Okay, so welcome everyone to the 2020 Occupational Medicine Board Review virtual course. Today is the first day we are doing a faculty virtual meeting. This evening we have Dr. Francesca Littow from the faculty for the course. I'm happy to answer any questions that you might have. I see some people are still joining. I think the best way to do it is to perhaps everyone stay muted until you have a question. And I'm trying to enable the chat box here so everyone could either type in a question. We're not sure how many people to expect this evening since we do have these calls almost every day this week. So we imagine it'll fluctuate, people will go in and out. So at this time I'll go ahead and turn it over to Dr. Littow. Hi, good evening everybody. So greetings from Norfolk, Virginia. Thank you very much for signing up and for joining us on what is our first virtual board review course. As a reminder tonight between seven and nine Eastern time, you've joined us for a discussion of clinical occupational medicine, which is the first big talk after the introductory talk by Dr. Meyer around study habits and kind of how to think about the exam. So we'll be looking at clinical occupational medicine one, which is again that big talk, that firehose talk that has neurology, the heme disorders and cancer. And then also any questions you might have from physical hazards. So what we've tried to do is divide up these office hour sessions by topic. That doesn't mean you can't ask something else. It just means, you know, especially if it's not, you know, my part of the course, I probably don't have the best answer. That said, Dr. Meyer and I have each at one point or another taught this entire course. So I could probably give you some sort of an answer. I can also take a look if you want to look at some of the review questions in the syllabus. If you have questions about the questions, you'll just need to let me know which question it is. And again, we'll be focusing on clinical occupational medicine one and the physical hazards talk mainly in this session. Bernice has sent out a schedule so you can look at the schedule to see what other topics we're covering each night this week. And then on Sunday afternoon, Dr. Meyer is going to take any other questions and do kind of a general course wrap up for you. So we don't yet have the chat feature. So it's kind of first come first serve. I promise that everybody will get a chance, although somebody figured out how to raise their hand. So you win. So Sandy, I can see your hand raised. Please go ahead and unmute yourself and please ask your question. Hello. Hi. Yeah. Good evening. Thank you for doing this first virtual meeting. Just a question. If this sessions will be recorded because not all the time, all the participants will be able to join. I'm just wondering if this session will be recorded or so that we can see what questions have been asked and we can take a look at that. I just was wondering if this session will be recorded or so that we can see what questions have been asked and we can take a look at that. I'm just wondering if this session will be recorded or so that we can see what questions have been asked and we can take a look at that. I'm just wondering if this session will be recorded or so that we can see what questions have been asked and we can take a look at that. I'm just wondering if this session will be recorded or so that we can see what questions have been asked and we can take a look at that. I'm just wondering if this session will be recorded or so that we can see what questions have been asked and we can take a look at that. I'm just wondering if this session will be recorded or so that we can see what questions have been asked and we can take a look at that. I'm just wondering if this session will be recorded or so that we can see what questions have been asked and we can take a look at that. I'm just wondering if this session will be recorded or so that we can see what questions have been asked and we can take a look at that. I'm just wondering if this session will be recorded or so that we can see what questions have been asked and we can take a look at that. I'm just wondering if this session will be recorded or so that we can see what questions have been asked and we can take a look at that. Yes, absolutely. Yes, we're going to be recording all of these this week as well as Sundays. Yes, absolutely. Yes, we're going to be recording all of these this week as well as Sundays. Yes, absolutely. Yes, we're going to be recording all of these this week as well as Sundays. Yes, absolutely. Yes, we're going to be recording all of these this week as well as Sundays. Yes, absolutely. Yes, absolutely. Yes, we're going to be recording all of these this week as well as Sundays. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. Yes, absolutely. 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Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. ThA, acroosteolysis. Hopefully, you remember the slide. And you would have seen the same slide if you've done the whole course already. You would have seen it twice. Because John and I, Dr. Meyer and I, we use the same library of pictures. And we both have the same slide, which is an X-ray or a radiograph of a hand showing what looks like dissolution. It looks like either a crush injury to every single distal phalanx or dissolution of the bones of the distal phalanx. And that is this acroosteolysis or lysis of the bones. So that's one thing that's associated with vinyl chloride. The other thing that should be stuck in your minds is that vinyl chloride monomer puts workers at risk of development of a rare cancer called angiosarcoma of the liver. And arsenic is another thing that does that. So if A said angiosarcoma of the liver, that would be another correct answer. So let's just look at the other answers. Hemolytic anemia, well, we kind of talked about that a little while ago. Hemolysis is associated with exposure to, among other things, arsenic or arsine gas or stybine gas, which comes from antimony. Both exposures would be more common in the semiconductor industry. High-level exposures to lead and some pesticides can also cause hemolysis, but those are less common. Lung cancer, there's a lot of things that are associated with lung cancer, not the least of which is environmental tobacco smoke. If you've done the physical hazards talk, we could talk about radon gas. It's associated with development of lung cancer, as well as some of the solvents like bischloromethyl ether. Bladder cancer is associated with exposure to dyes. And so that's something that you would be looking for. But again, we're talking about plastic pipes here. We're not talking about a pigment factory worker. So again, the correct answer here would be A, or acroosteolysis. So again, I know a lot of talking on my part. Any questions? I'm relying on Bernice to be the monitor of all things question. Yeah, I haven't seen anyone raise their hand. OK, so let's go on to number three. A metallurgist in a smelting plant becomes acutely ill, shocky, and tachycardic after looking into an ore extraction process. So what are they trying to tell you? OK, somebody is working in smelting. So what are we thinking about? We're thinking about heavy metals, because that's what we're smelting. And when somebody is acutely ill, shocky, and tachycardic, this is a clinical syndrome of hypovolemic shock. So what have we talked about that causes hypovolemic shock? We're talking about hemolysis. So thinking about what might cause hemolysis. And again, we've talked about a couple of things. Actually, twice now, we've talked about arsine gas and stibine gas. And so that's number C here, letter C, acute hemolytic anemia from arsine. Now, let's just go through the other answers, because I think even if you didn't know about arsine gas, if you recognize that this clinical picture is of hemolytic anemia or hemodynamic shock, you could have selected letter C. So there are kind of two ways to get there. But let's think about the other answers. So if you have acute hypoxemia from carbon monoxide or CO, you're going to pass out. You might seize. You might convulse. You might have chest pain. But exposure to carbon monoxide does not make you shocky. So that wouldn't be the best answer here. Acute pneumonitis or lung irritation from mercury exposure, again, people who have acute pneumonitis might have hypoxemia. They might have low oxygenation, and they might have trouble breathing. But they wouldn't necessarily be in shock. And then acute encephalopathy from magnesium, again, they might be disoriented and have mental status changes. But you could have encephalopathy and not necessarily be in shock. And yes, some of these, we're kind of splitting hairs here. But this is the board exam. So you're looking for the best answer and the most likely answer. And in this case, given the fact that it's smelting and that arsenic is related to the smelting process and that you have a picture of clinical shock and hypovolemia and that you know that hemolysis causes hypovolemia and shock, your best answer here would be choice C. Any questions about that one? OK. We looked at choice question four already. So question five, I kind of gave you that one already. But let's just go through the IARC categories. So for choice A, IARC category one, those are confirmed human carcinogens, things for which there is sufficient animal and human evidence that IARC has classified them as carcinogens. So things that we were talking about before, bischloromethyl ether, aniline dyes, asbestos, cadmium, pretty much anything that you're memorizing with a body part that causes cancer, arsenic, vinyl chloride, methylene chloride. These are things that are in category one. Category two has two A, which are the probable human carcinogens, and two B, that are the possible human carcinogens. These are things for which there is sufficient animal data and perhaps information at this time for them to be classified as a carcinogen. But we wouldn't throw them in the safe pile yet. And category four is the safe pile. That is the category where we have sufficient information to support that something is not a human carcinogen. So those are the four IARC categories. And in the slides, I've given you two links. Oh, sorry. I have a cat. That was cat-related noise. Given you two links that are to the IARC that also tables in there about cancer's corresponding industries, as well as exposures and corresponding cancers for the class one agents. OK, let's do question six. A worker develops numbness and dermatitis after working with materials in an artificial plastics polymerization plant. The most likely cause is, and then we have a list of things. So let's go back to what they're telling you, right? Numbness, so some kind of neuropathy, a sensory neuropathy at least, and skin irritation or dermatitis. And they said they're working with plastics. So that's three pieces of information. So you can start asking yourself, what do I know? What comes to mind that can cause a sensory neuropathy, skin problems, and you get exposed to it when you're making artificial plastics? So let's just kind of go through the choices here. Benzene is used for a whole lot of things, mostly in the petroleum industry, but it can have other applications, but not so much plastics. The other thing is that benzene causes blood cancers. And although it could cause some neuropathy, they're not telling you that they're looking at somebody who has a blood cancer. So I will put that on the not high on my list. Amine dyes are dyes, but again, not necessarily associated with the sensory neuropathy, the dermatitis, and the plastics polymerization plant. Isocyanate, probably heard a lot more about cyanate in the pulmonary lecture. And in this case, it's just kind of a detractor. Isocyanate can cause a dermatitis and occupational asthma, but is not associated with neuropathy. Now, acrylamide monomer is associated with numbness. It is associated with dermatitis, it's an irritant. And bethyl methacrylate and other acrylates are used in coatings. People who have dentures, or if you have a crown, the stuff that's used to make those in a fabrication lab to make the artificial tooth is methyl methacrylate. They're also used in making shiny coatings for things and in orthotics or prostheses. So those are things that would be in a plastics polymerization process and are associated with a neuropathy and skin irritation. So that acrylamide or acrylamide monomer specifically is the answer there. So again, a lot of talking on my part, any questions? And again, when looking at these, you can torture yourself with, well, it could be, but remember that a lot of things could be, what you're looking for is the best answer. So if one answer is better than the others, that is your answer. And just like when you're taking any other test, read the whole question and then read all the answers until you get to the one that is the best answer. In case nobody has told you this yet, in case nobody has told you this yet, there is no penalty for guessing on the boards. This is not the SATs. So try to answer every question. Skip questions. It's a computer-based exam. You can mark questions to skip them. Then go to all the ones that you are confident about, and then you come back to the ones that you're thinking of. And you've probably heard this advice before, but a lot of people say that statistically, if you just pick one of the letters, A, B, C, or D, and use that letter for every question that you're not certain of, then it's a higher likelihood of getting some of them right than if you just randomly picked a different answer for every guess. Okay, let's go on to question seven. Which of the following exposures is least likely to be carcinogenic? So this is a situation where you probably can sit here and say, well, you know, she had this whole slide set, and then she had a slide set on cancer. And a lot of things cause a lot of things, but which of them did I not see in the cancer slides? So mercury, we talk a lot about mercury in the review course. First of all, there's three different kinds of mercury. You have your elemental mercury, your inorganic mercury, and your organic mercury. There's all different kinds of ways you can be exposed to them. There's different health effects. There's different ways we do biomonitoring. But we didn't really talk about mercury causing cancer. It's kind of the one good thing about mercury. So that actually is the correct answer. Cadmium is associated with nasal and respiratory cancers. Benzidine dyes, that's one of the families of dyes associated with bladder cancer. And asbestos is associated, as you know, with not only asbestosis or a non-cancerous disorder, but also with bronchogenic carcinoma and with mesothelioma. So multiple cancers are associated with asbestos. But the correct answer here is A, mercury. I'll go on to number eight, then I'll pause for questions on everything at the end. So we have a refinery worker who presents for a quote unquote emergency medical surveillance evaluation after a reported overexposure to benzene during tank maintenance. Which substance would likely be elevated in his urine? So this is a question where they actually, you don't have to figure out a lot of stuff, right? I'm telling you the industry, I'm telling you what he was exposed to. He's exposed to benzene. The real question is the end of the question. What are you gonna find in his urine? Well, you might be saying, where's phenol? I didn't see phenol. It's a bad question. It is true that the OSHA standard for benzene phenol as the biological exposure in your urinary system at a certain level that corresponds with exposure to another substance. So for example, for benzene, the biological exposure indicator is TT muconic acid. And that's why B is the correct answer. For fun or for study, you could go back into that table and look at what methyl hypuric acid is a BEI for, because that would be another question that one could be asked. Beta-2-microglobulin is related to cadmium exposure. It is actually part of what is evaluated when a worker is exposed to cadmium. So it has nothing to do with benzene here. Measure it for many reasons. You can also measure it in accordance with the cadmium standard, again, to see the effect of cadmium on the kidneys. So both B and C are biological exposure indicators. B, TT muconic acid, is the biological exposure indicator that is listed here for benzene. So number nine, which of the following symptoms are most consistent with chronic elemental mercury exposure? Okay, so our friend mercury, right? So three different kinds, three different scenarios, very different health effects. So elemental mercury, that's the mad hatter. Inorganic mercury, we're talking about somebody's kidneys. Organic mercury, remember the pictures that, again, if you've been through the whole course, you see them in repro, you see them in the solvents talk and heavy metals. These are the pictures from Life Magazine of children who look like they have a cerebral palsy type syndrome. And that was caused by their mother's ingestion of fish contaminated with organic mercury or methylmercury in Minimata Bay. So elemental mercury is C, I'm sorry, that organic mercury is C. The spasticity and visual constriction, that's Minimata. We're looking for the mad hatter. So what's our triad that we're looking for, right? We have the swollen gums, we have the erythrism or the weird affect, the giggling of the mad hatter, and this distal, sometimes painful sensory neuropathy. So the best answer here is A, where you have two out of the three, but organic mercury in high levels and not our organic, I'm sorry, not our elemental mercury. And I apologize, I just made something more complicated than it needed to be. So again, the correct answer here is A. It is the best answer because those two are related to exposure to mercury. C is organic mercury, and D and B are some changes that one might see with exposure to inorganic mercury. But chronic exposure to inorganic mercury is actually most likely to hurt the kidneys. The stomatitis and melanoma and upper respiratory irritation would be from an acute exposure, not so much a chronic exposure. So I think we finished all these questions. And does anybody have questions on this set before we move on to the questions from Physical Hazards? Hi. Okay, I'm gonna show you. Okay.

Occupational Medicine

Board Review

Virtual Course

Dr. Francesca Littow

Clinical Occupational Medicine

Neurology

Heme Disorders