path environmental - formatted

Question 1

1. 8.03.43 CWP which is NOT TRUE ? Rob p269
   a. 2-5X increase risk of lung cancer independent of smoking
   b. <10% go onto Progressive Massive Fibrosis
   c. characterized by coal macules and coal nodules

Answer 1

a. 2-5X increase risk of lung cancer independent of smoking (No ↑ risk of lung cancer (moderate predisposition to carcinoma of the stomach) cf silicosis which does have an increased risk (SG)

1. 8.03.43 CWP which is NOT TRUE ? Rob p269 (–)
   a. 2-5X increase risk of lung cancer independent of smoking (No ↑ risk of lung cancer (moderate predisposition to carcinoma of the stomach) cf silicosis which does have an increased risk (SG)
   b. <10% go onto Progressive Massive Fibrosis (transition of simple to complicated CWP 2-8%)
   c. characterized by coal macules and coal nodules (Characterised by coal macules (small, focal aggregations of coal-dust laden macrophages, 1 – 2mm in size) and somewhat larger coal nodules (also contains delicate network of collagen fibres)
   • Involvement of pulmonary vasculature by scarring → pulmonary hypertension & cor pulmonale
   • incidence of TB increased (?increased susceptibility or socioeconomic factors)
   • Possible increased incidence of chronic bronchitis & emphysema, independent of smoking

Question 2

2. 8.03.44 In benign asbestosis pleural plaques, which would be MOST ATYPICAL ? Rob p272
   a. Pleural effusion
   b. Predominant anterior and posterior plaques
   c. Diaphragmatic involvement
   d. Parietal pleura
   e. Golden brown rods with iron containing proteinaceous material

Answer 2

e. Golden brown rods with iron containing proteinaceous material = asbestos bodies in asbestosis.

2. 8.03.44 In benign asbestosis pleural plaques, which would be MOST ATYPICAL ? Rob p272 (–)
   a. Pleural effusion
   b. Predominant anterior and posterior plaques
   c. Diaphragmatic involvement
   d. Parietal pleura
   e. Golden brown rods with iron containing proteinaceous material
   • Asbestos bodies = Golden brown, fusiform or beaded rods with translucent centre
   • Not in pleural plaques however
   Focal pleural plaques
   • common manifestation 6% general population
   • incidence
   o 10% at 20 years
   o 50% at 40 years
   Morphology
   • bilateral, mid-portion of chest ( 7 to 10 ribs )
   • anterior and posterolateral parietal pleura
   • domes of hemidiaphragms
   • well circumscribe plaques of dense collagen
   • thicker centrally, often calcified
   Histology
   • hyalinized collagen in sub mesothelial parietal pleura
   • no asbestos bodies

Question 3

3. Sep03.44 You are reviewing a case of Non accidental injury, looking at records of a sibling, the most striking finding is:
   a. SID’s of a sibling 13 months old
   b. Healing fracture of the clavicle at 1 month
   c. Brachial Plexus injury

Answer 3

a. SID’s of a sibling 13 months old

3. Sep03.44 You are reviewing a case of Non accidental injury, looking at records of a sibling, the most striking finding is: (–) (TW)
   a. SID’s of a sibling 13 months old
   b. Healing fracture of the clavicle at 1 month – F – birth injury
   c. Brachial Plexus injury – F – birth injury (home birth)
   • Morbidity associated with birth injury may be acute (e.g., that due to fractures) or the result of later-appearing sequelae (e.g., after damage to nerves or the brain). The distribution of injuries in a large municipal hospital, in descending order of frequency, is as follows: clavicular fracture, facial nerve injury, brachial plexus injury, intracranial injury, humeral fracture, and lacerations
   • Characteristic soft-tissue injuries in abuse are bruises, cigarette burns, bite marks and scalds, usually of the lower extremities and buttocks and a torn frenulum.
   • Retinal, subhyaloid and subconjunctival haemorrhages occur which are a consequence of shaking
   • Accidental bruising usually occurs over bony prominences. In abuse, bruising occurs frequently and multiple bruises of differing ages found in sites unlikely to be affected by accidental injury, such as the flanks or buttocks, are typical of NAI.
   • On plain radiographs there may be swelling and disruption of the normal soft-tissue planes at the site of the bruise or calcified soft-tissue haematomata may be apparent.
   • Calcification in the soft-tissues around the neck, or ‘necklace calcification’, represents fat necrosis following strangulation .

The following circumstances should alert the physician to the possibility of NAI.
1. The presence of an inappropriate, inconsistent or conflicting history.
2. The presence of unexplained soft-tissue injury.
3. The presence of a healing fracture or the presentation of the child in a shocked or dehydrated state resulting from a delay in seeking medical help.
4. Radiological evidence of trauma exceeds that expected from the clinical history.
5. The presence of skeletal injuries with a high specificity for abuse.
• Other suspicious circumstances include a failure to thrive of unknown cause suggesting emotional deprivation, poor nutrition and neglect, unexplained abdominal trauma, recurrent pancreatitis and a history of previous abuse to this child or a sibling
SIDS
• SIDS is the leading cause of infant mortality between 1 month and 1 year of age (in USA).
• Defined as: The sudden death of an infant under 1 year of age which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history.
• 90% of SIDS deaths occur in the first six months of life, most between 2 and 4 months.

Question 4

4. Sep03.55 Legionella is a :
   a. Gram negative bacillus
   b. Sporing coccus
   c. Protozoal
   d. Fungus
   e. Helminth

Answer 4

a. Gram negative bacillus

• Legionella pneumophila is a Gram-negative organism that causes a pneumonia (Legionnaires’ disease) which, when severe, has a 10–30% mortality rate similar to other severe community acquired pneumonias .
• Legionnaires’ disease is common in males and may be acquired in a community or nosocomial or epidemic fashion, with a tendency to geographical clustering associated with contaminated water sources, frequently air-conditioning systems and humidifiers.
• Underlying predisposing diseases include a post-transplantation setting, COPD, and heart failure.
• A short prodrome is followed by symptoms typical of a bacterial pneumonia, sometimes accompanied by extrapulmonary manifestations (neurological, gastrointestinal, renal, and cardiac).
• The diagnosis is most commonly made serologically and is therefore delayed.
• The most typical radiological patterns include solitary or multifocal homogeneous opacities, occasionally round and mass-like, or peripheral lobar consolidation simulating Strep. pneumoniae pneumonia.
• Rapid progression is common, with confluence and/or spread of the initial (frequently unilateral) consolidation to other lobes on the same or opposite side.
• Cavitation is described but is only common in immunocompromised patients and an effusion occurs in 10–35% of cases.
• Resolution may be rapid with appropriate treatment but at times is slow: in some series only 30–60% of radiographs had cleared by 15 weeks.
• In addition, resolution may be incomplete or interrupted by the appearance of new areas of consolidation.

• L. pneumophila is unique among bacteria because it is a facultative intracellular parasite of macrophages and of the aquatic protozoa Hartmannella vermiformis and Tetrahymena pyriformis. L. pneumophila bacteria enter the macrophage in two ways:
o (1) in nonimmune serum, complement-coated bacteria bind to macrophage CR1 and CR3 complement receptors and are engulfed by pseudopods; and
o (2) when coated with anti- L. pneumophila antibodies, bacteria bind the macrophage Fc receptors and enter by conventional “zipper” phagocytosis. Within the macrophage, L. pneumophila fails to induce a respiratory burst; the organisms block phagosome fusion with the lysosome, multiply, and eventually lyse the host cell.
• A 24-kD protein on the surface of the bacteria (called macrophage infectivity potentiator) is necessary for growth in the macrophages and protozoa and for infectivity in animal models

Question 5

21. Which lung cancer is least associated with smoking
    a. Classic carcinoid
    b. Small cell
    c. Large cell
    d. Adenocarcinoma
    e. Squamous cell

Answer 5

a. Classic carcinoid - associated with MEN 1; no known relationship to smoking or environmental factors.

21. Which lung cancer is least associated with smoking: (GC)
    a. Classic carcinoid - associated with MEN 1; no known relationship to smoking or environmental factors.
    b. Small cell - strongly associated with smoking.
    c. Large cell - associated with smoking.
    d. Adenocarcinoma - strongly associated with smoking; most common lung malignancy in women and non-smokers.
    e. Squamous cell - strongly associated - esp. male smokers.
    patients with small cell lung cancer have a smoking history; extremely rare in persons who have never smoked. c. Large cell - F d. Adenocarcinoma - F e. Squamous cell - T - strong correlation; but slightly less so

Question 6

22. Which lung cancer is most associated with smoking
    a. Classic carcinoid
    b. Small cell
    c. Large cell
    d. Adenocarcinoma
    e. Squamous cell.

Answer 6

b. Small cell - T - strong correlation; 98% of patients with small cell lung cancer have a smoking history; extremely rare in persons who have never smoked.
e. Squamous cell - T - strong correlation; but slightly less so than SCLC.

22. Which lung cancer is most associated with smoking: (GC)
    a. Classic carcinoid - F
    b. Small cell - T - strong correlation; 98% of patients with small cell lung cancer have a smoking history; extremely rare in persons who have never smoked.
    c. Large cell - F
    d. Adenocarcinoma - F
    e. Squamous cell - T - strong correlation; but slightly less so than SCLC.