mixed tocotrienols What agents help to decrease homocysteine? - Answers-Fish oil; coenzyme Q10; B vitamins; methylfolate; TMG What agents help to decrease Lp (a)? - Answers-niacin, vitamin C, proline, lysine. also focus on diet - reduce CHO, increase good fats How can hs-CRP be reduced? - Answers-Fish oil; omega-3 FA; statin, B-blocker, Coenzyme Q10; green tea; daily ASA What are the contraindications to replacement with growth hormone? - Answers- Malignancy, proliferative retinopathy Examples of ways to reduce elevated DHT in men - Answers-Saw palmetto, progesterone 1% cream What is the ideal level of 2:16 OHE? - Answers-> 4.

What percentage of circulating lymphocytes are comprised of B cells? - Answers- 5 - 15% Role of IL-1 in tumorigenesis - Answers-Promotes angiogenesis, tumor growth and metastases T or F: short term exposure to particulate matter in air is associated with increased risk of stroke - Answers-T What is the mechanism of action of carnosine? - Answers-Carnosine is an amino acid found in red meat that helps reduce glycation. It has antioxidant properties and helps lower BP via effects on sympathetic nervous system. Carnosine also protects against ischemia / reperfusion injury after a stroke by reducing toxicity of the excitatory neurotransmitter glutamate How do SERMS affect lipid profile? - Answers-SERMS such as Tamoxifen and Raloxifene decrease total cholesterol by 5% and LDL by 10%. They are not effective in lowering triglycerides and do not increase HDL s well as standard HRT. What are the effects of estrogen on neurotransmitter balance? - Answers-Estrogen increases serotonin availability and enhances dopamine and NE transmission Adverse effects of Tamoxifen therapy - Answers-May double or triple the risk of uterine cancer and also increases risk of blood clots. What is Raloxifene and what are its adverse side effects? - Answers-Raloxifene is a SERM used to treat osteoporosis. It may increase bone density up to 20% but also increases risk of breast CA. T or F: low levels of DHEA are often associated with hypothyroidism - Answers-T What role does Vitamin A play in immune system regulation? - Answers-Vitamin A supports phagocytosis by macrophages and neutrophils. It is involved in both innate and cell-mediated immunity. Also helps with TH1 - TH2 response. What is mechanism of action for cell death initiated by neutrophils? - Answers- Neutrophils induce cell death via NADPH oxidase which releases superoxide. Superoxide reacts with NO to produce peroxynitrite, a potent ROS. What is TNF-alpha? - Answers-TNF-alpha is the cell death pathway. It initiates apoptosis via activation of NF-kappa B. It has both pro and anti-tumorigenic effects in animal models. What is IL-6? - Answers-IL-6 is a messenger cytokine that activates B cells and promotes their maturation. Increases acute phase reactants such as CRP, ferritin and fibrinogen. Plays important role in heart disease and also has signaling implicated in tumorigenesis.

What is the function of T helper cells? - Answers-T helper cells respond to APC expressing MHC class II Ag to augment a cytokine response. Induces IFN-gamma and IL-2, a T cell growth factor. IL-2 also activates cytotoxic T cells (CD8). How is estradiol produced in body? - Answers-Estradiol is produced by aromatization of T in ovary and other tissues or by 17 hydroxylation of estrone in periphery. What is the function of the parietal lobe in the brain? - Answers-Proprioception, visual guidance, differentiate right from left, reading maps What are the functions of the frontal lobe of the brain? - Answers-Judgement; impulse control, attention span; critical thinking; empathy (things that make us HUMAN) What is the function of the temporal lobe of the brain? - Answers-Hearing, listening, short & long term memory, mood stability, naming things What is the function of the occipital lobe of the brain? - Answers-The occipital lobe is the visual processing center of the mammalian brain containing most of the anatomical region of the visual cortex. What enzyme of the body does Metformin act on? - Answers-Metformin acts on AMP kinase, which increases ATP production and deploys GLUT4, leading to increased glucose uptake Symptoms observed with temporal lobe dysfunction - Answers-memory issues; reading issues; word finding issues, poor visual recognition Symptoms observed with parietal lobe dysfunction - Answers-left / right confusion; denial of illness; neglect or unawareness; impaired position sense T or F: Metformin may help to lower incidence of cancer in diabetic patients - Answers-T. Metformin increases activity of AMPK which exerts effects on tumor suppression p and also inhibits aromatase expression in breast tissue. Metformin has been shown to lower pancreatic CA risk by 62% and studies have also shown decreased incidence of breast CA in diabetics treated with Metformin vs. other agents. What are the 4 mechanisms of action of Metformin? - Answers-1) decreases glucose absorption from the gut

2. inhibits hepatic gluconeogenesis
3. Increases sensitivity and # of insulin receptors
4. increases fatty acid oxidation T or F: statins aid in DNA repair. - Answers-T

Mechanism of action of Coenzyme Q10 - Answers-Coenzyme Q10 enhances ATP production via transfer of electrons within the mitochondrial oxidative respiratory chain T or F: Coenzyme Q10 may help heal and prevent gum disease - Answers-T Mechanism of action resveratrol - Answers-Resveratrol activate enzymes called sirtuins, which regulate transcription and apoptosis as well as energy utilization during circumstances of low caloric intake (AKA mimics state of fasting). What conditions has carnosine proved helpful in treating? - Answers-Carnosine curbs formation of AGE's. Can be used to treat Alzheimer's, cataracts, peripheral neuropathy, atherosclerosis. What foods possess natural ACE-I activity? - Answers-milk, casein, gelatin, sake, sour milk, sardine muscle, tuna muscle, fish, seaweed, garlic, hawthorne, egg yolk, hydrolyzed whey protein, omega-3 FA, pomegranate juice How many mg / day of T do men make? - Answers- 5 - 7 mg / day What is glycemic index? - Answers-Amount of a given food that will raise the blood glucose level equivalent to a 50 g carbohydrate load T or F: concomitant use of enalapril with taurine provides additive reductions in BP, LV hypertrophy, arrhythmias, and platelet aggregation - Answers-T Recommended daily dosage of potassium and recommended potassium / sodium ratio - Answers-5000 mg / day of potassium and 3:1 ratio of K:Na (although 5:1 is preferred) Optimal daily dietary consumption of fruits and vegetables - Answers-10 servings / day What are the hallmarks of Alzheimer's disease? - Answers-Accumulation of beta- amyloid plaque in brain; DNA damage (elevated 8-ohDG); poor antioxidant status T or F: Alzheimer's disease and Parkinson's disease are mitochondriopathies - Answers-T T or F: homocysteine stimulates NMDA receptor directly, leading to influx of calcium and hence acting as a mitochondrial toxin - Answers-T What is the endopat test? - Answers-Endopat is a measure of endothelial function. Endopat measures the vascular flow in a patient's arm after occlusion. Post occlusion dilation should be greater in the control arm due to release of NO. Sensitivity of SPECT scan for diagnosing Alzheimer's dz - Answers-74%

Medications that decrease conversion of T4 to T3 - Answers-Beta blockers, lithium, anticonvulsants, amiodorone T or F: T3 therapy is antiarrhythmic - Answers-T. T3 shortens the QT interval and makes lethal arrhythmias less likely. T or F: Low T3 is the strongest predictor of death in cardiac patients; more than lipids or EF - Answers-T Dosing of Testosterone in various forms - Answers-cream 50-150 mg / day Cypionate 50-150 mg / week pellets 75 mg (5-10) every 3 months HCG 1000-5000 IU / week Functional biomarkers for measuring calcium - Answers-bone resorption markers, serum 25-OHD, PTH Direct markers for measuring calcium - Answers-hair, urine Main estrogen produced before menopause - Answers-Estradiol Functions of estradiol - Answers-Increases HDL; decreases LDL; decreases triglycerides; increases GH; increases serotonin; increases endorphins; improves sleep; decreases fatigue; maintains memory; antioxidant status; helps maintain potassium and absorb calcium, Mg, zinc T or F: estriol is 80 times weaker than estradiol - Answers-T Actions of progesterone in body - Answers-Natural diuretic; increases scalp hair; enhances action of thyroid hormones; relaxes smooth muscle; neuroprotective; anti- inflammatory; prevents menstrual migraine headaches; calming; stimulates production of new bone; lowers cholesterol; protects breast tissue from overstimulation from E non-pharmacologic ways to boost T - Answers-Decrease caloric intake; increase protein in diet; exercise; amino acids (arginine, leucine, glutamine); sleep; lose weight; stress reduction; zinc T or F: 20% of women have high T levels as they go through menopause - Answers-T Where do immune reactions such as antigen interaction with APC's take place? - Answers-secondary lymphoid organs - spleen, lymph nodes, tonsils, etc Most abundant immune cell in circulation - Answers-polymophonuclear granulocytes. Comprise 60-70% of circulating lymphocytes. Protect by phagocytosis. Most common type of granulocyte. - Answers-Neutrophils - 90%

Percentage of eosinophils in circulation - Answers- 2 - 5% Where are mast cells found? - Answers-F. Mast cells are mainly found in connective tissues of body. They can; however, enter the brain from the blood during brain injury. Percentage of B cells in circulation - Answers- 5 - 15% How does Th1 stimulate immune response? - Answers-Th1 operates primarily through macrophage and produces cytokines including IL-2; TGF-beta and IL-10. Also stimulates cytotoxic T cells. How do Th2 cells operate on immune system? - Answers-Th2 cells operate primarily through B cells and release cytokines including IL-4, IL-5, IL-6, IL-10, and TGF-beta, helping to promote antibody production T or F: Asthma is associated with a TH1 response - Answers-F. Asthma involves Th response. Examples of antigen presenting cells - Answers-Microglia in brain; Langerhans cells in skin Most common immunoglobulin in circulation - Answers-IGG makes up 75% of total Ab. Most efficient against viruses and microbial toxins. Triggers C1 of complement chain. Provides passive immune defense to fetus in utero and to infant in first 6 months of life. Antibody that protects mucosal surfaces - Answers-IgA. T or F: Colostrum is rich in IgA. IgA protects newborn baby by reducing pathogen multiplication. - Answers-T Ab that is bound to mast cells by Fc receptors; triggers release of complement and chemotactic factors when activated - Answers-IgE Immuno-modulatory antibody that controls B cell activation - Answers-IgD T or F: cell mediated immunity can be actively transferred from one person to another - Answers-F Complexes that interact with immune cells and antigens to control Ag-Ab reactions and determine self from non-self - Answers-MHC (major histocompatability complex) T or F: persistently low albumin is a sign of chronic inflammation - Answers-T Basic tests of immune function - Answers-hs-CRP; IgA, IgG, IgM, neutrophil, monocyte and lymphocyte counts; iron panel and serum albumin

T or F: deficiency of Vitamin A reduces the integrity of the mucosal barriers - Answers-T T or F: supplementation with Vit A produces a better and safer response to vaccinations

• Answers-T T or F: Vitamin C should be taken with meals - Answers-False. vitamin C taken with meals, especially those rich in iron, may worsen active infection, since bacteria utilize iron for reproduction. Mechanism of action of thiazolidenediones (pioglitazone) - Answers-Insulin sensitizers; act on PPAR pathways to modulate the transcription of genes involved in glucose metabolism Mechanism of action of sulfonylureas - Answers-Stimulate insulin release by inhibiting the ATP-dependent potassium channel on pancreatic beta cells Mechanism of action of alpha-glucosidase inhibitors (acarbose) - Answers-Delay glucose absorption from GI tract Mechanism of action of GLP-1 analogues (Victoza) - Answers-Stimulate glucose- dependent insulin secretion; promotes satiety; increases glucose dependent insulin; slows stomach emptying; beta cell preservation DDP-4 inhibitors (sitagliptin phosphate) - Answers-slow inactivation of incretin hormones (eg GLP-1), which stimulate glucose-dependent insulin secretion natural methods of boosting glutathione - Answers-Riboflavin (B2); L-glutamine; L- glycine; whey protein; yogurt with live active cultures; NAC or L-cysteine; aged garlic extract; onions and leeks; melatonin; selenium; alpha lipoic acid; curcumin; milk thistle T or F: Vitamin K2 does not affect coagulation and can be taken safely by patients on Coumadin therapy - Answers-T Mechanism of action of chromium - Answers-Allows glucose transport into cells Vitamin D benefits to cardiovascular health - Answers-50% decrease relative risk of MI; reduced risk of HTN due to effects on renin; lowered inflammation and hence lower hs- CRP; suppressed foam cell formation by reducing oxidized LDL uptake in macrophages Ways insulin resistance contributes to hormone imbalance - Answers-Insulin resistance leads to increased insulin secretion which increases 17,20 lyase activity and increases DHEA levels. DHEA can then convert to T, which may be aromatized to E. Increases insulin also has effects on hepatocytes leading to decreased SHBG, hence increased free hormone. Overall effect is to increase free estrogen levels in body.

Metabolic syndrome criteria for diagnosis - Answers-3/5 of following: Increased waist circumference (> 40 inches men and > 35 inches women); Low HDL (< 40 for males, < 50 for females); high triglycerides (> 150); high fasting gluose; HTN. What is HOMA-IR? - Answers-HOMA-IR is a homeostatic model for insulin resistance based on plasma levels of fasting insulin and glucose that is used to assess insulin sensitivity. What is adiponectin? - Answers-Adiponectin is an adipose derived protein (adipokine) that is protective against atherosclerosis. It moderates fat tissue, promotes insulin sensitivity; and decreases hepatic glucose and lipid production. T or F: Stage 1 Insulin resistance is associated with declining adiponectin levels; normal to slightly elevated HOMA-IR; normal glucose; normal A1c; normal insulin and normal pro-insulin. - Answers-T Features of stage 2 IR (insulin resistance) - Answers-Decreased adiponectin; increasing insulin; normal pro-insulin; high normal HOMA-IR; elevated insulin; high post-prandial glucose. Beta cell impairment may be present. Features of stage 3 IR. - Answers-Elevated pro-insulin; elevated HOMA-IR; elevated adiponectin; elevated insulin; high A1c and high glucose. At what age does sarcopenia begin - Answers-Sarcopenia begins at age 50, and progressively worsens, affecting 30% of people over 60 and 50% of those > 80 Supplements that may help combat sarcopenia - Answers-Vitamin D; glucosamine; creatine; colostrum; whey protein; amino acids; HMB; carnitine; omega 3 fatty acids; HRT; trace elements; human growth hormone Optimal level of homocysteine - Answers-<10; also do not want it too low as this reflects over-methylation Changes observed in lung parenchyma with aging - Answers-Reduced elastic recoil and progressive reduction in compliance due to stiffening of chest wall lead to decreased vital capacity and increased residual volume. Total lung capacity remains constant. FEV1 decreases. Supplements that lower homocysteine - Answers-Vitamins B12, B6, folate, MTHF, TMG, garlic, SAME, beets, broccoli What is fibrinogen and how is it treated? - Answers-Fibrinogen is a clot promoting substance that contributes to risk of MI. It can be lowered by HRT; garlic; fish oil; bromelain; Vitamin E; gingko and green tea What is Lp(a)? - Answers-Is a small cholesterol particle that

causes inflammation and can clog blood vessels.

• Research has shown that people with high lipoprotein (a) have a 70% higher risk of developing heart disease over 10 years. T or F: statin drugs elevate Lp(a) - Answers-T Ways to lower Lp(a) - Answers-Natural HRT; fish oil; Vitamin C; niacin; L-carnitine; coenzyme Q10; L-lysine; L-proline; flax seed. If these methods fail, can use nattokinase

• Vitamin C. How to lower CRP - Answers-Exercise; baby ASA; fish oil; CoQ10; natural COX- 2 inhibitors (grapeseed extract, curcumin, green tea); statin drugs; beta blockers T or F: elevated ferritin increases risk of heart disease - Answers-T medications that block T4 to T3 conversion - Answers-Beta blockers Propranolol Birth control pills Estrogen Lithium Phenytoin Theophylline Chemotherapy Does Suppressing The TSH Cause Bone Loss? - Answers-no factors that affect conversion of T4 to T3 - Answers-heavy metals; stress; inflammation; inadequate protein intake; liver or kidney dysfxn; pesticides; nutrient deficiencies (iodine, selenium, zinc, iron Factors Associated with Low T3 or Increased Reverse T3 - Answers-Increased E, NE Free radicals Aging Fasting Stress Prolonged illness Diabetes Toxic metal exposure Elevated levels of IL-6, TNF-alpha, IFN- 2 Causes of Elevated rT3 - Answers-Common in CFS/fibromyalgia

Yo-yo dieting Heavy metal toxicity Infections Physical and mental stress T or F: Up to 72% of the world's population is affected by an iodine deficiency disorder. - Answers-T How to do an iodine challenge test - Answers-50 mg of an iodine/iodide mixture is given as a loading dose and the amount of iodine excreted in the urine over the next 24 hours is measured. Iodine deficient state: Levels below 90% excretion. How long does it take for iodine receptors to saturate when giving iodine therapy - Answers- 3 - 6 months T or F: over-replacement with iodine can cause thyroiditis - Answers-T Optimal ferritin levels to support thyroid function - Answers-Ferritin levels should be over 100 ng/ml Ferritin levels over 130 are suggested if the patient is cycling. T or F: Elevated CRP and homocysteine levels are associated with hypothyroidism. - Answers-T T or F: Elevated rT3 strongest predictor of mortality in first year post acute MI. - Answers-T T or F: Low T3 is predictive of AF post CABG - Answers-T Symptoms of cataract - Answers-Altered color vision (cannot see that clothes are mismatched or hair is not the usual color) Feeling of looking through a clouded piece of glass Increased sensitivity to glare from the sun or headlights Increasingly blurred vision Need for brighter illumination Double vision when looking out of only one eye Difficulty seeing in the dark

Vision that is brighter in one eye than in the other Risk factors for cataracts - Answers-- UV radiation

• Diabetes
• Topical or systemic steroid drugs
• Smoking
• Poor nutrition T or F: After the age of 40, the production of glutathione by your body diminishes. - Answers-T Nutrients that have been shown to effectively protect the eye against cataract formation: - Answers-- Carnosine
• Glutathione
• Taurine
• Cysteine
• Vitamins C, A, E (antioxidants)
• Vitamin B T or F: Macular degeneration is the leading cause of blindness after the age of 55 and affects more people than cataracts and glaucoma combined - Answers-T Which type of MD is more common (dry or wet?) - Answers-Dry is more common, affecting 85-90% of people with MD; wet type is more damaging and causes the majority of severe disease Risk factors for MD - Answers-Over the age of 55 Have blue, green, or hazel eyes Frequently exposed to sunlight without sunglasses Smoker Postmenopausal woman Risk factors for simple or chronic open-angle glaucoma - Answers-Clogged arteries High blood pressure Diabetes Smoking Alcohol excess African ancestry History of severe anemia or shock Symptoms of macular degeneration - Answers-Normally straight objects appear bent or wavy. A dark, blank or blurry spot appears in the

center of your vision. When you cover up one eye, what you're looking at changes size or color. How can macular degeneration be prevented? - Answers-Diet rich in antioxidants and carotenoids. Vegetables rich in lutein and Zeaxanthin include kale, spinach, parsley, celery and green peas, brussel sprouts, pumpkin Vitamin that may help prevent MD progression from dry to wet - Answers-Vitamin C; helps prevent broken blood vessels and new blood vessel growth over the macula Treatment for dry eyes - Answers-Eye drops with carnosine and antioxidants Supplements to aid mitochondrial function - Answers-niacin (B3), riboflavin (B2), pantothenic acid (B5), magnesium

• Carnitine
• Coenzyme Q- 10
• Lipoic acid Risks of estrogen given orally rather than trans-dermally - Answers-Increased CRP, increased risk of blood clots, increased conversion to estrone, elevated liver enzymes, increased SHBG T or F: Low SHBG may be an indicator of low thyroid function - Answers-T Causes of Low Testosterone - Answers-► Menopause ► Childbirth ► Chemotherapy ► Adrenal stress or burnout ► Endometriosis ► Depression ► Psychological trauma ► Birth control pills Functions of DHEA - Answers-►Decreases cholesterol ►Decreases formation of fatty deposits ►Prevents blood clots ►Increases bone growth ►Promotes weight loss ►Increases brain function ►Increases lean body mass ►Increases sense of well-being ►Helps one deal with stress ►Supports the immune system ►Helps the body repair itself and maintain

tissues ►Decreases allergic reactions ►Lowers triglycerides T or F: low AM cortisol may be an early warning sign for auto-immune disorder - Answers-T Functions Of Insulin In The Body - Answers-►Counters the actions of adrenaline and cortisol in the body ►Helps the body repair ►Helps convert blood sugar into triglycerides ►Keeps blood glucose levels from elevating ►Plays a major role in the production of serotonin ►At normal levels increases development of muscle 336 T or F: statins upregulate PCSK9 enzyme, which degrades LDL receptors - Answers-T. Can give statins with Berberine, a PCSK9 inhibitor, to avoid degradation of LDL receptors. T or F: NSAIDS may impair blood flow to the cochlea and cause hearing damage - Answers-T Antioxidants recommended in AREDS study for treatment of dry or "drusenoid" MD - Answers-Vitamin C, Vitamin A, Vitmain E, zinc, copper oxide. AREDS 2 also recommend adition of lutein, zeaxanthin, and omega 3 FA's together with original antioxidant formulation. Current available treatment modalities for MD - Answers-Focal ablation laser treatment; photodynamic therapy; transpupillary thermoplasty; VEGF inhibitors; macugen; lucentis Way to test for progression of dry to wet MD - Answers-Amsler grid T or F: Laser treatment for dry MD is helpful - Answers-F Dosing of magnesium - Answers-10 mg / kg Vitamin K is involved in 5 main processes in the body: - Answers-Blood coagulation Bone mineralization Vascular health and elasticity Cell signaling and cancer prevention Brain cell protection Causes of Vitamin K

Deficiency - Answers-Lack of adequate beneficial bacteria in the intestine Lack of dietary intake Use of broad-spectrum antibiotics Consumption of medications that cause malabsorption of fat Hydrogenated fat intake Necessary lab work to obtain for men on testosterone replacement therapy - Answers-• Total testosterone

• Free testosterone
• DHT
• Estradiol
• Estrone
• DHEA
• CBC
• Cortisol
• SHBG
• Progesterone
• PSA How do supra-physiologic doses of T affect insulin levels in a patient with diabetes? - Answers-Although T replacement may decrease insulin resistance; replacing with supra-physiologic doses INCREASES insulin resistance Side Effects of Too Much Melatonin - Answers-• Intense dreaming, nightmares
• Daytime sleepiness/fatigue
• Depression
• Headaches
• Increases cortisol
• Suppresses serotonin which increases carbohydrate cravings
• Suppression of estrogen and testosterone in women Causes of Low Cholesterol - Answers-Immune decline Chronic hepatitis Cholesterol lowering drugs Essential fatty acid deficiency Liver infection or disease Manganese deficiency Adrenal stress Recreational drugs (cocaine, marijuana) Excessive exercise (especially in females) Low fat diets

Psychological stress Cancer What are tocotrienols and how do they affect cholesterol? - Answers-Are a special kind of vitamin E Modifies the expression and activity of HMGCoA reductase (this enzyme decreases how quickly your body makes cholesterol) Reduces apolipoprotein B and lipoprotein plasma levels Decreases plaque formation in your arteries Methods To Increase HDL - Answers-L-carnitine Niacin Guggulipid Policosanol Coenzyme Q- 10 Magnesium Pantethine How does high estrogen levels affect SHBG? High testosterone? - Answers-High estrogen increases SHBG. High T levels decrease SHBG production. Causes of low SHBG in men - Answers-Hypothyroidism, steroid usage, Cushing's, acromegaly, obesity, hyperprolactinoma agent used to treat low T in patients wishing to preserve fertility - Answers-clomid. not effective in pt older than 55. dosage 25-50 mg / day. Preferred method of treatment of low T in younger patients - Answers-HCG. Treatment of choice in males without leydig cell failure. Need to have LH < 3 in order for tx to be effective. most common dosing is 1000 mg twice weekly SC. need to have hormonal holiday - 6 weeks on, 2 weeks off. what does presence of high fecal triglycerides indicate - Answers-fat maldigestion which type of fiber is responsible for lowering blood sugar and lowering blood cholesterol? - Answers-Soluble fiber function of insoluble fiber in gut - Answers-Aids with bulk formation and elimination of waste Gas patterns at different times after eating - Answers-Immediately after meals - lack of stomach acid or food allergies 1/2 - 1 hour after meals - small bowel overgrowth or unfriendly bacteria

several hours after meals - pancreatic enzyme deficiency, food allergies and / or lactose intolerance Cholesterol is precursor for what 5 steroid hormone classes - Answers-Progestagens; glucocorticoids; mineralocorticoids; androgens; estrogens Most common cause of penile erectile dysfunction? Other causes of ED? - Answers- Vascular disorders = #1 cause of ED. Other causes are psychological, hormonal, or due to enzyme interference (PDE-5 decreases erection) Treatments for ED - Answers-Antidepressants (serotonin increases ejaculatory threshold and delays ejaculation), desensitizing products, exercises such as stop-start technique Top 10 factors contributing to relative ineffectiveness of chemotherapy - Answers- Cancer cell DNA mutation; gene amplification; drug-pumping mechanism; repairing DNA breaks; cance proinflammatory cytokines involved in cancers - Answers-TNF@, IL1, IL6, IL8 Role of pH in cancer - Answers-Caner maintains an acidic extracellular medium. Cancer cells use glucose / anaerobic glycolysis, generating lactic acid. Cancer cells push excess hydrogen ions out of the cell, generating extracellular acidic milieu.

• Answers-The Hayflick Limit Theory of Aging (so called after its discoverer Dr. Leonard Hayflick) suggests that the human cell is limited in the number of times it can divide. Empirical evidence shows that the telomeres associated with each cell's DNA will get slightly shorter with each new cell division until they shorten to a critical length. Role of telomeres and telomerase in cancer - Answers-A ribonucleoprotein enzyme complex known as telomerase maintains telomere length in cancer cells by adding TTAGGG repeats onto the telomeric ends, compensating for the normal shortening of telomeres in all dividing cells. Hormone that SHBG has strongest affinity for - Answers-DHT Causes of low SHBG levels in women - Answers-Hypothyroidism; obesity; PCOS; androgen replacement; hyperinsulinemia; Cushing's disease; acromegaly; high levels of IGF-1; high prolactin Causes of high SHBG in women - Answers-Liver disease; hyperthyroidism; anorexia; steroid usage; OCP usage or oral estrogen; hypogonadism; pregnancy; cirrhosis T or F: high SHBG has a strong association with osteoporosis and may also predict severity of prostate CA - Answers-T

Implications of low SHBG in men - Answers-Low SHBG is implicated in states of inflammation such as metabolic syndrome and obesity. Mechanism of action of modified citrus pectin as an anti-cancer agent - Answers-MCP the only proven natural inhibitor of galactic-3, a lectin that is involved in cell adhesion and migration. Galectin-3 on the surface of cancer cells allows the cells to aggregate as well as disseminate through the circulatory system. MCP helps to control cancer development and metastasis, and reduces inflammation and fibrosis throughout the body. ozone in air pollution harms the heart - Answers-T. Studies have shown that healthy adults exposed to ozone x 2 hours experience increase in markers of inflammation including CRP, IL-1, PA-1, etc How cadmium affects estrogen levels - Answers-Cadmium binds to estrogen receptor and acts as an estrogen mimetic. IT has been linked with development of breast and prostate CA. 1/2 life of T3 - Answers-1/2 life of T3 is 7 hours (whereas T4 has a half life of 7 days) Mechanism of action of Victoza - Answers-Liraglutide (Victoza) is a long-acting glucagon-like peptide-1 receptor agonist, binding to the same receptors as does the endogenous metabolic hormone GLP-1 that stimulates insulin secretion. Mechanism of action of Actos (TZD) - Answers-Pioglitazone is an agonist for peroxisome proliferator-activated receptor-gamma (PPARγ). PPAR receptors are found in tissues important for insulin action such as adipose tissue, skeletal muscle, and liver. Activation of these receptors modulates the transcription of a number of insulin responsive genes. Effects of low iron on thyroid - Answers-Low iron leads to elevated TSH and elevated T4 (decreased conversion to T3) How does high cortisol affect the immune system? - Answers-High cortisol suppresses TH1 response, hence leads to increased viral infections and intracellular infections. what are the 2 major classes of inflammatory mediators? - Answers-Prostaglandins and leukotrienes. Prostaglandins increase blood flow to site of injury. leukotrienes determine the extent of the inflammatory response. Only essential omega-3 FA - Answers-alpha linolenic acid & linolenic acid T or F: omega 3-FA's have been proven to reduce rate of telomere shortening - Answers-T

Daily intake of Vitamin C of 300 mg / day reduces risk of blinding cataracts by 77-83% - Answers-T Nutrients required for beta-oxidation - Answers-NAD (derived from niacin); FAD (derived from riboflavin, or B2), acetyl-CoA (derived from thiamine, lipoic acid, and pyruvate) T or F: sardine muscle contains VAL-TYR, found to lower BP in hypertensive subjects - Answers-T Factors that decrease formation of EPA and DHA from ALA - Answers-Increased omega-6 FA intake, saturated fats, saturated fats, alcohol and alcohol Mechanism of action of omega-3 FA and PUFA on BP - Answers-Stimulate NO production; increases glycogen storage; increases glucose uptake; reduces plasma NE; and decreases leukotrienes Recommendations for diet and lifestyle in hyperlipidemia - Answers-- consume at least 10 servings / day of fruits and vegetables, whole grains, mixed and insoluble fibers

• moderately high protein intake 1.5-1.8 g / kg / day
• 60 minutes exercise / day (aerobic + resistance) Mechanism of action of omega-6 FA (GLA, DGLA) on BP - Answers-GLA and DGLA enhance synthesis of vasodilating prostaglandins PGE1 and PGI2. Also block stress induced HTN by increasing PGE1, decreasing plasma aldosterone and reducing RAAS II receptor density Examples of soluble fiber - Answers-guar gum, guava, psyllium, oat bran. Eating 60 g/ day of oatmeal, 40 g / day of oat bran, or 7 g / day of psyllium helps reduce BP Dosage of allicin required / day to reduce BP - Answers-10,000 mcg of allicin or amount contained in 4 cloves of garlic Functions of alpha lipoic acid to reduce inflammation - Answers-- Increases levels of glutathione, cysteine, Vit C and E
• Binds endogenous aldehydes
• Normalizes membrane calcium channels by providing sulfhydryl groups
• Increases NO
• Reduces iNOS
• Reduces monocyte binding to endothelium
• Increases linoleic acid mechanism of action of taurine - Answers-Increases urinary sodium, decreases plasma renin activity, decreases aldosterone, decreases plasma NE and E T or F: lipid lowering efficacy of Vitamin E is reduced in presence of a concentration of tocopherols exceeding 20% - Answers-T

Nutrient involved in synthesis of coenzyme A that is necessary to synthesize and metabolize proteins, CHO and fats - Answers-Pantethenic acid (B5) Mechanisms of action of pantethine on cholesterol - Answers-Pantethine reduces LDL and VLDL, increases HDL. Reduces oxidation of LDL. Increases Krebs cycle activity. Fatty acid synthesis is decreased by 50% and cholesterol synthesis by 80% Mechanism of action of fibers on lowering dietary cholesterol - Answers-Binding of bile acids and cholesterol; up regulation of LDL receptors; Increased clearance LDL; inhibition of fatty acid synthesis; improved insulin sensitivity; increased satiety. SOLUBLE fibers lower cholesterol. Implications of APOE4/4 - Answers-Increased risk for AD; increased risk of problems following head injury; more rapid decline in ALS; and increased risk and more rapid decline of MS T or F: those who fall in highest quartile for skin fold measurements have 3-fold increased risk of Parksinson's - Answers-T Mechanism of action of alpha-glucosidase inhibitors (ex acarbose) - Answers-Delay glucose absorption from GI tract T or F: COPD may occur with or without airflow obstruction - Answers-T Morphologic changes occurring in lungs with aging - Answers-AP diameter increases; alveolar size increases; distance between alveoli increase with age T or f: patients with age-related MD may be up to 50% increased risk for both ischemic and hemorrhagic stroke - Answers-T Factors contributing to death of brain cells in AD - Answers-Free radical formation; excessive glutamate; accumulation of beta-amyloid; twisting of tau; inflammation of brain tissue Functional tests of use in diagnosing neurologic impairment - Answers-SPECT and PET scans; fMRI T or F: age related loss in muscle mass is due to reduction in type 1 fibers and loss of strength due to atrophy of type II muscle fibers - Answers-T Piperine has been show to inhibit conversion of certain regulators of angiogenesis - Answers-T Lung diseases associated with reduced DLCO - Answers-emphysema, pulmonary fibrosis

T or F: increase in lung PaCO2 ALWAYS indicates inadequate alveolar ventilation and respiratory acidosis - Answers-T Conditions associated with low lung PaCO2 - Answers-- Hyperventilation

• Increased respiratory rate (i.e due to metabolic acidosis) Test that is the single best parameter in assessing cardio-pulmonary fitness - Answers- VO2max - a measure of the maximum volume of oxygen that an athlete can use during aerobic exercise. It is measured in (ml/kg/min). What is the anaerobic threshold? - Answers-Point during exercise at which lactic acidosis takes over and generates excessive amounts of CO2. Usually occurs at 60% of VO2max. T or F: approximately 85-90% of all tumor biopsies are telomerase positive - Answers-T T or F: macular degeneration causes total blindness - Answers-False. Peripheral vision will always be spared in MD, unless other concomitant diseases are present. Changes in PaO2 and PaCO2 in lungs seen with aging process - Answers-- PaO2: sequential changes reveal a peak in PaO2 in teens followed by a gradual decline (due to decreased elastic recoil)
• PaCO2 and pH remain constant over the remainder of a person's life T or F: VO2max declines with age, independent of other factors - Answers-T. This effect can be mitigated via aerobic training. ASA relation to cancer risk - Answers-An ASA / day associated with a modest decrease in cancer mortality, particularly GI cancer What is myrosinase? - Answers-Enzyme needed to form sulforophane, found in broccoli sprouts, mustard, horseradish and wasabi. May help reduce risk of CA. What is nitrosation? - Answers-Cellular process in which substances in foods and water are converted into cancer causing compounds. Garlic may inhibit this process. Role of piperine in CA - Answers-Piperine inhibits cellular mechanisms that are necessary in angiogenesis. Piperine is found abundantly in black pepper. Lycopene consumption in the diet may reduce angiogenic capability of cancer cells - Answers-T T or F: women just receiving CEE without MPA in WISE study did not who increase in rate of breast CA - Answers-T