Topical Review Test A: Hepatitis and Infection Control NDB-1 TOPICAL REVIEW TEST A: . HEPATITIS AND INFECTION CONTROL ‘This is a review of hepatitis and related infection control issues in dentistry. Following the review, you will ake 2 30- question review test and then we will briefly review the answers to these 30 questions. Hepatitis is of special interest to dentists especially since the 1970s when some clusters of hepatitis B cases were traced to specific dental offices. It was found that hepatitis B could be transmitted through contaminated instruments from patient to patient, patient to provider, or provider to patient. As a result ofthese cases, today’s concepts of barrier methods and universal precautions developed. Hepatitis is a nonspecific inflammation of the liver, secondary to a variety of causes. For example, viruses including hepatitis A, hepatitis B, non-A/non-B hepatitis, and hepatitis D can all cause hepatitis. However, other viruses may also cause hepatitis as well as toxic chemicals such as carbon tetrachloride. Regardless ofthe causative organism, all viral hepatitis atacks have a similar set of signs and symptoms. It generally cannot be determined what type of organism is involved merely by looking atthe set of symptoms. Signs and symptoms include damage to hepatocytes, decreased liver function, fever, fatigue, chills, decreased appetite, headache, myalgia, tendemess of the upper abdomen, hepatomegaly, splenomegaly, joint pain, cervical lymphadenopathy, photophobia, clay-colored stools, darkened urine with increased bilirubin, and jaundice (that is, a yellow coloring of the skin and sclera of the eyes). Increases are noted in liver transaminase and alkaline phosphate enzymes. Prothrombin time is also increased, usually to greater than three seconds beyond normal. In hepatitis B. in particular, the disease may progress to a chronic form, either benign or destructive. Additionally, a connection has been noted between hepatitis B and later development of liver cancer. We will now review the specific viruses and diseases associated with them. Hepatitis A is known as short incubation hepativic or !.S.awous hepatitis. It is caused by a single-stranded RNA virus of the enterovirus family. It is generally spread by the tecal-oral route. That is, virus particles are shed in the feces of the infected person and these viral particles enter the food or water supply and infect others. Typical sources of hepatitis A viral particles include contaminated water, shellfish grown in contaminated ‘water, or milk or other food contaminated by fecal matter. Often large groups of people will be affected at one time, such as a camp, army base or school. The incubation period for hepatitis A is much shorter than that for hepatitis B. Typical incubation periods for hhevatitis A average 20-40 days or 3-6 weeks. Patients recovering from hepatitis A are generally immune after one exposure to the disease and there is no chronic phase of the disease following recovery from the acute phase. The disease is spread only during the acute phase. Children may contract hepatitis A and be relatively asymptomatic, without jaundice. It is common to find antibodies to the virus known as anti-HAV antibodies in children and adults who do not report any clinical history of the disease, thus indicating the mild nature of the disease in many children. Hepatitis A markers (that is, particles related to the disease) are named as follows: the hepatitis A viral particle is known as HAV. The antibody to HAV which confers lifelong immunity to the disease is known as anti- HAY and is a form of IgG. There is another form of anti-HAV known as IgM anti-HAV. The presence of IgM anti-HAV indicates recent infection within the past 4-6 months. The hepatitis virus itself (HAV) is visible in feces of infected patients under electron microscopy. and due to its similarity to other enteroviruses, it is known as enterovirus 72. HAV viral particles are especially resistant to chemical disinfectants and, therefore, a potential infection control problem. For ‘example. the virus can resist formalin 1 to 400 concentration for three days or 100° celsius boiling water for five minutes. Hepatitis B. on the other hand, is known as long incubation hepatitis or serum hepatitis. It is the hepatitis form of most interest to dentists. The hepatitis B virus is a double-stranded DNA virus which appears ina variety of forms. The form which most resembles a typical virus is the Dane particle, consisting of a core and envefope with a diameter of about 42 nanometers. A 22 ‘nanometer spherical particle and a 22 nanometer wide filament exist as well as a 28 nanometer core only. The Dane particle, the sphere and the filament all contain the hepatitis B surface antigen or HBsAg which will be discussed in some detail later. Typical sources of HBV virus include blood contamination of intravenous drug apparatus, medical or dental instrument blood contamination, and sexual contact. High risk groups include healthcare workers. male homosexuals, hemophiliacs, people receiving blood transfusions, and IV drug abusers. Both the sources of the virus, the methods of spread and the risk groups parallel closely that of the HIV virus which causes AIDS. Incubation period for the HBV virus varies from 4-25 weeks, but average 7-8 weeks or about 90 days. It is therefore known as long incubation hepatitis. Vaccines are available to prevent development of hepatitis B. Heptavax. developed in the 1970s, contains antigens developed from human plasma. In the 1980s a newer vaccine, Recombivax. was developed using genetically engineered yeast cells to produce ‘antigens. In both cases. the body develops anti-HBs surface antigen antibodies to the vaccine and these antibodies confer immunity on the recipient. __ We're going to look now at the hepatitis B markers; that is. the virus particles, antigens, antibodies, their names, their significance and the tests for them. ‘The hepatitis B particle or virus is known as HBV. The surface antigen which is present on most forms of HBV (that is, the Dane panicle, the spheres and the filaments) is known as hepatitis B surface antigen or HBsAg. This antigen was originally identified as the Australian antigen, found first in an Australian aborigine and later found to be, infact. the hepatitis B surface anugen. HBsAg ‘can be found in blood, semen. mucous, urine. bile, feces and other body fluids, although these are not equally infective. HBS antigen ‘KAPLAN 7NDB-I VE or HBsAg indicates current infection and can be detected by ELISA which is enzyme-linked immunosorbent assays and also RIA ot immunoassays. Anti-HBs is the antibody to HBsAg and it indicates one of three things: previous infection, previous vaccination with Heptavax or Recombivax, or exposure to hepatitis-immune globulin, a form of passive immunity sometimes given as a treatment for certain hepatitis B cases. HIBcAg is the hepatitis B core antigen. There is no lab test for this antigen. Anti-HBc is the antibody to HBcAg and this can also indicate a previous infection. This antibody, anti-HBe, can be teste for in lab. HBeAg is another hepatitis B antigen not completely understood. Its presence is associated with viral replication and infectivity. Anti-HBe is the antibody to HBeAg and its presence usualy indicates low infectivity. ‘In terms of important clinical relations, HBsAg, the surface antigen is the usual test for active hepatitis B. However, there may be a small window period approximately 5-6 months after infection where HBsAg may be very low temporarily. At this point, a confirmatory testis run for ant-HBc; that is, the antibody to the core antigen. A negative result for both HBsAg, which is the surf antigen, and ant-HBc, which is the antibody to the core antigen, indicates the absence of hepatitis B disease. In addition, if there is a negative test for HAV, which was the hepatitis A virus particle, then by exclusion, the diagnosis of the hepatitis patient will be some form of non-A/non-B hepatitis which willbe discussed later. Diagnosis of hepatitis comes from the combination of lab tests described so far and the clinical, medical and social history of the patient; for example, use of IV drugs or visiting an area of known hepatitis A outbreak, etc. Differential diagnosis for hepatitis B includes other forms of hepatitis, infectious mononucleosis, and for brief periods of time, immune disorders such as lupus, serum sickness and rheumatoid arthritis. This is due to the presence in some patients with hepatitis B of a temporary stage of arthralgia, antritis, ash and hematuria, which is blood in the urine probably relate to circulating immune complexes. Non-A/non-B hepatitis has sometimes been referred to as hepatitis C. However, there appear to be atleast two distinet forms ‘of non-A/non-B hepatitis. Non-A/non-B hepatitis, also known as NANB hepatitis, was first noticed in patients receiving blood transfusions which had already been screened for both hepatitis A and B. In fact, most transfusion-related hepatitis cases currently are NANB hepatitis since both hepatitis A and B can be tested for in the blood. NANB hepatitis has a variable incubation period; no laboratory markers of yet or tests available. Diagnosis, as mentioned previously, is by exclusion; that is, by ruling out both hepatitis A and B by laboratory tests. It is sometimes possible to screen blood for NANB hepatitis by looking for elevated enzyme levels in the blood, particularly ALT or alanine amino transferase. The most recent nomenclature for this virus is Hepatitis C. It appears to be more difficult to transfer than Hopatitis B, but easier than HIV. No current treatment exists and is likely to become of great interest to dentistry inthe future. ‘Another hepatitis-related entity is hepatitis D or the delta particle. This is an RNA virus, but it can only be found in association with hepatitis B. That is, patients with active hepatitis B may also have hepatitis D which worsens the condition and prognosis for recovery. Apparently. the delta particle requires hepatitis B enzymes in order to reproduce. Hepatitis D may, in fact, be an association of delta virus RNA with hepatitis B surface antigen, ‘As expected, the transmission of hepatitis D from person to person closely parallels that of hepatitis B. Interestingly, immunity to hepatitis D results in immunity to both hepatitis B and D in the future. ‘Another hepatitis form, sometimes known as hepatitis E, exists and is an enteric virus, somewhat like hepatitis A. In terms of hepatitis and healthcare workers, the dental hepatitis B clusters of the 1970s led the CDC, which isthe Centers for Disease Control. and the ADA, the American Dental Association, to develop universal precautions. This approach assumes that all patients might be potentially infectious and employs the same protective measures for all patients. These measures include sterilization or disposal of critical instruments (those which pierce the skin or mucous membrane) and the use of barrier methods such as gloves, masks and protective eyewear. Noncritical dental surfaces such as countertops are disinfected or covered with disposable barrier materials such as plastic sheeting. It has been found that the universal precaution methods first used to protect patients and healthcare workers from HBV work well enough also to protect from HIV. Regulation of the healthcare workers relative to hepatitis comes in the form of OSHA regulations. OSHA, a unit of the Department of Labor. is concerned with worker safety only. That is, it has no direct interest in patient care. However, in order to prevent healthcare workers, including dental workers, from contracting hepatitis B, OSHA, the Occupational Safety and Health ‘Administration, has required employers to develop a document known as an exposure control plan. This plan is discussed in greater detail in other topical review tests, including the topical review test on HIV and infection contro. Briefly, all employees must be categorized as exposed, exposed when doing specific tasks only, or not exposed, based on their particular work functions. Relative to hepatitis B, exposed employees and those exposed when doing particular tasks must be offered hepatitis B vaccinations. The vaccine must be provided free of charge and employees declining the offer must sign an informed declination form. Employees retain the right to change theit mind at any time and receive the vaccine again free of charge. Current vaccine types are given in sets of three injections: an initial, a 1 month and a 6 month injection. “as developed by (PPP PPP PPP PPPTopical Review Test A: Hepatitis and bifection Control . NDB-1 TOPICAL REVIEW TEST A: HEPATITIS AND INFECTION CONTROL 1, Hepatitis D requires the presence of: ‘A. Hepatitis A antigens B. Hepatitis B enzymes CC. Hepatitis C D. Anti-HBs E. HBVcore antigen 2. The reaction of the immune system to Hepatitis B 4, Universal precautions recommendations of ADA and CDC originated from previous efforts to control HIV virus Hepatitis A virus Hepatitis B virus NANB Hepatitis virus None of the above poop 5. Which of the following viruses is a DNA virus? ‘Which of the following are clini of hepatitis? ‘A. Weight loss B. Hepatomegaly C. Cervical lymphadenopathy D. Myalgia E. Allof the above ‘Which form of hepatitis is known as serum hepatitis? ‘A. Hepatitis A B. Hepatitis B C._NANB Hepatitis D. Hepatitis D . Which form of hepatitis is LEAST likely to be spread through blood contamination? ‘A. Hepatitis A B. Hepatitis B C._NANB Hepatitis D. Hepatitis D During a “window” of absence of HBsAg in serum lab tests, the secondary confirmatory test for HBV is: ‘A. Anti-HBc B. HBcAg C. Ani-HBs D. Anti-HBe A. Hepatitis A B. Hepatitis B GO ON TO THE NEXT PAGE. C. Delta particle D. HBsAg E. None of the above ‘KAPLAN 7NDB-1 10. A serum lab test fora dentist who has received Recombivax, but has no history of hepatitis, should show: Avs HBsAg B. Anti-HBs C. HBeAg D. Anti-HBe 11. ‘The “Australian” antigen was later found to be A. HAV HBV HBsAg HBcAg Delta particle 12, Which fie followings a single sanded RNA vires? HAV HBV Delta particle ‘Two of the above All ofthe above rons 13. A“Dane particle” is a form of: 16. 17, 18, 19. 20. Delta virus structure appears to be: A. B. c. D. E. ‘The Hepatitis most closely linked to hepato-carcinoma A. B. c. D. NANB Hepatitis E. sag cn be denied tough moop> ‘Unusual stability and resistance to disinfectants is shown by moop> HBsAg can be detected in which of the following body {luids of chronic carriers? ‘Which source and product name is correctly linked? A, B. c. D. Hepatitis moOm> Delia virus DNA coated by HbsAg Delta virus RNA coated by HBsAg Delta virus DNA coated by HBcAg Delta virus RNA coated by HBcAg [None of the above Hepatitis B Hepatitis D All of the above ELISA tests RIA tests electron microscopy of feces Two of the above All of the above HBV HAV NANB hepatitis Delta particles Al of the above Blood Saliva Urine Feces All ofthe above Blood serum ~ Hepatavax Blood serum — Recombivax Yeast DNA ~ Heptavax None of the above GO ON TO THE NEXT PAGE. «as developed by FRPP PPPTopical Review Test A: Hepatitis and Infection Control 21, ‘Treatment for acute hepatitis 27. Negative results for which pair of lab tests will usually ‘A. Antibiotics rule out active Hepatitis B? B. Recombivax . ‘A. HBsAg and Anti-HBs C. EBIG B. HBsAg and HBcAg D. Reduction of caloric intake C. HBsAg and Anti-HBc E. None of the above D. Anti-HAV and Anti-HBs 22. Hepatitis B vaccination consists of how many 28. Which set of terms is correctly linked? ‘A. serum hepatitis, hepatitis A. short incubation hepat B. long incubation hepatitis, hepatitis B, infectious hepatitis D. Four: initial, 1 month, 2 months, 6 months C. _NANB hepatitis, short incubation hepatitis, serum hepatitis D. Hepatitis A, infectious hepatitis, short incubation 23. The offering of hepatitis B vaccine for “exposed” hepatitis employees is: ‘A. Mandatory and must be free to the employee B. Mandatory, but the employee may have 10 29. Which hepatitis form is diagnosed through exclusion of contribute part of the cost other types? C. Not mandatory ‘A. Hepatitis A 1D. Mandatory for dentists but not support staff B. Hepatitis B C._NANB Hepatitis D. Hepatitis D 24. A “cluster” of hepatitis cases associated with drinking * water ata summer camp is most likely: ‘A. Hepatitis A 30. Which group below is at high risk for hepatitis B? B. Hepatitis B A. Health care workers C._NANB Hepatitis B. Male homosexuals D. Hepatitis D CC. prison inmates D. IV drug abusers E. Allofthe above 25. A “cluster” of hepatitis cases associated with a dental office is most likely: ‘A. Hepatitis A B. Hepatitis B C._NANB Hepatitis D. Hepatitis D STOP. END OF TEST. 26. A “cluster” of hepatitis cases associated with blood transfusions is most likely: ‘A. Hepatitis A B. Hepatitis B C._NANB Hepatitis D. Hepatitis D ‘KAPLAN zA AeA eee kk q as developed by 3 Zé voc emuvAaLue #8 a 3 eereg Zz added ena as | 2S> Fat veasannnan< Bee 285 iddgadseeag 5 £24 ee ae oom mm te tm \ Be Sad tee SKE SK a a NDB-Iee a ee ee va Topical Review Test A: Hepatitis and Infection Control NDB-1 TOPICAL REVIEW TEST HEPATITIS AND INFECTION CONTROL : EXPLANATIONS, 1. The'correct answer is choice B. Hepatitis D is a form of RNA virus which appears only when associated with hepatitis B. It appears to require hepatitis B enzymes in order to reproduce. Hepatitis D may actually be hepatitis D RNA associated with hepatitis B surface antigen. Note in the incorrect answers that hepatitis A and C are not associated with hepatitis D. Note also that anti-HBs is an antibody to surface antigen; i is not the surface antigen itself. So the correct answer to question | is choice B. 2. The correct answer is choice E. Hepatitis B surface antigen is known as HBsAg. It is found as part of three different hepatitis B particles. including the Dane particle which is a normal viral-type particle, the 22 nanometer sphere and the 22 nanometer filament. ‘Anti-HAV is the antibody to hepatitis A. HBcAg and HBsAg are antigens and not antibodies. An anti-HBe is the antibody to the antigen HBeAg which indicates high viral replication and infectivity 3. The correct answer is choice C. Only OSHA, the Occupational Safety and Health Administration, has regulatory power which it exerts over healthcare workers by way of workplace regulations. CDC, the Centers for Disease Control, studi-+ infection- related issues and provides recommendations. ADA, the American Dental Association, also acts in an advisory capacity anc will issue infection control recommendations. PHS is the Public Health Service, a branch of Health and Human Services Department, and performs a variety of functions, including funding of health centers and projects 4. The correct answer is choice C. Universal precautions ~ treating all patients as potentially infectious and barrier methods such as the use of gloves, masks and face shields -- developed in the 1970s as a result of a reaction by CDC and ADA to hepatitis B clusters associated with dental offices. These precautions now serve to protect workers and patients from HIV and other pathogens as well. 5. The correct answer is choice B. Hepatitis B is a double-stranded DNA virus. Hepatitis A and D, the delta particle, are both single-stranded RNA viruses. Delta particle refers to the organism which causes hepatitis D. HBsAg is the surface antigen of hepatitis B and is not a complete vir itself. 6. Thecorrect answer is choice E. Regardless of the causative agent of hepatitis, signs and symptoms are similar. They include fever. weight loss, loss of appetite, hepatomegaly, splenomegaly, lymphadenopathy or swollen glands, myalgia, weakness, jaundice ‘and other symptoms. 7. The correct answer is choice B. Hepatitis B is known as serum hepatitis due to the bloodborne nature of its spread. Hepatitis Ais known as infectious hepatitis, referring to its spread through contamination of water and food supplies. NANB hepatitis and hepatitis D do not have any common names. 8. The correct answer is choice A. Hepatitis A is spread primarily through fecal-oral contamination. Hepatitis B is spread ‘mostly through blood or sexual contact as is hepatitis D which only exists in the presence of hepatitis B. NANB hepatitis is spread mostly through transfusion of blood as blood is easily screened for both hepatitis A and hepatitis B, 9. The correct answer is choice A. During a period of time after infection by HBV. approximately 5-6 months after the initial infection. a window period may exist during which it may be difficult to identify HBsAg in the blood. During this time, a ‘confirmatory test for anti-core antigen or anti-HBc is used. Negative tests for both HBsAg and anti-HBc indicates the absence of hepatitis B infection. 1 ‘The correct answer is choice B. Recombivax and Heptavax. two forms of hepatitis B vaccine, supply the body with antigens similar to HBsAg which causes the body to form anti-HBs antibodies. This is a form of active immunity and the anti-HBs antibody will show up in lab tests. No anti-HBc antigen will develop as hepatitis vaccines do not contain any core antigen of HBV. 11. The correct answer is choice C. The Australian antigen. first detected in an Australian aborigine with hepatitis B, tured out to be identical to that known as HBsAg. Remember that this antigen is found in three particle types: the Dane panicle, the 22 nanometer sphere and the 22 nanometer filament. 12, The correct answer is choice D. two of the above. Both hepatitis A (which is HAV) and the delta particle (hepatitis D) are single-suanded RNA viruses. Hepatitis B or HBV virus is a double-stranded DNA virss, Sotwo of the answers are RNA viruses and is is choice ‘KAPLAN 7NDB-I 13. The correct answer is choice B. A Dane particle is probably a complete hepatitis B virus, complete with DNA, core proteins and a surface envelope with surface envelope proteins. It also contains the hepatitis B surface antigen. It was named appropriately after its discoverer, Dane. 14, The correct answer is choice D. Although hepatitis B viral particles have a core with genetic material and core proteins such as HBcAg, the genetic material will be DNA, not RNA. Dane particles, 22 nanometer spheres and filaments, are all HBV particle types with hepatitis B surface antigen activity, as is, of course, the hepatitis B surface antigen itself. 15, The correct answer is choice B. Delta particle causes hepatitis D which is only active in the presence of hepatitis B. It is believed that hepatitis B enzymes are required for a replication of delta particle. Hepatitis D may be an association of delta particle RNA with hepatitis B surface antigen. 16. The correct answer is choice B. Hepatitis B is extremely dangerous due to the inflammatory effects on the liver, decreased liver function, chronic extended destructive stage, and also a link to increased chance of developing hepatocarcinoma, 17, The correct answer is choice D, two of the above. The hepatitis B surface antigen can be detected through ELISA which is enzyme-linked immunosorbent assay and RIA which is radioimmune assay. Hepatitis A viral particles or HAV can be detected by electron microscopy of fecal material asthe viral particles are shed in the feces of the infected person. 18. The correct answer is choice B, HAV. HAV or hepatitis A virus is extremely resistant to surface disinfection, including 1 to 400 formgifn for three days and boiling water for five minutes. This presents a problem in terms of control and its spread within closely gfffined groups of people, such as groups of soldiers, children in camps, ec. 19. FF The correct answer is choice E, all of the above. Hepatitis B surface antigen is found in a wide variety of body fMuids, including those of chronic carriers. Blood, saliva, tears, semen, mucous, urine and feces may all contain HBs surface antigen. In terms of the infectivity, however, blood is most infective with semen, also considered to be highly infective. This is similar to the relative infectivity of body fluids for HIV. 20. The correct answer is choice A. Heptavax and Recombivax are two types of hepatitis B vaccine. Heptavax was developed ‘earlier using purified hepatitis B surface antigen from human blood. Recombivax uses hepatitis B surface antigen produced through ‘genetically engineered yeast cells. In both cases, they cause the recipient to produce anti-HBs antibodies. 21. The correct answer is choice C. HBIG is hepatitis B immune globulin, a form of concentrated antibody to hepatitis B. It is a form of passive immunity and, if given in time, can reduce the severity of hepatitis B disease. Antibiotics have no effect on viruses. Recombivax is a preventive vaccine that is best administered before contact with the virus, not after. In some cases. an exposed employee will receive a post exposure follow-up of both vaccine and HBIG. Increased caloric intake is suggested for hepatitis patients ‘due to increased loss of food through nausea and diarrhea. 22, The correct answer is choice C. Current Heptavax and Recombivax protocols call for three vaccinations: initial, 1 month and month. It is possible that this may change if improved or changed vaccines develop. 23. The correct answer is choice A. All employees who are classified as “exposed” to bloodborne pathogens in any way must be Offered free vaccine. Any that refuse the vaccination must sign a waiver indicating that the vaccine was offered, why it was suggested that they receive it, and that the employee can change the decision at any time in the future and still receive the vaccine free of charge. 24, 25 and 26 will ll be answered together. 24, ‘The correct answer here will be choice A. 25. The answer here will be choice B. hepatitis B. 26. The correct answer here will be choice C which is non-A/non-B hepatitis. Although symptoms ofall forms of hepatit similar. a combination of history and lab tests can distinguish which virus is involved. Hepatitis associated with drinking water at summer camp is probably hepatitis A as itis spread chiefly through the fecal-oral route. Hepatitis associated with a dental office has historically been hepatitis B, spread through blood possibly from unsterlized instruments. Hepatitis associated with transfusions at ‘one time might have been hepatitis B, but since both hepatitis A and hepatitis B can now be tested for in lab transfusion hepatitis ‘now is most likely to be neither A nor B: that is. non-A/non-B hepatitis (hepatitis C).. e «a5 developed by@ @ @-@ eero Topical Review Test A: Hepatitis and Infection Control 27. _ The correct answer is choice C. The standard test for active hepatitis B is the test for hepatitis B surface antigen or HBsAg. In the “window” period where this antigen level may drop, the confirmatory testis for anti-core antibody or anti-HBc. Remember that there is no current lab test for hepatitis core antigen itself. The correct answer is choice D. Hepatitis A has a shor incubation period and is infectious through the fecal-oal route and is. ‘ore, known as infectious hepatitis. Hepatitis B has a longer incubation period and is spread primarily through blood contact; thus tive name serum hepatitis, 29, ‘The correct answer is choice C. Non-Anon-B hepatitis is suspected when a patient has signs and symptoms of hepatitis, but tests negatively for HBsAg (the surface antigen. uati-HBcAg (the anti-core antibody) and also HAV (Which is the hepatitis A virus). Especially when accompanied by recent transfusion history, a diagnosis can be made by excluding both hepatitis A and B, and that is, of course, non-A/non-B hepatitis. Remember that hepatitis D is only possible in the presence of hepatitis B and so itis not diagnosed by exclusion, ‘The correct answer is choice E. Any group of people with high probability of exposure to infected blood or semen will be in « high risk group for both hepatitis B and D as well as for HIV. Healthcare workers, male homosexuals, prison inmates and IV drug abusers all fit into these categories. So our correct answer is all of the above. NA 3056 c.3 Kaplan Center Materials Hepatitis/Intectio Topical Review Test ATO (SU HEALTH PROFESSIONS DIV. UB ‘il i | 35215 00057803 PLAN 7Ja Re RB eee ee Topical Review Test B: HIV and Infection Control NDB-1 TOPICAL REVIEW TEST B: HIV AND INFECTION CONTROL -« This is a review of HIV and related infection control issues in dentistry. Foll review test and then we will briefly review the answers to these 30 questions, HIV virus has been identified by a variety of names during its period of isolation and discovery. including HIV. LAV. ARV. HTLV II] and others. Most researchers have agreed to use HIV, although HTLY III. or Human T Lymphotropic Virus Ill. may still be seen as a name referring to this virus. HIV is in the large group known as retroviruses: that is, they are RNA viruses which use a reverse transcriptase in order to reproduce. In brief, they cause the target cell to make DNA copies of the viral RNA genome. While originally thought to be closely related to the oncoviruses HTLV I and HTLV Il, recent work shows HIV to be most closely related to a group of retroviruses known as lentiviases or slow virases. The name is due to the fact thatthe diseases caused by these viruses develop slowly. often aking yeas 10 ‘develop. These diseases include sheep encephalitis, or visna maedi disease, and equine infectious anemia in horses. LLemiviruss als have careers bar shaped nileoids as oppose tothe more common spherical ncleoids found in many viruses. The target cells of HIV virus generally contain surface receptors known as CD4+ receptors. These target cells are most commonly Té helper lymphocytes. However, ‘monocytes, astroglia and B lymphocytes may also become infected. B lymphocytes are especially vuinerable if previously infected by EBV or Epstein-Barr virus. Commonly, blood, brain, testes, thymus, spleen and other organs are sites where infected cells can be isolated. Destruction of T4 lymphocytes, in particular, is common, and the ratio of T4 helper lymphocytes to the TS suppressor lymphocytes declines. The T4 over T8 ratio is used as a diagnostic sign of disease progress, as isthe absolute number of T4 cells, and the total virus particle count. ; Risk groups refer to groups of people with certain characteristics of lifestyle, medical condition or occupation that are more likely to develop HIV-related disease. ‘These risk groups in the United States include male homosexuals, TV drug abusers, sexual pariners of IV drug abusers, people receiving blood products such as hemophiliacs, people receiving blood transfusions (although this has declined with the advent of HTV antibody testing of blood). and to a limited extent, healthcare workers can be considered a risk group. We'll discuss more about these risk groups later. “The first signs of AIDS, which is the later symptomatic form of HIV infection, were seen in the early 1980s as a syndrome cof symptoms found in a group of male homosexual patients in San Francisco. The syndrome included oral and esophageal candidiasis cor thrush; presence of Kaposi's sarcoma, a rare sarcoma of vascular tissue; decreased immune response; and presence of Pneumocystis carinii pneumonia, an uncommon form of pneumonia. Only much later was this set of symptoms connected with the presence of HIV virus. The disease was named AIDS or Acquired Immune Deficiency Syndrome. Later study showed that the symptoms were consistent with a breakdown in the immune system caused by the virus attacks on leukocytes, in particular, T-lymphocytes. ‘The diseases common in AIDS patients, but uncommon in the general population, are primarily opportunistic infections. ‘They are caused by common, normally nonpathogenic organisms which become dangerous due to the compromised condition of the AIDS patient's immune system. Similar opportunistic infections can be found in patients immunocompromised for other reasons ‘such a8 other immune disorders or patients taking immunosuppressive drugs following transplants. Opportunistic infections can be ‘caused by all manner of microorganisms, including protozoans such as Pneumocystis carinii which causes pneumonia, Toxoplasma ‘gondii, and Cryptosporidium which causes severe diarrhea. Opportunistic fungi include Candida albicans, which causes thrush or candidiasis; Cryprococeus, Coccidioides and Histoplasma. Bacteria include Mycobacterium tuberculosis and related ‘Mycobacterium avium. However, in AIDS patients, the tuberculosis bacteria commonly spreads to tissues beyond the lungs. This is known as disseminated TB. Virus types which cause serious disease in the immunocompromised AIDS patient include cytomegalovirus or CMV, herpes simplex and hepatitis B. A tumor associated with AIDS is Kaposi's sarcoma, a tumor of vascular tissue causing purplish lesions of the skin, tongue. palate, lymph nodes and visceral organs. ‘Transmission of HIV virus and HIV-infected cells from person to person has been extensively studied. Many body secretions have been found to contain HIV viral particles, yet the fluids differ markedly in their ability to transmit the virus and accompanying disease to another person. The virus can be detected in blood, semen, saliva, vaginal secretions and tears, among other fluids However. blood and semen are by far the two most effective transmitters ofthe virus. This is consistent with the fact that TV drug use ‘and sexual contact are the two primary means of transmitting the disease. ‘Sexual practices also differ widely in their ability to wransmit HIV virus, with anal intercourse considered to be the most effective and. therefore, the most dangerous unprotected sexual practice from an AIDS point of view. Casual contact with HIV+ patients poses little risk, even among members of the same household. Likewise, healthcare workers appear to be at low risk for exposure to HIV virus from patients. except to the extent that needles or sharps are involved. Most of the few reported cases of healthcare workers becoming HIV+ through job-related accidents involved needle sticks or exposure of non-intact skin to large quantities of HIV+ blood. ‘At the time of recording this tape, the case of a Florida dentist who apparently transmitted HIV virus to a number of patients ~ including a young woman. Kimberly Bergalis, who later died of AIDS ~- remains unsolved. Theories have involved both the use of unsterilized instruments and deliberately injecting the patients with blood mixed with anesthesia, although, again, at this time all lowing the review, you will take a 30-question ‘KAPLAN 7” ss a NDB-I explanations are conjecture. With the exception of this case, dental transmission of HIV appears to be minimal to nonexistent. There is no evidence for airborne transmission of HIV or insect-borne transmission such as by mosquito. ‘Signs and symptoms of HIV infection vary greatly. Often. two weeks to some months after infection. an individual may experience fuclike symptoms: fever. lymphadenopathy. diarthea. malaise. weakness. or night sweats. These symptoms. however. are not unique to HIV infection and vary grealy from individual to individual in intensity, onset and duration. An individual may then be asymptomatic for many years, and how many is not known. and itis quite variable. Whether all HIV+ people progress to AIDS is ‘ot known as wel. although most have to this date. A later stage of symptoms in an HIV+ person is known as ARC or AIDS-Related Complex. It is also known as Pre-AIDS or AIDS Prodrome. Signs and symptoms at this stage may include weight loss, extended cases of diarrhea, severe night sweats and Iymphadenopathy. ‘The precise definition of AIDS has changed over the previous few years and is ceraiily likely to change again. However, is a good idea to know generally what is involved in stating that a patient is not merely HIV, but has AIDS. Most definitions of AIDS require that a patient have a lab result of HIV: that is, that there are anti-HIV antibodies present. The HIV+ individual also then must have a certain number of conditions, symptoms, diseases or characteristics of AIDS. How many and which ones may vary according to changing AIDS definitions, bu the following conditions are often included in a diagnosis of AIDS in the HIV+ individual: low Té lymphocyte counts, low T4/T8 ratios, extreme weightloss or wasting, esophageal candidiasis, airy leukoplakia (a white thickening ofthe mucous membranes, often onthe tongue or in vaginal mucous membranes), Preumocystis carinii I pneumonia, CMV or cytomegalovirus retinopathy, CMV colitis, CMV pneumonia, Kaposi's sarcoma, cryptococcosis, Cryptosporidium diarrhea, toxoplasmosis, disseminated Mycobacterium tuberculosis, presence of other Mycobacterium species related disease, HIV encephalopathy, and other conditions. Normally, presence of a numberof these conditions inthe HIV+ individual leads toa diagnosis of AIDS. ‘Kaposi's sarcoma is not definitively related to an infectious agent and it relationship to compromised immune systems is not Precisely known. It was formerly a rae neoplasm found primarily in Mediterranean-origin males over 5O years of age or younger equatonal African males. It is, however, more severe in AIDS patients and may be somehow associated with cytomegalovirus infection, although this is not definitively known. Pediatric AIDS isthe presence of AIDS in young children. Besides vansmission as described previously through sexval contact and blood, AIDS can be transferred through birth by contact with vaginal mucous membranes, through blood exchange with the placenta during development, and through breast milk. 1 ‘An unusual aspect of pediatric AIDS involves the use of the HIV antibody test in pediatric patients. Newborn children from HIV+ mothers wll exhibit positive results to HIV antibody tests. However, not all of these children are infected with HIV virus. This is because the test for HIV antibody, known as an ELISA test, does not test presence of viral particles, only the presence of antibodies il to the viral panicles. The childs blood may contain anti-HIV antibodies produced by the mother and transferred through the placenta into the child's bloodstream. ‘These antibodies may disappear ata late time ifthe child itself isnot infected with virus. Ifthe child is IB infected, the child's immune system will then produce its own anti-HIV antibodies andthe child will continue to test positive. ‘A controversy currently exists concerning HIV testing of newborns. Proponents say that early testing can bring early effective treatment of the newborn. Opponents sate that a confidentiality issue exists because ifthe child tests positive. then the mother is automatically positive as well In this ease, mandatory testing ofthe newbom becomes an automatic testing of the mother. yy This isue is likely to remain unsetled for some time to come. Signs and sympoms of pearie AIDS often show up by two years of ago and include Preumocrstis carn pneumonia. yy lymphocytic pneumonitis, candidiasis, bacterial sepsis, HIV wasting syndrome with extreme weight loss, Mycobacterium infections, CMY infections herpes infections and, overall failure to thrive. Testing for HIV. as stated previously is primarily done through the ELISA test or enzyme-linked immunosorbent assay test. if This test, as stated before. tests for antibody to HIV surface antigens. A more sensitive test known as the Western Blot test can test, forthe presence of HIV viral proteins. However, the standard HIV biood test in use today is the ELISA test. A Western Blot test can be used to eliminate false-positive tests from the ELISA test. ‘We now switch tothe topic of infection contol as it relates to HIV. NDB II students are advised to use all supplementary IE topical review tests inthe couse for further information on this and related topics. Infection control in dentistry is influenced by a diverse group of agencies, including the CDC or Centers for Disease Control; ‘OSHA. the Occupational Safety and Health Administration: and ADA, the American Dental Association. In general, the CDC studies infectious diseases, including transmission of disease in healthcare settings, and issues recommendations. It does not, however, have any enforcement powers. The ADA may issue its own guidelines for dentists to follow. However, the ADA is a professional organization and not a governmental one, and also has no enforcement powers. OSHA is a branch ofthe Deparment of Labor and hi interests only inthe protection of healthcare workers and not patients. It issued a recent set of guidelines known as the Bloodborn Pathogens Standard which requires dental workplaces to develop a bloodborne pathogens exposure control plan which details the safety, ‘measures in place at each worksite. = The history of infection control measures in dentistry traces primarily back tothe 1970s when a few clusters of hepatitis B Infections were traced to dental offices. CDC issued recommendations. later adopted by ADA, known as “Universal Precautions 1 They include the philosophical idea that all patents are treated the same way; that is that they are all potentially infectious. All ? as developed Oy WETopical Review Test B: HIV and Infection Cont. patient contacts require the use of gloves. Procedures involving splash or spray require eye protection and masks. “Critica instruments (that is. those that pierce the intact skin or mucous membrane such as needles, explorers. etc.) must be disposable sterilized. Touch and splash surfates such as instrument trays. light handles. etc., must be covered with disposable liners or disinfecte betweeg patients. Disinfectants must be EPA or Environmental Protection Agency registered. These universal precautions, whe strictly applied, are sufficient to protect against hepatitis B transmission. They are also sufficient for prevention of HIV transmissio In comparing the conversion rates of HIV and HBV needlesticks, it has been shown that: ‘They are approximately equa in frequency HBV conversion is slightly greater than HIV HIV conversion is slightly greater than HBV HBV conversion is significantly greater than HIV pomp Topical Review Test B: HIV and Infection Control Pacumocystis carinii peumonia is directly caused by: HIV virus: a fungus a protozoan abacteria pop> ‘Opportunistic infections associated with AIDS include all of the following except: A. Toxoplasmosis B. Candidiasis C. Mycobacterium avium D. Hepatitis A E. Cryptosporidium diarrhea ‘A positive test for antibodies to HIV virus indicates: Presence of AIDS Presence of ARC Exposure to HIV virus Exposure to HIV virus or HIV vaccine pomp Disinfection of a smooth surface containing HIV virus ‘can be accomplished: by heat and pressure only by overnight exposure to glutaraldehyde only by a variety of common disinfectants by exposure to sodium hypochlorite only poe> GO ON TO THE NEXT PAGE. ‘KAPLANNDB 10. Besides blood, othet body Muids containing HIV virus 15. The ELISA tests detects: and proven highly infective, include A. HIV vial panicles A. sTeas B)_ HIV surface antigens B. Semen C. Anilbody to HIV surface antigens ©. Sativa D._ Etecirophoreically separated viral proteins D. Allofthe above 16. The Wester Blot test detects: 11, HIV virsis categorized a a retrovirus because: ‘A. HIV vial parties A. tis aDNA virus with reverse transcriptase B_ HIV surface antigens B. Itisan RNA virus without reverse tansripase C. Antibody to HIV surface antigen CC. Itcauses target cells to make DNA copes ofthe D. Eleciophoretcally separated viral proteins RNA viral genome D. Iteauses the target cells to make RNA copies of the DNA viral genome. 17, The “benchmark organism” fr effectvenes of surface disinfectans is: A HV 12. Changes in T cell counts due to HIV infection usually 2 BV fecha: C. mycobacterium |A. creasing TA/TS rato due 10 ineeasng numbers of D._Sporeforming bacteria Theells B._ Decreasing T4/T8 ratio due to increasing numbers of Te cells 18 The “benchmark” organism for effectiveness of CC. Decreasing T4/TS ratio due to decreasing numbers autoclaving is: of Tells A HV D. Increasing T4/T8 ratio due to decreasing number of 2 BBV TBeells C. mycobacterium ._Spore-forming Bacteria 13, Indications that an HIV+ patient has developed AIDS foclode: 19. Signs and symptoms which may occur weeks after A. Esophageal candidiasis exposure to HIV virus include: B. CMV retinopathy Cs C. PCP pneumonia Br emphadenopathy D. Brain infection by Mycobacterium avium & E, Allof the above Bah cweas E. Allof the above 14. A positive HIV antibody tes in a newborn indicates that: 20. Which of the following agencies has regulatory power A. Both mother and newbom ae HIV infected concerning infection contol polices? B. The newbom is infected and the mother may be A. ADA infected Be C. The mother is infected and the newbom may be ©. OSHA infected. D. All ofthe above . The mother and newborn may or may not be infeed GO ON TO THE NEXT PAGE. 3 ai developed by ha FRR ARR RRR RR eeiii 21. 2, 23, 24. 25. Which of the fojlowing guidelines is important in selecting and using aliquid disinfectant? ‘A. The product should coniain an EPA number Br The product should be mixed in strict accordance with printed instructions C. The product should state on the label that it kills Mycobacterium wberculosis D. The product should display the ADA seal of, acoepeance E. Allofthe above “Critical” instruments, used in or near the oral cavity, which may become contaminated with blood and saliva must be: disinfected between uses sterilized between uses cleaned between uses can be disinfected or sterilized between uses pop> Biological monitors, used for autoclave testing are ‘A. viruses B. live bacteria CC. bacterial spores D. fungal spores E. a combination of bacteria, viruses and fungi ‘Which of the following may interfere with the ability of the autoclave to sterilize an instrument? ‘A. Failure to remove debris from instrument B. Overloading of autoclave C. Allowing blood or debris to dry on an instrument D. Autoclaving without precleaning of instruments E. three of the above F. Allofthe above Universal precautions are effective in preventing disease transmission from: ‘A. dental worker to patient only B. patient to dental worker only C. patient to patient only D. Allofthe above 26. 27. 28. 29. 30. Topical Review Test B: HIV and Infection Control OSHA “Engineering Controls” include all of the following except: puncture-resistant containers for sharps needle recappers hand-washing ventilation devices for administering CPR yap OSHA “Work Practice Controls” include all of the following except: ‘A. hand-washing. B. restrictions on eating in treatment rooms CC. restrictions on storing food in refrigerators with potentially infectious material D. puncture resistant containers for sharps OSHA “personal protective equipment” includes all of the following except: gloves masks ‘gowns needle recappers face shields moO> Current ADA recommendations for handpiece disinfecting/sterilizing include: Steam autoclaving Surface disinfectant wiping Flushing for 1 minute, followed by surface disinfecting Disinfecting by glutaraldchyde soaking None of the above mo OB> Which of the following procedures is NOT acceptable by OSHA regulations? ‘A. needle recapping of any type B. needle recapping by use of a recapper CC. needle recapping through careful two-handed technique 1D. needle recapping by onchanded “scoop” technique E. all of the above methods ARE acceptable STOP. END OF TEST! ‘KAPLANg PRUNE Eee eed cas developed by 21 22. 2. 24. 25. 26. 27. 28. 29. 30. ‘ANSWER KEY 1. 2 3B. Te 15. 16. a7. 18, 19. 20. NDB-1 TOPICAL REVIEW TEST B: HIV AND INFECTION CONTROL NDB-1Topical Review Test B: HIV and Infection Control . NDB-I TOPICAL REVIEW TEST B: HIV AND INFECTION CONTROL . EXPLANATIONS, 1. "The correct answer is choice C. HIV virus is in the family of lentiviruses or slow viruses. They are retroviruses in that they have an RNA genome and they use a reverse transcriptase to cause the target cell to produce DNA copies of the RNA viral genome. ‘The mode of transmission, however, is much like that of HBV or hepatitis B virus. However. that is question 2. 2. The comect answers choice A. HIV virus is primarily transmit though sexual contact and blood contact such as tha of Zontaminatd neces used by 1V drug abuser. Hepais Bis ransmited in similar ays and high sk groups for HIV wansmission secre ut tak group tor HBV vine wansnsson, including IV dr abusers, male Homosexuals and o Some extent in that they Mandl contarisated chats come bealicare workers, Note that hepatitis A. or HAV, is not generally ansmited this way and is normally transmitted through a fecal-oral route. This will be discussed in some detail in the ‘topical review test on hepatitis and infection control. 3. The correct answer is choice C. HAV virus isthe virus which causes hepatitis A. HTLV Ill, HIV, LAV and ARV all refer 16 the HIV virus. Different investigators isolating the virus a different times in different places came up with different identifying names, although the current agreed-upon name is now HIV. “The correct answer is choice E. HIV virus will atack a wide variety of leukocytes and any cell containing a CD4+ receptor in its membrane. T lymphocytes, macrophages, monocytes and B lymphocytes can all be attacked by the virus. 5. The correct answer is choice D. When healthcare workers are exposed to blood through needle stick accidents, the conversion rate for HBV greatly exceeds that for HIV. What this means is that the risk is much greater that the healthcare worker will contract, hepatitis B than that the worker will develop AIDS. Some estimates for conversion for HBV from a single needle stick with infected blood range from 6-30%, while for HTV they are estimated at less than 1%. 6 The correct answer is choice C. Pneumocystis carinii is a protozoan which often causes pneumonia in immunocompromised patients. It is an opportunistic organism in that it will almost never cause disease in the healthy individual and is only pathogenic due to the AIDS patients inability to mount a proper immune response. 7. The correct answer is choice D. Hepatitis A is a viral disease spread primarily through the fecal-oral route; that is. from food ‘of water contamination by feces. It is not an opportunistic disease associated with AIDS. Toxoplasmosis is a protozoan-caused disease. Candidiasis is a fungal disease. Mycobacterium avium infection is a bacterial disease, and Cryptosporidium diarrhea is a protozoan disease. All of these diseases except hepatitis A are found more often and more severely in immunocompromised patients. 8 The correct answer is choice C. Patients develop antibodies to HIV virus some weeks or months afier exposure. The ELISA, test tests for the presence of these antibodies. It establishes that at some time the patient was exposed to HIV virus and produced antibodies as an immune response. Asymptomatic patients, patients with ARC or patients with full-blown AIDS will all test positive for antibody. so a positive test cannot indicate the clinical condition. Likewise, a positive test will not indicate exposure to HIV vaccine as there is no effective vaccine available at the ime of production of this review test. 9. The correct answer is choice C. Smooth surfaces such as countertops can be disinfected by a variety of methods and do not need to be sterilized. Most countertops, of course, cannot fit into your dental autoclave unless you have a large autoclave or a small countertop. Effective smooth surface disinfectants for HIV include iodophors, sodium hypochlorite (bleach), glutaraldehyde and many other chemicals. 10. The correct answer is choice B. Many body fluids may contain viral particles, including blood, semen. tears, saliva anc vaginal secretions. However, only blood and semen at this point appear to be highly infective. Precautions should be used for other body fluids as wel, but Blood and semen are clearly most infective. 11. Thecomect answer is choice C. A retrovirus has an RNA genome and uses reverse transcriptase enzyme 1 cause a target 2] to produce DNA copies of the RNA viral genome, 12. The correct answer is choice C. The main target of HIV virus is the T4 cell. This is a helper lymphocyte with OKTS 0 (CD4+ receptor in the membrane, As these cells are destroyed, the ratio ofthese cells to TB suppressor lymphocytes decreases: that is fewer Té lymphocytes remain relative to a relatively unchanged number of T8 lymphocytes. PLAN 7jie NDB-I = 13. The correct answér is choice E. Esophageal candidiasis. CMV retinopathy. Pneumocystis carinii pneumonia. infection by Mycobacteria other than M. tuberculosis, disseminated TB. HIV encephalopathy. HIV wasting syndrome. Kaposi's sarcoma, cryptococcosis, toxoplasmosis and other conditions are all possible indications of progression to AIDS. 14. The correct answer is choice C. A positive HIV antibody test in the newborn indicates that the newborn has HIV antibodies. Icmay have produced them itself actively, indicating that it was exposed to HIV virus from the mother. On the other hand. it may have received antibodies from the mother (in this case. passive!;). and itis not infected by HIV virus and only contains the mother’s antibodies. In either case, however, the mother is HIV+. 1S. The correct answer is choice C. The ELISA test tests for antibodies made againsthe surface antigens of the HIV virus and ‘ot for any part of the virus itself. The confirmatory Western Blot test tests for electrophoretically separated proteins of the virus itself. So the correct answer to question 15 is C and 16 is D. 16, The correct answer is choice D. See explanation above. 17, ‘The correct answer is choice C. /A benchmark organism is used to test the effectiveness of a particular procedure. In the case of disinfection and sterilization, the benchmark organism is one that is especially hard to kill. On surfaces, the Mycobacterium species such as M. muberculosis are especially hard to kill by disinfectant. Disinfectant which kills these bacteria will more easly kill HIV, HBV, other viruses, bacteria and fungi on the smooth surface. 18 The correct answer is choice D. Spore-forming bacteria are especially hard to kill through autoclaving. Other bacteria, viruses, protozoans and fungi are killed more easily. Thus, spore formers are the benchmark organism for autoclave testing. Spores of the genus Bacillus are used. 19. The correct answer is choice E. First signs and symptoms following exposure to HIV virus may range from mild to severe ‘and vary greatly in time of onset and duration. Mild flu-like symptoms may occur and lymphadenopathy, fever, malaise, myalgia, right sweats, weakness and other symptoms may occur. 20. The correct answer is choice C. Only OSHA is a governmental body with a power to regulate. As a branch of the Department of Labor, it establishes regulations regarding worker safety, including protection of healthcare workers from bloodborne pathogens. ADA is a professional organization of dentists, while CDC is a research and advisory body of the Department of HEW ‘without regulatory power. 21, The correct answer is choice E. An EPA registration number and the ability to kill M. tuberculosis are mandatory. Proper ‘mixing i, of course, necessary. and an ADA seal is advisable, although not mandatory. 22, The correct answer is choice B. Critical instruments which penetrate mucosal surfaces or which penetrate intact skin must be ‘sterilized or disposable. Disinfection is not sufficient. Remember that sterilization kills all life forms, while disinfection does not. Disinfection may be used for semicritical or noncritcal surfaces. 23. The correct answer is choice C. Bacterial spores are the benchmark organism for autoclave tests. They are harder to kill than fangal spores, live bacteria, viruses or other microorganisms. 24, The correct answer is choice F. All instruments must be well cleaned before autoclaving. Generally, instruments are detergent soaked to prevent drying of blood or tissue, then they are hand-scrubbed by wire brush, dried, packaged and autoclaved Debris or protein material onthe instrument can shield pathogenic microorganisms from the heat or chemical vapor of the autoclave or chemiclave. Overpacking the autoclave shields some envelopes from reaching maximum temperature. 25, The correct answer is choice D. Universal precautions developed by CDC are meant to break the chain of transmission of pathogens. Gloves may protect the dentist from infected patient blood or protect the patient from contaminants on the dentist's hand. Instrument sterilization can protect one patient from a previous patient. Similar cases can be made for eyewear or masks which may prevent droplet infection spread from worker to patient or vice versa. ion of 26 & 27. The correct answer will be choice C for question 26 and choice D for question 27. OSHA's descri Engineering Controls usually refers to objects or hardware -- such as sharps containers, needle recappers, eyewash stations, etc. -- ‘which protect healthcare workers. Handwashing is a policy or procedure and is therefore a work practice control, as are any other 70 ‘as developed by Cee ee 2 2 2Topical Review Test B: HIV and Infection Contro, procedures such as restrictions on food storage. eating in treatment rooms. etc. Puncture-proof sharps containers are engineering controls. 28. _-~ The correct answer is choice D. Personal protective equipment is worn by the worker and may include lab coats or jackets. scrubs. masks. eyewear and gloves. Needle recappers which are not worn. unless the dentist is extremely odd. are really engineering controls according to OSHA. 29. The correct answer is choice A. Former recommendations for handpieces used to involve disinfecting them between patients. However, studies show that water lines within handpieces might be reservoirs for microorganisms. Since these interior surfaces cannot bbe reached by disinfectants, handpiece sterilization became the ADA recommendation, 30. The correct answer is choice C. OSHA regulations on recapping syringe needles are designed to prevent needle sticks to the healthcare worker. Recapping devices can be used, disposable syringes can be used, a one-handed scoop technique can be used which ‘does not expose the other hand to the needle, but two-handed recapping techniques cannot be used, NA 3057 C.3 | Kaplan Center Materi HIV/Infection Control Topical Review Test B i -ESSIONS | OW. UB | KAPLAN 7“Part December 1996 101. Which of the following vitamins is the LEAST likely to be involved in tooth development and calcification? pop> vop> moom> 402. The major function of serum LDL is to transport which of the following? Biochemistry-Physiology Exam 106. Which of the following represents the chemical substance that is the immediate source of energy for muscle contraction? Giycogen ‘AcetyiCon Lact acid Creatine phosphate ‘Adenosine triphosphate ‘Bisa om he testing “ estat bay tts hve ®_Taapenes tom he etre 107. ger end esta boy hs a ._reaty aids rom apne tue D. Cholesterol and phospholipids from A total oamotc pressures. Peripheral tissues B. colloid osmotic pressures. & Galera ees, and cle oxo presse Phospholipids from the liver D. chloride ion concentrations. Etat on concantaos 103. The fuid-mosaic model for membrane structure proposes that ‘A the outer and inner faces of the ‘membrane are identical. B. _ peripheral proteins are situated only on the outer face of the plasma membrane. C. integral proteins are associated with the hydrophobic phase of the bilayer. D. both polar and nonpolar ends of membrane phospholipids are within the hydrophobic phase of the bilayer. moop> 104. A protein in solution is at its isoelectric point when the 108. Breathing a gas mixture with § percent CO, utimately leads to which of the following? Hypoventiation Adecrease in heart rate {stimulation of central chemoreceptors An inhibition of peripheral chemoreceptors AA decrease in cerebrospinal fid hydrogerion concentration 109. Ovulation is triggered by a marked increase in Which of the following? ‘A piHis the same as that ofthe blood. logarithm of the concentration is zero. pH allows for maximum solubilty pH is such that no migration occurs during electrophoresis. DH is produced by a 4:1 mixture of the protein solution with isotonic saline. ™ oop moom> 105. The absolute refractory period of a nerve action potential is determined by the duration of which Estrogen Estradiol Progesterone Luteinizing hormone Folicle-stimulating hormone 110. Which of the following must be digested before being in a form that can be absorbed by of the following? enter * ‘A. Sodium activation gat opening A Monegiyceries 8. Sodium inactivation gate closure 8 Faty ac . Potassium activation gate opening Sees D. Potassium inactivation gate sosure D. Shene 18111. Alpha-ketoglutarate, oxygen, and ascorbic acid are essential for which of the following processes? 116. }. Where in the autonomic nervous system is norepinephrine stored? ‘A. Preganglionic sympathetic nerve ‘A. Incorporation of proline endings B._Hydroxylation of proline B. Postganglionic sympathetic nerve . Gamma-Carboxylation of protine endings D. Oxidative deamination of lysine C.Preganglionic parasympathetic nerve E. Activation of procollagen peptidase endings 1D. Postganglionic parasympathetic nerve endings 4112. Low Density Lipoprotein (LDL) particles get into cells by 117. Which of the following will inactivate human ‘A. simple diffusion. immune deficiency virus (HIV) reverse B. cell-cell fusion transcriptase? . active transport. D. facilitated diffusion. A ATP E. receptor-mediated endocytosis. BACT c. dATP 113. Which of the following represents the major pathway for metabolism of excessive intraneuronal free norepinephrine? D. Fluorouracil E. Methotrexate 118. Which ofthe folowing hormones conserves A Hydrolysis by cholinesterase body protein, carbohydrate, and fat stores? 8. Deamination by monoamine oxidase C. _Hydroxylation by monoamine oxidase A Cortisol D._ Hydroxylation by dopamine beta B. Glucagon hydroxylase ©. Insulin Methylation by catechol-O-methy!_ D. Somatotropin transferase 114, Assuming that P,, = 26 tos, under conditions 119. ach ofthe following is involved in gene where pO, = 30 forss, the average number of (0, moleciles bound ‘per hemoglobin molecule is closest to ‘greater than 2. ‘greater than 3. moom> ‘cloning EXCEPT one. Which one is this EXCEPTION? Restriction nucleases Reverse transcriptase A DNA ligase Os. B. RNA polymerase fess than 4 ©. DNA polymerase | almost 2 D E 120. Which of the following has a high affinity for 446. Inthe DNA molecule, guanine on 1 strand i 4 g and is binding caleium and collagen in the califying joined to cytosine on the complementary strand by which ofthe folowing bonds? matric? A Amide A. Calcitonin B. Osteogenin 8. 1 hydrogen 3 ©. 2hysrogen ©. Osteonectin D. 3 hydrogen D. Amelogenin E. Phosphodiester E. Fibronectin 16121. In the glycolytic sequence, the enzyme that brings about the transition from 6-carbon metabolites to 3-carbon metabolites is ‘A. phosphoglucoisomerase. 8. _phosphofructokinase. C._ phosphorylase. D. hexokinase. E. aldolase. 122. Which of the following represents a striated muscle that contains transverse tubules, a slow rate of calcium sequestration, and is, inhibited by acetyichotine? Cardiac Skeletal Mult-unit smooth Single unit smooth pom> 123. Tay-Sachs disease is associated with an inborn error of metabolism involving a specific enzyme which normally degrades a particular ‘molecule in the gray matter. This enzyme acts (on which of the following? ‘A Polysaccharid B. Acyiglycerols C. Gangliosides D. Fatty acids E. Proteins 424. Vascular smooth muscle relaxes in response to A hyperoxia. B. adenosine. C. vasopressin. . angiotensin. E. norepinephrine. 4125. Which ofthe following is MOST often associated with free fatty acid transport in human blood? A Albumin B. Globulin ©. Cholestero! D. Sphingolipid E. Mucopolysaccharide v7 126. 127. 128, 129, Whi proteins of enamel? During oxidative phosphorylation, the energetically unfavorable proton gradient is created using energy from which of the following? ATP hydrolysis, ATP synthesis. ADP transport Electron transfers The reduction of NAD* moom> Which of the following explains why enamel is harder than bone? ‘A Enamel crystals are larger and more firmly packed. B. Enamel contains amelogenins in its ‘organic matrix. . Enamel contains more magnesium and carbonate. D. Enamel crystals have more surface E. Enamel contains more collagen. of the following represents) the matrix A Carboxyiglutamic acid containing proteins ‘Type | collagen ‘Amelogenins Proteoglycans Elastin moop ADH receptors in the nephron are located on the tubular membrane of which of the following? ‘A. Distal tubule B. Proximal tubule C. Ascending loop of Henle D. Descending loop of Henle130. 131. 132. 133. 134, |. Which of the following changes promotes the formation of extracellular edema? ‘A Increase in tissue fluid hydrostatic Pressure B. Increase in plasma protein ‘concentration Decrease in capillary hydrostatic pressure Capillary fitration exceeds capilary absorption E. Capillary absorption exceeds capillary fitration 99 In addition to phosphoric acid, which of the following are the products of hydrolysis of lecithin? Glycerol, fatty acids, serine Glycerol, fatty acids, choline ‘Sphingosine, acetic acid, inositol Gilyceraldehyde, fatty acids, choline Glyceraldehyde, faty acics, ethanolamine moog> Which of the following BEST characterizes hydroxyapatite? A Has an amphiphilic surface 8. Contains 12 ions per unit cell C. As found in bone and enamel contains no ion substitutions D. Has 2 higher solubilty product constant than fluoroapatite Polyuridylic acid in a cell-free system capable of protein synthesis results in production of polyphenylalanine. In this system, polyuridylic acid functions as DNA. transfer RNA, messenger RNA. ribosomal RNA. mitochondrial RNA, moop> A derivative of vitamin K is the coenzyme for which of the following? Production of menadiol Esterification of retinol Hydrolysis of peptide bonds Cross-linking of fibrinogen Carboxylation of glutamate side chains moom> 18 135. What single substance is effective in reversing ketosis in a non-diabetic patient? Urea Glucose Insulin Leucine Palmitic acid moom> 136. Intensity of sound is dependent mainly on which of the following physical characteristics of sound waves? A Frequency 8. Amplitude CC. Wavelength D. Secondary waves E. Sympathetic vibrations 137. ATP inhibits phosphofructokinase even though ATP also is a substrate for the ‘enzyme. Which of the following types of inhibitions BEST explains this phenomenon? A Allosteric B Competitive ©. Irreversible ©. Uncompetitive E. Noncompetitive 138. Which ofthe folowing BEST explains why proteins are abie to buffer physiologic solutions over a wide range of pH? ‘A They are macromolecules of high molecular weight B. They contain many functional groups with differing pks. ©. They have unique tertiary structures that sequester hydrogen ions. ©. They have peptide bonds that are resistant to hydrolysis. 139. The intrinsic factor for vitamin B,, absorption jis produced in the A liver. 8. stomach, C. pancreas. D. duodenum, E. lacteals140. 141, 142. 143. 144, 145. Which of the following bonds link the ‘monomeric units of nucleic acids? A onic B. Peptide C. Thicester D. Glycosidic E. Phosphodiester Decreased response of sense organs when exposed to a constant stimulus is called occlusion. summation. adaptation. facilitation. sensory deprivation. moom> Emotional feelings are MOST closely related to which area of the brain? Thalamus Brain stem Cerebellum Hypothalamus Limbic system moom> Each of the following is @ glycosaminoglycan EXCEPT one. Which one is this EXCEPTION? Chondroitin sulfate Dermatan sulfate Hyaluronic acid Heparan sulfate keratin moos» ch te vn inet ae vs pe on i rons, rage OR Lee, Pay onde: coarse A 5 c. D. E Each of the following describes hyaluronate EXCEPT one. Which one is this EXCEPTION? Polyanion Highly polar Glycosaminoglycan Compact, folded structure Extracellular matrix component moom> 18 146, 147. 148. 149. 150. Glutamate decarboxylase, an enzyme that catalyzes the formation of gamma-amino butyric acid (GABA), is unique to bone. skin. heart muscle. nervous tissue connective tissue, moom> The largest amount of body water can be found in which of the following? Urine Blood plasma Intracellular fluid Interstitial uid Stomach and intestines moos> ‘MOST fluid reabsorption by the kidney occurs in which ofthe following? ‘A. Distal tubule 8. - Proximal tubule C. Collecting duct D. Ascending loop of Henle Descending loop of Henle ‘Which of the following portions of the cardiovascular system contains the greatest volume of blood? Arterioles Capillaries Systemic veins ‘Chambers of the heart Pulmonary vasculature moom> Each of the following enzymes functions in ‘association with a membrane EXCEPT one. Which one is this EXCEPTION? Succinate dehydrogenase Na" /K: ATPase Adenylate cyclase Phosphofructokinase Coenzyme Q reductase moom>151. Which of the following generates a slowly developing long-term response in target tissues by binding to an intracellular receptor? Glucagon Estrogen Prolactin Growth hormone Parathyroid hormone moom> 182. Which of the following functions as part of the extracellular matrix? Mucin Heparin Collaginase Chondroitin sulfate Dolicho! phosphate moo@> 153. Which of the following represents the pH of solution that has @ 10°M concentration of OH ion? A 5 B 7 c 98 1D. Determinable only ifthe pk, is known, E. Determinable only ifthe base composition is known. 154. Compared to slow-twitch (Type I) muscle fibers, each of the following is more characteristic of fast-twitch (Type I) muscle fibers EXCEPT one. Which one is this EXCEPTION? ‘A They contain more mitochondria, B. They have higher myosin ATPase activity ©. They have fewer capillaries surrounding them. D. They have a more extensive sarcoplasmic reticulum, E. They contain higher concentrations of alycolyticenzymes. 185. Which ofthe following is MOST likely to cause respiratory acidosis? ‘A. Moving from high altitude to sea level B. Untreated diabetes melits ©. Hypoventiation D. Kidney failure Vomiting 20 156. Hydrolysis of sucrose by the enzyme sucrase yields ‘A. glucose only, B. glucose and maltose. ©. glucose and fructose. D. glucose and galactose. E. fructose and mattose, 187. Calcium ions initiate contraction in skeletal muscle when they A bind to T tubules. B. _ bind to troponin. C. interact with actin, D. interact with myosin, E. bind to sarcoplasmic reticulum, 188. Which of the following enzymes converts ‘rypsinogen to trypsin? A. Enterokinase B. Peptidase C. Secretin D. Pepsin 159. Enzymes that catalyze the anaerobic Processes of carbohydrate metabolism are found predominantly in which part of a cell? A. Cytoplasm 8. Membrane ©. Cell wall D. Nucleus E. Mitochondria 160. Each of the following characterizes a peptide hormone EXCEPT one. Which one is this EXCEPTION? A. Stored in secretory granules B. Synthesized in a precursor form C. Binds to intracellular receptors D. Acts by generating a second messenger Usually transported unbound in plasma m161. Which of the following substances represents an unsaturated fatty acid? A Cholesterol B. Palmitate C. Stearate D. Choline E. Oleate 162. Which ofthe following acids represents both a product of bacterial glycolysis and is cariogenic? A Lactic B Acetic ©. Succinic D. Propionic E, Phosphoric 163. What linkages occur in glycogen at branch points between glucose units? Alpha-t.4 Alpha-1,6 Beta-1,3, Beta-1.4 Beta-1.6 moom> 164. Protein kinase regulate the activities of key enzymes through which of the following? Oxidation Hydrolysis Acetylation Phosphorylation Dephosphorylation moom> 165. Regulation of each of the following mechanisms is associated with the hypothalamus EXCEPT one. Which one is this EXCEPTION? Sleep Water balance Body temperature Pupillary diameter Carbohydrate metabolism moom> a 166. 167. 168. 169. Each of the following represents an amino ‘acid found in proteins and used directly in the reactions of protein synthesis EXCEPT one. Which one is this EXCEPTION? Proline Aginine Tryptophan Asparagine Hydroxyysine moopm> For a reaction catalyzed by an enzyme with a k, = 1 mM, which of the following represents the effect on the velocity if [] is changed from 10 mM to 20 mM? (Assume that the enzyme obeys Michaelis-Menten kinetics.) ‘Small decrease ‘Small increase Twotold decrease Twotold increase ‘Twentyfold increase moom> Each of the following is an effect of parathyroid hormone EXCEPT one. Which one is this EXCEPTION? ‘A. Stimulation of 1-alpha-hydroxylase in kidney B. Stimulation of osteoclastic activity in bone C. Stimulation of calcium reabsorption by kidney . Inhibition of phosphate reabsorption by kidney E, Inhibition of intestinal absorption of calcium Which of the following iver enzymes, absent from other tissues, gives the liver an advantage over other cells in taking up glucose after a meat?’ A Glucokinase B. Aldolase C. Hexokinase D. Enolase E. Glucose-6-phosphatase170. In which of the following conditions might the 471. 172. 173. 174, systolic blood pressure be abnormally high? ‘A Cardiac shock B. Hear failure C.Anaphylactic shock D. Decreased arterial compliance E. Ventricular fibrillation hich of he following occurs priariy in ais and is characterized by nreased airway resistance, decreased difusing Capecty ofthe lng, and croniefpemanga hypoxia? e- gco® Asthma Emphyse 430° Hyalin membrane disease moom> The concentration of which of the following ‘amino acids can be used as an estimation of the amount of collagen present in a tissue? A Hydroxyproline B. Aspartic acid C. Proline D. Serine I the air temperature is 105°F and the relative humidity is 10 percent, then which of the following represents the primary cause for loss of body heat?” ‘A Evaporation B. Conduction ©. Convection D. Radiation E.Hyperventiiation Which of the following hormones is released by the zona fasciculata and exerts permissive actions to allow insulin, glucagon and ‘epinephrine to work more effectively at their target tissues? A Androstenedione 5. Somatomedin ©. Aldosterone D. Thyroxine E. Cortisol 22 175. 176. 177. 178. 179. Which of the following enzymes or processes ensures that the correct amino acid is incorporated for a particular codon during protein synthe: A Amino Acyl-RNA synthetase 8. Ribosomal protein synthesis CC. Post-transcription splicing D. RNA synthetase E. Helicase If protein is catabolized for energy, then MOST of the energy is derived from which of the following? {Urea production Oxidative deamination Transamination reactions Cleavage of peptide bonds (Oxidation of c-Keto acids derived from ‘amino acids moom> Each of the following lipid classes is incorporated into membranes EXCEPT one. Which one is this EXCEPTION? Cholesterol Ganglioside Triglyceride Sphingomyetin Phosphatidyichotine moom> ‘The amplitude of an action potential can be increased MOST easily by increasing which of the following concentrations? ‘A. Intracellular sodium 8. Extracellular sodium ©. Intracellular chloride D. Intracellular potassium E. Extracellular potassium Decreased arterial pressure upon standing is compensated by A decreased heart rate B. dilation of mesenteric vessels. ©. constriction of systemic arterioles. D. dilation of venules.180. Synaptic vesicle contents are released at the 184. Each of the following combinations lists the neuromuscular junction when which of the ‘name of the hormone, its chemical type, and following occurs? its major tissue of origin EXCEPT one. Which fone is this EXCEPTION? ‘A. Hyperpolarization of motor end-plate B. Shortening of skeletal muscle Hormone Chemical ‘Tissue C. Release of ATP from nerve terminal Type D. Entry of calcium at nerve terminal E. Release of acetyicholine from motor A ACTH Steroid Adrenal end-plate cortex B. Vasopressin Peptide Posterior pituitary ©. Epinephrine Catecholamine Adrenal medulla D. Thyrotropin Glycoprotein Anterior 181. Which ofthe following characterizes exergonic pituitary reactions? E. Somatostatin Peptide Hypothalamus A. Decreased entropy B. Increased enthalpy ©. Decreased enthalpy D. Negative free energy change E. Positive free energy change 185. Which of the following causes activation of the pyloric pump, relaxation of the pylorus, and ‘contraction of the lower esophageal sphincter? A Gastrin 8. Secretin ©. Pepsinogen D. Acetychotine 182. In an aqueous solution at pH 7, a peptide E, Cholecystokinin containing 1 amino group side chain and 2 carboxy! group side chains would have which of the folowing net charges? A 2 Boot 186. An animal is in negative nitrogen balance if its co Dot A urine is nitrogen-free BD B. trogen intake equals output ©. trogen intake exceeds output D. nitrogen output exceeds intake now tissue is being synthesized 183. A subject consumes 250 mi of oxygen per minute wih a tidal volume of 400 mi and a respirator rate of 18 per minute. Which ofthe following represents this subject's respiratory 187. Each of the following can cause glucosuria minute volume In Hers? EXCEPT one. Which one is this EXCEPTION? A 18 neve Ty RE ‘A Low insulin tevel B45 B. High blood sugar level c. 54 ©. Impaired tubular reabsorption D. 72 D. High glomerular fitvation rate E 100 E. High renal threshold for glucose188. The clearance rate for a substance that is completely removed from the blood during fone pass through the kidney is equal to which 192. Which of the following represents the major force that causes glomerular filtration? of the following? ‘A Tubular hydrostatic pressure B. Tubular colloid osmotic pressure A Renal plasma flow C. Glomerular capillary hydrostatic B. Filtration fraction pressure C. Urinary excretion rate D. Glomerular capillary colloid osmotic D. Glomerular fittration rate pressure E, Tubular transport maximum 193. Ifthe plasma clearance of a substance which is trely fitered is less than that of inulin, then 189, A marked fall fom normal in the oxygen tension in arterial blood would stimulate the A the substance becomes bound to receptors in the protein in the tubules. B. there is net secretion of the substance ‘A central nervous system inthe tubules. ‘chemoreceptors. ©. there is a net reabsorption of the B. aortic arch and the carotid sinus, substance in the tubules. C. aortic and carotid bodies. D. the substance is neither secreted nor D. walls of the great veins. reabsorbed in the tubules. . E, respiratory center. E. the substance is secreted in the proximal tubule to @ greater degree than its in the distal tubule. 190. Oxygen tension is GREATEST in which of the following blood vessels? 194, Hypoactivity of the posterior pituitary gland A Aorta leads to 8. Pulmonary vein ©. Pulmonary artery A dwarfism, D. Coronary artery 8. cretinism E. Goronary vein C. acromegaly. D. diabetes insipidus. 181. Which of the following groups includes only 195. The metabolite, 25-nydroxycholecaleierol, is amino acids essential for humans? derived MOST immediately from ‘A. Valine, serine, leucine A ergosterol B. Leucine, lysine, glycine B. cholesterol €. Tyrosine, threonine, tryptophan ©. 7-dehyaro-sitostero D. Phenylalanine, methionine, proine D._ 7-dehydro-cholesterol E_ Tryptophan, methionine, isoleucine E. 22-dihydro-ergosterol 28196. In a complete heart block, the tlectrocardiograph shows which of the following? A Anincreased PQ interval B. _Anincrease in height of the P wave C. One QRS complex for every three P waves D. An increase in amplitude of the QRS. complex E. Dissociation of the P wave and the QRS complex. 197. Cardiac output is expressed as a product of stroke volume and heart rate. venous pressure and heart rate. stroke volume and respiratory rate. stroke volume and diastolic filing venous pressure and coronary blood flow. moom> 198. MOST of the CO, in blood is combined as moom> carbaminohemoglobin. 199. A deficiency of choline in the diet can cause ‘abnormalities in the metabolism of lipids. proteins. minerals. carbohydrates. ‘nucleoproteins. moop> 200. Which of the following is a function of the enterogastric reflex? A Decreases the opening of the gastroesophageal sphincter Increases motility of the esophagus Decreases motility of the stomach Increases motility ofthe ileum Increases gallbladder emptying moom 25RELEASED NATIONAL BOARD DENTAL EXAMINATIONS PART 1 TEST: BIOCHEMISTRY-PHYSIOLOGY FORM: 12 DATE: D96 vawon E A c D E D D D A A D E A c B oveww vom voaom >puo>m O>o>m - indicates item not scored 26Biochemistry/Physiology Released 1997 NDB-1 BIOCHEMISTRY/PHYSIOLOGY RELEASED 1997 ANSWER KEY 1. Bi Ea, CL E18, D 102. E12 A M2 EB 162 A 182 D 103, C12 C M3, E163. B83, D 10, D124, B14, NA 168, D184. A 10s, B12. A 145, D6, D188. A 106. E126. D 146, D 166, E 186. D 107, A A, C67, BBD, 108, C128 C8, B16. EBB. A 109, D129, A M9. C16, A 18. C 10, E13, D150. D 17. D 190. B 1, BOIS, BOS BOIL NA LE 12 EB 13 D 18% D Im A 192 13 B13, C183. C1 A 18 4, Do 1M, ES, AI, E94. MS. D 1S. BOSS, COIS, A 98. —D 6B 136, B 156, © 176 E 196. E 7, Bo, A187, BOT, © 197, A 18 C138 BB O1SK A 78, BOS, 119. B13, BOS. A 17, 99. A m0. C 140, E160, C 180, D200. C KAPLAN 5NDB-1 NDB-1 BIOCHEMISTRY/PHYSIOLOGY RELEASED 1997 EXPLANATIONS. 101. The correct answer is Choice B. Tooth development and calcification are similar to that of bone. They are affected by various factors of metabolism such as the availability of calcium and phosphate in the diet, and rate of secretion of thyroid, growth, and parathyroid hormones. Vitamins are also essential in the formation of teth. Vitamin A (Choice A) is necessary for normal growth and proliferation of epithelial cells, vitamin C (Choice C) activates prolyl hydroxylase which promotes normal formation of collagen, and vitamin D (Choice D) increases calcium absorption and helps control calcium deposition in hard tissues. Choice B, Vitamin By, is least likely tobe involved in tooth development since it functions as a cocarboxylase specifically needed inthe final metabolism of carbohydrate and amino acs. 102. The correct answer is Choice E. Lipoproteins are compounds containing both lipids and proteins. Serum LDL or low density lipoproteins are intermediate-density lipoproteins with a high concentration of cholesterol, moderately high concentration of phospholipids, and minimal amount of triglycerides. Their primary function is to transport their lipid components, cholesterol, cholesterol esters, and phospholipids from the liver to the peripheral tissues (Choice E). Choice A through D are all incorrect since serum LDL does not perform functions described in those choices. 103. The correct answer is Choice C. The fuid-mossic model for embryological membranes was proposed in 1972. This model suggests that membranes are made up of a bilayer of phospholipid molecules with their hydrophobic tails pointing toward the center of the structure where they interact with the hydrophobic tals of the opposing phospholipid layer. Integral proteins are found scattered in the hydrophobic phase of the bilayer (Choice C). These proteins may extend through the entire thickness of the membrane and they may also move freely within the plane of the phospholipid bilayer. Choice A is incorrect as the outer and inner faces of the membrane are not identical. The inner face as made up of the hydrophobic portion of the phospholipid molecules while the outer face is made up of the hydrophilic portion. Choice B is incorrect since membrane proteins may extend through to the outer face of the membrane but are not situated only on the outer surface. Choice D is also incorrect since the model contends that only the non-polar end of the phospholipid molecule stays within the hydrophobic phase of the bilayer. 104, The correct answer is Choice D. The isoelectric point is the pH reached when there is no net electric charge on a protein. In ‘other words, no migration of a protein in an electric field occurs during electrophoresis (Choice D) Choices A. B, C, and E do not describe isoelectric point. 105. The correct answer is Choice B. The absolute refractory period of a nerve action potential is the period during which an action potential cannot be elicited by any amount of excitatory stimuli, This occurs during closure of sodium channels inactivation gates (Choice B). When the inactivation gates of the sodium channels open, a new action potential can then be initiated. From the above discussion, choices A, C, and D are incorrect. 106. The correct answer is Choice E. When a muscle contracts, work is performed and energy is required for this process. The immediate source of energy is provided by the cleavage of adenosine triphophate (ATP) (Choice E) to form adenosine diphosphate (ADP). The concentration of ATP present in muscle fibers is limited and only sufficient to maintain full contraction for | to 2 seconds, As muscle contraction continues, creatine phosphate (Choice D) is used to rephosphorylate ADP to form new ATP. The amount of creatine phosphate, however, is also limited. It will carry the muscle contraction for another 3-5 seconds. Glycogen (Choice ‘A) is then used to reconstitute both ATP and creatine phosphate. So though both glycogen (Choice A) and creatine phosphate (Choice D) are important energy sources during muscle contraction, they are not the initial or immediate source of energy. Acetyl CoA (Choice B) reacts in the citric acid cycle to release large amounts of energy to convert ADP to ATP in the mitochondria. It is not, however, used by the muscle during its contraction. Lactic acid (Choice C) is an end product in the breakdown of glycogen. It is also not a primary energy sourrce. 107. The correct answer is Choice A. The human body is made up of 60 % fluid. It is distributed among two major compartments ‘The intracellular fluid is found inside cells, and extracellular fluid is found in between cells. Extracellular fluid in turn is divided into interstitial fluid and blood plasma. Intracellular fluid and interstitial body fluids differ significantly in composition but in homeostasis, they have similar total osmotic pressures (Choice A). Colloid osmotic pressure (Choice B) is caused by proteins present in plasma and interstitial fluid. It is normally not associated with inaceular fluid Sodium ion concentration (Choice C). and chloride ion concentration (Choice D), are much higher in interstitial uid Potassium ion concentration (Choice E), however, is much higher in intracellular fuid 7 ‘as developed by TARP RP RRP RP RRR RR RRR RRBiochemistry/Physiology Released 1997 108. The correct answer is Choice C. CO> has a direct effect on the respiratory center ofthe brain in controling respiration. Breathing a gas mixture with excess CO will stimulate control chemoreceptors (Choice C) to cause increased strength of pulmonary ventilation, thus reducing CO2 concentration by expiring greater amounts of CO out of the body. Choice A is incorrect as an excess amount of CO> will ultimately lead to hyperventilation as the lungs labor to rid the body of COp, Choice B is also incorrect as CO concentration in the blood can stimulate peripheral chemoreceptors especially at the onset of exereise. It will ot, however, inhibit peripheral chemoreceptors as stated in tis choice. Choice E is incorrectas excess CO can pass through the blood-cerebrospinal fluid barrie, react with water present to form hydrogen ions thus increasing the hydrogen ion concentration inthe cerebrospinal fluid. 109, The correct answer is Choice D. Ovulation is the first step in the female reproductive cycle when a single ovum is released from an ovarian follicle. Its triggered by a marked increase of luteinizing hormone (Choice D) secreted by the anterior pituitary gland. ‘The luteinizing hormone in turn causes a cascade of effects until the follicle ruptures with the discharge of the ovum. Estrogen, choice A, is incorrect as it has a strong feedback effect in the anterior pituitary gland to maintain low secretory rates of both FSH and LH. Estrogen is in fact used in oral contraceptives to suppress ovulation. Estradiol, Choice B, is one of the three estrogens presents in the human female. Itis also an incorrect choice as explained above, Progesterone, Choice C, is also incorrect as it promotes secretory changes of the uterine endometrium in preparation for implantation during the latter part of the reproductive cycle. Follicle stimulating hormone, Choice E, causes growth of the follicles before ovulation, but will not tigger ovulation. 110. The correct answer is Choice E. Foods from which the human body obtains nutrition can be classified into carbohydrates, fat, and proteins. These substances generally cannot be absorbed by the intestinal mucosa without the process of digestion. Carbohydrates, for example, are mainly large disaccharides and polysaccharides that must be hydrolyzed before they can be utilized by the enterocytes of the small intestine. Maltose (Choice E), @ disaccharide found in starch that must be split into its constituent monosaccharide before ican be absorbed by the enterocytes. Monoglycerides (Choice A) and fatty acids (Choice B) are the digestive end products of fat. They are both readily (glucose) absorbable by enterocytes. Fructose (Choice C) is one of the monosaccharides formed from digestion of ‘cane sugar. Iis already in a form that can be absorbed by enterocytes via facilitated diffusion Glycine (Choice D), an amino acid, can also be absorbed directly by enterocytes without further digestion 111. The correct answer is Choice B. In this question, the Key is ascorbic acid or vitamin C. Understanding the primary function of vitamin C will lead us to the correct answer. Ascorbic acid is an effective reducing agent that is essential for activating the enzyme prolyl hydroxylase. This enzyme in the presence of alpha-Ketoglutarate and oxygen promotes the formation of hydroxyproline, an Integral constituent of collagen. Collagen synthesized in the absence of vitamin C is weak and defective. The condition known as scurvy is marked by fragile blood vessels, skin lesions, cessation of bone growth, and failure of wounds to heal ‘Choices A, C, D and E do not require these substances for processing. 112. The correct answer is Choice E. Low density lipoproteins (LDL) are large spherical particles made up of a core of esterified cholesterol surrounded by a lipid bilayer containing protein. It is the primary source of cholesterol for cells outside of the liver and intestine. LDL are transported into cells by receptor-mediated endocytosis (Choice E). When cholesterol is needed, a cell synthesizes receptor proteins for LDL and inserts them into its plasma membrane. LDL binds to these receptors and is taken up by the cell during endocytosis. When too much free cholesterol is accumulated, the cell shuts off LDL receptor synthesis and thus stops the flow of cholesterol into the cell, ‘Choices A through D do not describe the pathway in which LDL is transported into a cell 113, The correct answer is choice B. After secretion, norepinephrine is removed from its secretory site in a number of ways. The majority of norepinephrine is retaken up by the adrenergic nerve endings via active transport. The remaining diffuses away into the surrounding body fluids and then into blood. If there is excessive intraneuronal free norepinephrine left, itis quickly destroyed by ‘monoamine oxidase present in the nerve endings themselves by deamination (Choice B). Choices A, C, and D do not describe norepinephrine metabolism. Choice E, methylation of norepinephrine. by catechol-O-methyl transferase occurs mainly in the liver so this choice is also incorrect. KAPLAN 7NDB-1 114, The correct answer is choice D. Using the oxygen dissociation equation for hemoglobin. where y is the fractional occupancy of oxygen binding sites, PSO is the partial pressure of oxygen at which 50% of sites are filled, and pO2, the partial pressure of unbound oxygen: (70,)" | Where n =2.8 for hemoglobin (02)" +(50)" * Plug in the given numbers, we get Y=0.6 or 60% of the sites of hemoglobin are bound. This can also be translated, for every hemoglobin, greater than 2 (Choice D) oxygen molecules are bound since the available hemoglobin is more than 50% saturated with oxygen. Choices A, B, C, and E are all numerically incorrect 11S. The correct answer is Choice D. The DNA molecule is a long double strand helix where alternating phosphoric acid and deoxyribose make up the backbone with purine and pyrimidine bases lying between the two strands connecting them. The purine base adenine always bonds with the pyrimidine base thymine on the complementary strand, and purine base guanine always binds with pyrimidine base cytosine. The bases are in turn bound together by hydrogen bonds. Adenine forms two hydrogen bonds with thymine ‘while guanine forms three hydrogen bonds (Choice D) with cytosine. Choices A, B, C and E are incorrect. 116. The correct answer is Choice B. Norepinephrine is synthesized and stored in vesicles located in the postganglionic sympathetic nerve endings (Choice B). Preganglionic sympathetic nerve endings (Choice A), preganglionic parasympathetic nerve endings (Choice C), and postganglionic parasympathetic nerve endings (Choice D) are all cholinergic because the neurosecretory transmitter for these neurons to acetylcholine. 117, The correct answer is Choice B. The human immune deficiency virus (HIV) is a retrovirus that causes AIDS. It is transmitted predominantly via infected semen during sex or by parenteral transfer of infected blood. Once in the blood stream, the virus selectively secks out T lymphocytes for growth. In the process of replication, the virus destroys the target cells, With time, a marked reduction in the total number of T-helper cells leads to the lack of immune response seen in persons with AIDS. At present azidothymine or AZT (Choice B) has been shown to have a significant effect in controlling HIV replication. Like all retroviruses, HIV depends on its reverse transcriptase for replication, and AZT inhibits HIV proliferation by inactivating its reverse transcriptase. Choice A, ATP or adenosine triphosphate is a high energy compound utilized by cells to activate intracellular metabolic reactions. ‘Choice C, dATP or deoxyadenosine 5'—triphosphate is also incorrect. Choice D, flurouracil is an antineoplastic agent effective in the management of carcinoma. It interferes with the synthesis of DNA and inhibits the formation of RNA which often leads to unbalanced growth and death of the cells. Flurouracil may affect normal cells but its target cells are those that grow rapidly such as neoplastic cells It has no effect on retroviruses. Choice E, methotrexate, is an antimetabolite used in the treatment of neoplastic disease. It also interferes with DNA. synthesis, repair and cellular replication. Actively proliferating cells such as malignant cells are generally more sensitive to this drug. Italso does not affect HIV, 118. The correct answer is Choice C. Of the hormones listed, only insulin (Choice C) conserves body protein, carbohydrates, and fat stores. It inhibits the breakdown of proteins in cells, causes carbohydrates to be stored as glycogen in liver muscles, and it stimulates fat storage in adipose tissue. Cortisol. Choice A, isa potent glucocorticoid that stimulates gluconeogenesis by the liver. It also reduces cellular protein and promotes mobilization of faty acids from adipose tissue. Glucagon is secreted by the alpha cells of the islets of Langerhans. Is primary function isto increase blood glucose concentration by stimulating breakdown of liver glycogen, and activation of adipose cell lipase making increased quantites of free fatty acids. These functions are opposite of insulin Somatotropin, Choice D. is also known as growth hormone. It promotes growth of almost all tissues of the body by conserving carbohydrates, enhancing body proteins, and increasing utilization of fat stores for energy. 119. The correct answer is Choice B. Cloning produces a population of cells with identical properties, These cells are the result of DNA cloning from a single parent cell. The process involves the insertion of a fragment of DNA into a plasmid or a bacterial virus and then growing these in bacterial cells. As the bacteria divide, the plasmid also replicates to produce an enormous number of copies Of the original DNA fragment. As gene cloning involves the replication of DNA material, an RNA polymerase (Choice B) responsible for RNA synthesis is not utilized. Choice A. a DNA ligase enables two DNA fragments to join by forming covalent phosphodiester bonds between them, Choice C. the DNA polymerase | catalyzes new DNA synthesis. TS as developed Byana gS mien Biochemistrs/Physiology Released 1997 Choice D, restriction nucleases are essential for cutting a specific section of DNA strand into a fragment to be used for cloning. Choice E, reverse transcriptase is used during replication to reproduce a complementary DNA strand from an RNA template. 120. The correct answer is Choice C. New bone is formed when fresh matrix consisting chiefly of collagen is laid down by osteoblasts, This matrix is rapidly converted into hard bone matrix by the deposition of calcium phosphate crystals. Osteonectin (Choice C). a bone specific protein, aids inthis process by providing sites for the growth of the calcium crystals and anchoring them to the oganic matrix. Its high affinity for binding calcium and collagen in the calcifying matrix enables osteonectin to carry out this important function, Calcitonin, Choice A, is a hormone secreted by the thyroid gland. Its primary function is to reduce plasma calcium concentration by increasing deposition of calcium in bone. It does not have a strong affinity to bind calcium to collagen. ‘Osteogenin (Choice B),a protein matrix of bone, and amelogenin (Choice D), a matrix protein of human enamel do not have high affinity to bind calcium and collagen. Fibronectin (Choice E) is a glycoprotein found in extracellular matrix. Its primary function is to promote cell adhesion. It does not, however, facilitate binding of collagen and calcium crystals. 121. The correct answer is Choice E. Glycolsis is a sequence of reactions that convert glucose into pyruvate with the production of ATP, an essential cellular energy source. The sequence of events in this metabolic pathway must be memorized. Aldolase, Choice E, catalyzes the splitting of fructose 1,6 diphosphate, a 6-carbon metabolite into two 3-carbon metabolites, dihydroxyacetone phosphate and glyceraldehyde 3-phosphate. Choice A, phosphoglucoisomerase brings about the isomerization of glucose 6-phosphate to fructose 6-phosphate. Choice B, phosphofructokinase catalyzes the phosphorylation of fructose 6-phosphate by ATP to fructose 1,6-diphosphate. Choice C, phosphorylase in general mediates the transfer of an inorganic phosphate group to an organic acceptor. It will not bring about the transition of a 6-carbon metabolite to a 3-carbon metabolite. Choice D, hexokinase facilitates glucose phosphorylation by ATP to form glucose 6 phosphate. This is the first step in alycolysis. 122. The correct answer is Choice A. Muscle tissues are divided into three classes based upon their histologic appearance and function. These are skeletal or striated muscle, visceral smooth muscle, and cardiac muscle. Cardiac muscle is also striated in appearance but its unique function warrants it in a class by itself. Of the three types of muscles discussed above, only cardiac muscle (Choice A) corresponds to all conditions stated in this question. ‘Skeletal muscle (Choice B) contains transverse tubules but does not have slow calcium channels. Skeletal muscles are not inhibited by acetylcholine, Smooth muscles (Choices C and D) do not have transverse tubules but posess numerous slow calcium channels. ‘Acetylcholine has a stimulating effect on smooth muscles. 123. The correct answer is Choice C. Tay-Sachs disease is a serious condition inherited as an autosomal recessive. The affected individual will manifest symptoms before a year old. Weakness, retardation in development, and difficulty in eating are typical of this condition. Tay-Sachs disease is usually fatal before the age of three. This deadly disorder is the result of greatly elevated levels of gangliosides (Choice C) in the brain. Gangliosides are complex sphinglolipids synthesized and degraded by sequential removal of their terminal sugars by glycosyl hydrolases. In Tay-Sachs disease, these specialized enzymes are either missing or deficient leading to abnormally high levels of ganglioside. Choice A polysaccharides are combinations of monosaccharides that make up a large portion of carbohydrates. These will not tigger Tay-Sachs disease. Choice B, acylglycerols are also incorrect Choice D, fatty acids are the digestive end product of fat. They will not cause Tay-Sachs disease. Similarly, elevated levels of protein (Choice E) will not cause Tay-Sachs disease. 124. The correct answer is Choice B. Of the following substances, only adenosine (Choice B) has a vasodilator effect on blood vessel smooth muscles. It is released from the tissue in response to Oxygen deficiency causing increased blood flow and oxygen concentration, Choice A hyperoxia, or an increased oxygen content in body tissues, will cause a local vasoconstriction in the blood vessels ‘and not vasodilation, Choice C vasopressin, or antidiuretic hormone, is mainly responsible for the retention of water in the body. In large concentrations, it will cause constriction of the blood vessels and elevate blood pressure. Choice D angiotensin is a powerful vasoconstrictor. Its primary role isto increase the total peripheral resistance in regulation of arterial pressure. KAPLAN @NDB-I Choice E norepinephrine is released by the sympathetic nerve endings during stress or exercise. Norepinephrine stimulates the veins and arterioles by constriction of these vessels. 128, The correct answer is Choice A. Fat is stored mainly in adipose tissues until required by the body to provide energy. It is transported to the other tissues in the form of faty acids. Upon leaving the fat cells of adipose tissues, fatty acids ionize strongly in the plasma and combine with albumin molecules (Choice A) of the plasma proteins, These bound fatty acids are then caried to various points ofthe body to be utilized for cellular energy. Choice B globulin, like albumin is also a plasma protein. Its main function, however, is to protect the body from invading organisms and not transporting fatyaci ‘Choice C cholesterol is an important lipid present in the diet, These are mainly converted by the liver into cholic acid which in conjunction with other substances form bile salts. Bile salts ae essential in digestion and absorption of fa. Choice D sphingolipids refer to any lipid containing @ long chain base. These include gangliosides (mentioned in question 123), sphingomyelin etc. They are not associated with free fatty acid transpor. Choice E mucopolysaccharides are complexes containing proteins and polysaccharides. These are also not associated with free fay acid transport 126. The correct answer is Choice D. Oxidative phosphorylation takes place in the mitochondria. It is a process by which a majority of the ATP used in aerobic organisms is produced. This occurs when NADH or FADH formed in glycolysis, fatty acid ‘oxidation and the citric acid cycle transfers electrons to molecular oxygen by a series of electron carriers. Oxidative prosphorylation is then coupled by a proton gradient using energy from electron transfers (Choice D). ‘Choices A, B, C and E do not provide energy for this proton gradient. 127. The correct answer is Choice A. Enamel covers the outer surface of the tooth. It has a highly mineralized crystalline structure with 95% to 98% of inorganic matter by weight. Enamel contains very large and very dense hydroxyapatite crystals that are larger and ‘more firmly packed than crystals of bone (Choice A). This characteristic of enamel makes it the hardest substance in the human body. Choices B, C, D, and E do not explain enamel’s unique hardness. 128. The correct answer is Choice C. As discussed in question 127, the human tooth enamel is made up of approximately 95-98% of inorganic matter by weight. The remaining structure is composed of an organic matrix and water, Protein such as amelogenin (Choice C) is formed in the matrix. Choice A, carboxylglutamic acid containing protein, is not found in enamel. Choice B, type 1 collagen, is found in skin, tendon, bone and cornea but does not represent matrix protein of enamel. Choice D proteoglycans along with extracellular fluid make up the ground substances in bone. Choice E elastin is also a connective tissue protein. It is the major component of elastic fibers that can stretch to several times their length. Large amounts of elastin are found in the walls of blood vessels and ligaments. It is not present in enamel, 129. The correct answer is Choice A. The nephron is the functional unit of the kidney. It is organized into different components, ‘each with specialized functions. ADH receptors are located on the distal tubule (Choice A) portion of the nephron. The distal tubule is responsible for the reabsorption if ions such as sodium, potassium, and chloride. Under the influence of ADH, the distal tubule can also dilute or concentrate the urine by regulating the amount of water entering into its lumen, Choice B, proximal tubule, functions mainly in the reabsorption of glucose, No ADH receptors are present in this segment of the nephron. Choice C, ascending loop of Henle, is virally impermeable to water and it's also responsible for reabsorption of ions. Choice D the descending loop of Henle is highly permeable to water and functions mainly to allow simple diffusion of substances through its walls. Like the absorption part of the loop, it does not posess ADH receptors. 130. The correct answer is Choice D. Extracellular edema occurs when an excess amount of fluid is accumulated in the extracellular tissue space. This is most often the result of capillary filtration exceeding capillary absorption (Choice D).. Choice A. an increase in tissue fluid hydrostatic pressure, and Choice B, an increase in plasma protein concentration, will not cause ederna Choice C an increase not a decrease in capillary hydrostatic pressure may cause edema, Choice E capillary absorption exceeding capillary filtration will definitely not cause edema, but rather the opposite, 131. The correct answer is Choice B. Lecithin is an important phospholipid present in liver bile. It facilitates emulsification of fat in the digestive process. Upon hydrolysis, lecithin yields phosphoric acid, glycerol, choline, and two molecules of fatty acids (Choice Bp Choices A.C, D, and E are incorrect as lecithin will not hydrolyze into these products, 20 «as developed byBiochemistry/Physiology Released 1997 132. _ The correct answer is Choice D. The enamel of human teeth has a highly mineralized crystalline structure with hydroxyapatite salt as its principal component. Other minerals and trace elements are present in smaller amounts, The remainder of the enamel is made up of an organic matrix and water. In the presence of fluoride, fluoroapatite is precipitated from calcium and phosphate ions present in saliva and replaces the more soluble salts in enamel. This results in a more acid resistant enamel surface because fluoroapatite has a ower solubility product constant than hydroxyapatite (Choice D). Choices A through C do not characterize hydroxyapatite crystals. 133." The correct answer is Choice C. In a landmark experiment the addition of polyuridylic acid to a cell-free, protein synthesizing system resulted in the synthesis of polyphenylalanine. This experiment led to the breaking of the genetic code. In this instance, polyuridylic acid served as a messenger RNA (Choice C). ‘Choices A, B, D and E are all incorrect as explained above. 134. _ The correct answer is Choice E. Vitamin K is essential for the normal synthesis of prothrombrin and several other cloting factors in the liver. It acts as a coenzyme for the carboxylation of glutamate side chains (Choice E) into 8 - carboxyglutamate, Without this vitamin K-independent carboxylation reaction, the prothrombin formed does not bind Ca? and may result in hemorrhage and death. Choice A through D are incorrect as vitamin K is not the coenzyme for any of the reactions listed. 135. The correct answer is Choice B. Ketosis refers to a condition with elevated concentration of ketone bodies in the blood and interstitial fluid. It occurs most often in starvation and in diabetes mellitus. Ketosis in a non-diabetic patient is the result of ‘carbohydrate depletion from lack of intake. This leads to lessened availability of glucose which triggers a series of events that progress 10 excessive fat utilization and conversion of fat breakdown products to ketone bodies. The single most effective substance in reversing. ketosis in this case is, therefore, the administration of glucose (Choice B) to stop fat breakdown, Choice A urea is the principal end product of nitrogen metabolism in the human body. It is excreted in the urine. Urea will not reverse ketosis. Choice C insulin will reverse ketosis in patients with diabetes mellitus by increasing utilization of glucose and decreasing abnormal fat metabolism. It will not, however, reverse ketosis in a non-diabetic patient. Choice D leucine is an essential amino acid. It will not reverse ketosis in any patient. Choice E palmitic acid is a fatty acid present in triglycerides. It also will not reverse ketosis 136. The correct answer is Choice B. The intensity of sound detected by the human ear depends mainly on the amplitude (Choice BB) of sound waves. The amplitude is the maximum displacement of a sound wave. Choice A frequency is defined as the number of sound wave cycles per unit of time. It is not a measure of intensity. Its a measure of pitch. Choice C wavelength is the distance between one point on a sound wave to the next point in the same phase. Again itis not detected as sound intensity by the ear. Choice D secondary wave results when a second sound wave is added to an existing wave. The human ear is capable of hearing ‘and interpreting these as the original frequencies. Again, it does not determine how loud the sound is. ‘Choice E sympathetic vibrations are not a measurement of intensity of sound waves. 137. The correct answer is Choice A. Phosphofructokinase is the most important control element in glycolysis. In turn, itis, controlled by high levels of ATP via allosteric inhibition (Choice A). Phosphofructokinase is therefore most active when the cell needs energy as signaled by a low ATP level. When ATP is abundant, phosphofructokinase is nearly inactivated and glycolysis is switched off Choices B, C, D, and E are all incorrect. 138. The correct answer is Choice B. Proteins are composed of amino acids. An amino acid consists of an amino group, a carboxyl ‘group, a hydrogen atom, and a side chain. These side chains which total twenty in all differ in size, shape, charge, hydrogen bonding capacity, and chemical reactivity. The diversity and versatility of these twenty unique groups give proteins their wide range of functions. Similarly, these side chain groups also give proteins the ability to buffer physiologic solutions over a wide range of pH. From the discussions above, Choice B, they contain many functional groups with differing pHs, is the correct answer, Choices A, C and D are not the best explanations for this question 139, The correct answer is Choice B. Vitamin By? is essential for the final maturation of red blood cells. A deficiency will lead to pernicious anemia. This condition is most often caused by poor absorption of vitamin B,2 from the gastrointestinal tract as a result of gastric atrophy or achlorhydria. The normal gastric secretions contain a glycoprotein known as intrinsic factor. It is secreted by parietal cells ofthe stomach (Choice B) and must be present for adequate absorption of vitamin By2. KAPLAN aNDB-1 ‘The intrinsic factor is not produced in iver (Choice A), pancreas (Choice C), duodenum (Choice D) or lacteals (Choice E). 140. The correct answer is Choice E. The monomeric units of nucleic acids which form the backbone of DNA are linked together by phosphodiester bonds (Choice E). The 3-hydroxyl of the sugar of one deoxyribonucleotide is joined to the S'-hydroxyl of the adjacent sugar by a phosphodiester bridge. Choices A through D are incorrect. 141. The correct answer is Choice C. A common characteristic that applies to all sensory organs is that their response to @ constant stimulus decreases after a period of time. This special trait is known as adaptation (Choice C). Adaptation occurs in all sensory receptors but to different extents and by different mechanisms. Choice A occlusion as a general term refers to the act of closing or the state of being closed. It does not describe sensory organ response to stimuli Choice B summation often refers to the additive effect of frequent repetitive stimuli applied to nerve terminals to achieve ‘excitation. Again, it does not involve sensory organs or their response Choice D facilitation is the enhancement or reinforcement of a nervous activity by the arrival of signals from other neurons. Choice E sensory deprivation occurs when some or all usual external stimuli are absent. It will often result in psychological stress and abnormal behavior. It also does not apply to sensory receptors response to stimuli. 142. The correct answer is Choice E. Emotional drives, motivation, and behavior are most closely associated with the limbic system of the brain (Choice E). It is located in the midbasal region of the brain. Choice A thalamus, located in the lower region of the brain, contributes to the subconscious activities of the body such as control of blood pressure and respiration, Choice B the brain stem consists of the medulla, pons, and mesencephalon. It is concerned with the motor and sensory functions forthe face and head regions. Choice C the cerebellum lies above the pons and medulla and is chiefly responsible for motor coordination and body equilibrium. Choice D the hypothalamus is important in the control of autonomic body functions to maintain homeostasis. 143. The correct answer is Choice E. Glycosaminoglycans are the polysaccharide chains of proteoglycans. They are made up of disaccharides in repeating units containing either glucosamine or galactosamine. On at least one of the sugars in the disaccharide, a negatively charged carboxylate or sulfate group is present. Of the following choices, only keratin (Choice E), a fibrous protein, found in hair and nails, does not belong to the glycosaminoglycan family. 144, Not scored. 14S. The correct answer is Choice D. Hyaluronate or hyaluronic acid is synthesized in the golgi apparatus. It is a polyanion (Choice A) with a high polarity (Choice B). It belongs to a group known as glycosaminoglycans (Choice C) which are the principal ‘components of the organic matrix in both cartilage and bone (Choice E). Structurally, hyaluronate is a very long filament that is not ‘compact or folded (Choice D). 146. ‘The correct answer is Choice D. GABA is a neurotransmitter secreted by nerve terminals in the spinal cord, cerebellum, basal ganglion and many areas of the cortex. Its function is almost always inhibition of nervous excitation. GABA is formed by the ‘decarboxylation of glutamate catalyzed by glutamate decarboxylase, an enzyme that is unique to the nervous tissue (Choice D). Choices A, B, C and E are incorrect as glutamate decarboxylase is not found in those tissues 147. ‘The correct answer is Choice C. The human body is made up of 50 to 60% of water by total body weight. Most of this water is found in intracellular fluid (Choice C) which constitutes approximately 33% of total body weight. ‘The amount of water in urine (Choice A) is variable. It depends on a-number of factors, including the amount of fluid intake, and the amount that is reabsorbed. It does not account, however, for the largest amount of body water. Choice B body plasma contains only ~4.5% of water by total body weight. Choice D interstitial fluid accounts for approximately 27% of water by weight, It is the source of the second largest quantity ‘of water found in the body. Choice E stomach and intestines also contain a substantial amount of fluid but do not have the largest quantity. 148, The correct answer is choice B. The nephron is the functional unit of the kidney. It consists of two main parts. The ‘glomerulus portion through which large amounts of fluid are filtered from the blood, and the tubule portion in which the filtered fluid from the glomerulus is converted into urine. Fluid absorption by the kidney occurs in the tubule portion of the nephron. This section is further divided into segments each with a special function 2 ‘as developed byBiochemistre/Physiology Released 1997 ‘The proximal tubule (Choice B) has the highest capacity for fluid reabsorption. In fact, most of the fluid reabsorbed by the kidney occurs here. “The distal wbule (Choice A) is mainly responsible for reabsorption of ions. It is virtually impermeable to water and urea. ‘The collecting duct (Choice C) is the terminal segment of the nephron tubule system. It reabsorbs less than 10% of filtered ‘The ascending loop of Henle (Choice D) is also virtually impermeable to water. It is chiefly concerned with reabsorption of solute, ‘The descending loop of Henle (Choice E) is highly permeable to water and moderately permeable to most solutes. It, however, only reabsorbs about 20% of the filtered water, far less than the proximal tubules, 149. The correct answer is Choice C. The greatest volume of blood by far is contained in the systemic veins (Choice C). It comprises 64% of blood in the systemic circulation, The veins serve as a major reservoir of blood for the body along with their Jmportant function as conduits for transport of blood from tissues back to the heart. ‘The arterioles (Choice A) and capillaries (Choice B) carry approximately 7% of the blood. ‘The chambers of the heart (Choice D) also contain 7% of the blood. ‘The pulmonary vasculature (Choice E) holds 9% of blood volume. 150. The correct answer is Choice D. Of the enzymes listed, only phosphofructokinase (Choice D) is not associated with a ‘membrane. Phosphofructokinase, an important regulating enzyme, is found in the cell cytosol where glycolysis takes place. Choice A, succinate dehydrogenase, an enzyme in the citric acid cycle, is an integral part of the inner mitochondrial membrane. Choice B Na*/K* ATPase is associated with the plasma membrane. It facilitates the transport of Na* and K* across plasma membrane. Choice C adenylate cyclase is also bound to the plasma membrane. It catalyzes the synthesis of cyclic AMP. Choice E coenzyme Q reductase is an integral part of the inner mitochondrial membrane. It is an enzyme involved in ‘oxidative phosphorylation, 151. The correct answer is Choice B. OF the following hormones, only estrogen (Choice B) binds to protein receptors inside the Cell, notin the cell membrane. The combined hormone-receptor complex then activates the DNA strands of the cell nucleus generating. a slowly developing long term response in target tissues. Glucagon (Choice A), prolactin (Choice C), growth hormone (Choice D) and parathyroid hormone (Choice E) combine with specific membrane receptors of the target cell causing an activation of a cascade of enzymes inside the cell membrane to stimulate target functions. 152, The correct answer is Choice D. Of the following, only chondroitin sulfate (Choice D) functions as part of the extracellular matrix. It isa proteoglycan that acts as a filler between collagen fibers and cells, Chondroitin sulfate is also a principal component in the organic matrix of bone and cartilage. ‘Mucin (Choice A) isa mucus secretion produced by salivary glands that acts as a lubricant for surface protection Heparin (Choice B) is a powerful anticoagulant produced mainly by the basophilic mast cells located in the pericapillary connective tissues. Collagenase (Choice C) is an enzyme that catalyzes the hydrolysis of collagen. It is not a functional part of normal extracellular matrix Dolichol phosphate (Choice E) is a very long chain lipid that acts as a carrier for oligosaccharide. 153, The correct answer is Choice C. The pH of a solution is the measure of its hydrogen ion (H+) concentration. In this question, however, we are given the hydroxyl ion (OH-) concentration, Using the equation for ionization of water: H*] [on] where Kw is the ion product of water and H* and OH- are expressed in molarity. *] iio]NDB-1 1x10 m=H* we find H* = 1x10 m to convert H* concentration to pH: pit=—og [a] pit==tog[110%x] pH=9 9. So the correct answer is Choice C ph 154, The correct answer is Choice A. All muscles are composed of a mixture of slow-twitch (type I) fibers and fast-twitch (type 11) fibers. The fast fibers are capable of rapid and powerful muscle contraction such as for jumping and running. The slow fibers are more adept at prolonged and continued muscle activity such as the support of the body itself against gravity. (Of the following characteristics listed, only Choice A, they contain more mitochondria, is a description of slow-twitch muscle fibers instead of the fast-twitch muscle fibers. Choices B, C, D and E are all characteristic of the fast witch (type I) fibers. 155, The correct answer is Choice C. Respiratory acidosis is a condition caused by retention of CO> due to abnormal or inadequate pulmonary ventilation. This may be a result of pathologic conditions that damage the respiratory centers in the brain or that decrease the lung's ability to eliminate CO2 such as obstruction or pneumoni Of the following choices, hypoventilation (Choice C) is the most likely cause of respiratory acidosis as discussed above. Inadequate pulmonary ventilation increases H2CO3 and hydrogen ion concentration in the blood resulting in acidosis. ‘Moving from high altitude to sea level (Choice A) will not cause respiratory acidosis. Respiratory alkalosis, however, may ‘occur when a person ascends from sea level to high altitude Untreated diabetes mellitus (Choice B) may result in acidosis but it is caused by pathologic levels of insulin and not by an abnormality in respiration. Kidney failure (Choice D) can lead to acidosis resulting from failure of the kidney to eliminate acidic products from the body. Itis also not a cause of respiratory acidosis 156. The correct answer is Choice C. Sucrose is a common disaccharide present in table sugar. When hydrolyzed by sucrase, sucrose yields glucose and fructose (Choice C). Choices A, B.D and E are not products of sucrose. Maltose will hydrolyze to 2 glucose molecules, while lactose hydrolyzes to glucose and galactose. 157, The correct answer is Choice B. Calcium ions bind strongly to troponin (Choice B) changing the condition between troponin- ‘tropomyosin complex and actin inthe relaxed mascle state to produce a new relationship that leads to muscle contraction. ‘T-tubule (Choice A) facilitates transmission of action potentials to all skeletal muscle fibers. It does not bind with calcium Calcium ions also do not bind with actin (Choice C) or myosin (Choice D). Actin must attach to the heads of the myosin filaments to cause contraction. ‘Sarcoplasmic reticulum (Choice E) releases calcium ion in the vicinity ofall myofibrils to bring about contraction 158, The correct answer is Choice A. Trypsin is a powerful proteolytic enzyme present in pancreatic secretions. It aids in the digestion of proteins. When synthesized in the pancreatic cells, the proteolytic enzyme is in its inactive form trypsinogen. It is important for the enzyme to remain inactive as it will digest the pancreas itself. Trypsinogen is activated to trypsin only after it is released into the intestinal tract by enterokinase (Choice A). Enterokinase is secreted by the intestinal mucosa when chyme comes into contact with the mucosa, Peptidase (Choice B) is an enzyme present in the microvilli of the small intestine capable of splitting large polypeptides into their components 2 “as developed by a a orBiochemistry/Physiology Released 1997 Secretin (Choice C) is a hormone secreted by duodenal and jejunal mucosa in response to high acid content in the small intestine. This hormone in turn stimulates pancreatic secretion of sodiuin bicarbonate. Pepsin (Choice D) is the major digestive enzyme of the gastric juices. It is active in an acidic environment to digest proteins and collagen 159, The correct answer is Choice A. Enzymes that catalyze carbohydrate metabolism or glycolysis in the absence of oxygen are found predominately in the cytoplasm (Choice A). Under anaerobic conditions, the pyruvate molecules from glycolysis stay in the cytosol and are then converted to ethanol or lactate. Under aerobic conditions, pyruvate enters the mitochondria and continues oxidative phorphorylation. ‘Choices B through E are all incorrect. 160. The correct answer is Choice C. Peptide hormones include the posterior pituitary hormones, antidiuretic hormone, and ‘oxytocin. Each of these hormones contain only nine amino acids. Peptide hormones are also characterized by the descriptions given in Choices A,B, D and E. They will not, however, bind to intracellular receptors (Choice C). Peptide hormone receptors are located in or on the surface of the cell membrane. Steroid hormones bind to intracellular receptors. 161. The correct answer is Choice E. Fatty acids are long-chain hydrocarbon organic acids. An unsaturated fatty acid is one in which its carbon chain contains one or more double or triple bonds capable of absorbing additional hydrogen atoms. Oleate (Choice E) isan 18-carbon chain unsaturated fatty acid with one double bond in the middle of the chain. Cholesterol (Choice A) is one of the most abundant lipids in the body. It does not contain fatty acids. Palmitate (Choice B) is a 16-carbon chain fatty acid that is fully saturated. Stearate (Choice C) is an 18-carbon fatty acid fully saturated with hydrogen atoms. Choline (Choice D) is a relatively small hydrophilic compound essential in the formation of some phospholipids such as lecithin. It is not a fatty acid. 162. The correct answer is Choice A. Bacterial plaque in the oral cavity is primarily made up of anaerobic bacteria. Anaerobic bacteria metabolize sucrose in the diet via glycolysis to yield lactic acid (Choice A). Lactic acid is extremely cariogenic. It causes a severe and prolonged drop of pH in the oral environment resulting in demineralization of enamel. A single sucrose rinse can depress pH ‘up to I hour. ‘Acetic acid (Choice B) is an oxidative product of ethanol. It is not a product of bacterial glycolysis and will not cause tooth decay. Succinic acid (Choice C) is an intermediate in the citric acid cycle. It will not produce caries and is not a product of bacterial alycolysis. Propionic acid (Choice D) can be found in sweat and is not a product of glycolysis and is not cariogenic. Phosphoric acid (Choice E) makes up part of the DNA helical strand structure and is also not cariogenic or produced by bacteria 163. The correct answer is Choice B. Glycogen is a storage form of glucose that can be readily utilized when needed. It is most highly concentrated in the liver and skeletal muscle. Structurally glycogen is a very large branched polymer made up of glucose residues. The glucose residues are linked by alpha-1, 4-glycosidic bonds and the branches are created by alpha-1,6-glycosidic bonds (Choice B). As discussed above, alpha-1, 4 bonds (Choice A) link the glucose residues in @ chain but do not occur at branch points. Choices C, D, E are all incorrect. 164. The correct answer is Choice D. Protein kinase when activated by cyclic AMP modulates key enzymes in different cells by phosphorylation (Choice D). In this way, cyclic AMP can influence many cellular processes. For example. protein kinases phosphorylate glycogen synthetase rendering it inactive and phosphorylate phosphorylase kinase rendering it active. So cyclic AMP is indirectly responsible for stimulation of glycogen breakdown and inhibition of glycogen synthesis. Choices A, B, C and E do not describe the process in which protein kinase exerts is influence, 165, The correct answer is Choice D. The hypothalamus is primarily concerned with regulation of the autonomic nervous system, kis associated with sleep (Choice A), water balance (Choice B), body temperature (Choice C), and carbohydrate metabolism (Choice B), 11 is not, however, responsible for pupillary diameter (Choice D). Pupillary diameter is influenced by the amount of light available and stimulation of parasympathetic and sympathetic nerves. ‘KAPLANNDB-1 wing amino acids, proline (Choice A), arginine (Choice B). tryptophan (Choice ©, and asparagine (Choice D) are all in their simplest form and can be used directly in the reactions of protein synthesis Hedroxylysine (Choice E) has a precursor of amino acid lysine. Lysine with the aid of lysy! hydroxylase is hydroxylated 10 hydroxylysine in the presence of oxygen. - ketoglutarate and ascorbate. 166. The correct answer is Choice E. Of the follo Menten kinetics describes many enzyme reactions. The rate of catalysis [V) 167. The correct answer is Choice B. The Michae! varies with the substrate concentration [S] as proposed by the Michaelis ev, 19 Vo Vo 5) Ky where Vmax is the maximum velocity of catalytic reaction and Km is the Michaelis constant. When substrate concentration is 10mM: [lomM Vey, ‘== TomM]+1 V = Vue tl Vina 90) tn) ‘When substrate concentration is 20mM: V=Vpg, OM P2ommj+1 =V pay Ze v= Vou Gal = Vax 95) small amount (Choice B) when the substrate concentration is changed ‘The velocity of the reaction is therefore increased by from 10mM to 20mM. 168. The correct answer is Choice E. Parathyroid hormone, secreted by the parathyroid glands, is important in calcium and phosphate metabolism. In general, parathyroid hormone will cause an increase in blood calcium concentration and a decrease in phosphate concentration. (Of the following, only choice E, inhibition of intestinal absorption of calcium is not an effect of parathyroid hormone, In fact, parathyroid hormone will greatly enhance calcium absorption from the intestine. ‘Choice A stimulation of -alpha-hydroxylase in the kidney will cause an increase in 1,25 hydoxycholecalciferol formation leading to an increase in calcium absorption from intestine. ‘Choice B will also increase calcium concentration by reabsorption of bone and releasing calcium ions into the blood stream. Choice C will also increase calcium concentration in the blood. Choice D inhibition of phosphate reabsorption by the kidney will decrease phosphate concentration in the blood. 169. The correct answer is Choice A. Glucokinase (Choice A) is present only in the liver. It catalyzes the phosphorylation of slucose into glucose-6-phosphate. Once glucose is phosphorylated, itis temporarily held inside the liver cell because phosphors ated flucose cannot diffuse back through the cell membrane, Glucose-6-phosphate can then either be converted back to glucose for immediate use or stored as glycogen depending on body conditions. Choices B, C, D and E will not aid in liver uptake of glucose after a meal 2 diastole, a period of relaxation. Systolic and 170, The correct answer is Choice D. Systole is the period of contraction followin; he systolic pressure is about 120 mm Hg and diastolic pressures are often measured by the ausculatory method. In a young adult, t about 80 mm Hg for diastolic pressure. Systolic blood pressure may be abnormally high when the arteries become hardened with arteriosclerosis and Fave decreased compliance (Choice D), 26 a developed by rTM Ar rr RP PPP PPP PPP PPP PPP RPP PPARBiochemistry/Physiology Released 1997 Conditions in Choices A, B, C and E will not cause an abnormally high systolic pressure. In these circumstances, the systolic pressure may be lower than normal because the contractility of the heart is compromised. ATL. Not scored. 172. The correct answer is Choice A. Collagen is a fibrous protein found in skin, bone, tendon, cartilage, teeth, and blood vessels, Collagen is made up of amino acid residues in a remarkably regular sequence. It also contains hydroxylysine and hydroxyproline (Choice A) which are present in very few other proteins. In fact, the concentration of hydroxyproline may be used 10 estimate the amount of collagen present in a tissue. Choices B, C, and D are all present in collagen but they are also present in many other proteins so these amino acids can't be used to estimate the amount of collagen present. 173, ‘The correct answer is Choice A. Heat loss from the skin to the surroundings may be accomplished in a number of ways depending on existing conditions. When the air is relatively dry with humidity at 10% and the air temperature (105°F) greater than the body temperature (98°F), the primary cause for body heat loss is through evaporation (Choice A). Evaporation is an essential cooling ‘mechanism by which the body rids itself of heat. Conduction (Choice B) is heat lost from the surface of the body to other objects or air. The heat is transferred when the air is ‘colder than the skin. Once the temperature of the air equals that of skin, heat conduction stops. When the air temperature is greater than the skin, however, the body gains more heat from the surrounding air. Convection (Choice C) is heat removed from the body by convection air currents. In general, this accounts for very little heat loss. Radiation (Choice D) is the loss of heat in the form of infrared heat rays. When the temperature of the surroundings is higher than the body temperature, a greater quantity of heat is radiated to the body than from the body. Hyperventilation, Choice E, refers to excessive breathing rate with loss of CO2. ' ' ' ' ' ' 1 ' ' ' 1 ' ' ' (Choice By carso ot only exes pensive aon fo stl slocgin, and epncpsine it ls inpoaat in Olctng and reducing inflammation ' ‘Androstenedione (Choice A) is an androgen secreted by the testes. Somatomedin (Choice B) is a small protein formed by the liver. ts primary effect sto stimulate all aspects of bone growth, 1 Aldosterone (Choice C) is also secreted by the adrenal cortex but by the thin outermost layer on the zona glomerulosa ‘Thyroxine (Choice D) seereted by the thyroid gland, increases the general level of body metabolism by increasing the rate of MH chemical reactions inthe cells. ' 1 ! . ' 1 1 i i a a i i ' 175. _ The correct answer is Choice A. Correct sequencing of amino acids during protein synthesis is dependent upon specific amino- acyl-RNA synthetase (Choice A). Amino-acylt-RNA synthetase catalyzes the activation of amino acids and their linkages to (RNAS. ‘These tRNAs in turn recognize the codons on mRNA and protein synthesis continues. Choices B,C, D and E are all incorrect. 176. _ The correct answer is Choice E. Though carbohydrate and fat are preferred for energy utilization in the body, protein can also be catabolized for energy. Protein is first degraded into its amino acid components. These amino acids are then deaminated to yield -keto acids. Oxidation of keto acids then follows with the release of energy. The ATP formed from the metabolism of proteins via this route is slightly less than the ATP formed by glucose through glycolysis Choices A, B, C and D will not yield the most energy from protein metabolism. 177. The correct answer is Choice C. Membranes are composed of lipid and protein molecules held together by non-covalent interactions. Three major classes of lipid molecules make up the lipid bilayer for various plasma membranes—cholesterol (Choice A), glycolipids and phospholipids. Ganglioside (Choice B) is a complex glycolipid found mainly in the membrane of neurons. ‘Sphingomyelin (Choice D) is an important phospholipid found in the membrane of Schwann cells, Phosphatidylcholine (Choice E), also known as lecithin is also an essential phospholipid found in membrane. Triglycerides (Choice C) are made up of long chain fatty acid molecules. They are used mainly as a source of energy for various metabolic processes in the body. Triglycerides are not present in the membranes. So the correct answer is Choice C. 178. The correct answer is Choice B, The action potential across the membrane of a nerve cell is mediated by changes in sodium and potassium permeability accompanied by changes in charges brought about by sodium and potassium ions. At rest, the cell is negatively charged with a greater concentration of sodium outside the cell than inside the cell. During the onset of depolarization, the KAPLAN 2NDB-1 ‘membrane becomes highly permeable to positively charged sodium ions and these ions flow into the cell causing the action potential to rise rapidly in the positive direction resulting in a spiking of the amplitude From the above discussion, increasing the extracellular sodium will most easily increase the amplitude of an action potential (Choice B). Choices A, C, D and E will most likely not cause an increase in the amplitude of an action potential 179, ‘The correct answer is Choice C. Immediately upon standing from a prone or supine position. a person's arterial blood pressure in the head and upper part of the body tends to fall. The baroreceptors located in the walls of large systemic arteries compensate by cliciting strong sympathetic discharge throughout the body resulting in constriction of systemic arterioles (Choice C) and thus raising blood pressure. Decreased heart rate (Choice A), dilation of mesenteric vessels (Choice B), and dilation of venules (Choice C) will all decrease blood pressure further which is undesirable inthis case. 180. The correct answer is Choice D. When an action potential depolarizes the presynaptic terminal, calcium ions flow into the terminal triggering the release of transmitter substance from synaptic vesicles. The quantity of transmitter substance that is released into the synaptic cleft is often directly related to the number of calcium ions that enter the terminal, From the above discussion, Choice D, entry of calcium at nerve terminal, is the correct answer. 181, The comrect answer is Choice D. Exergonic reactions take place with release of energy to the surroundings. These reactions are characterized by a negative free energy change (Choice D). Decreased entropy (Choice A) is not correct since the entropy will increase in an exergonic reactions. Increased enthalpy (Choice B) is also incorrect as an exergonic reaction will release heat to its surroundings and therefore decrease enthalpy of the system. Positive free energy change (Choice C) is characteristic of endergonic reactions and not exergonic reactions. 182, The correct answer is Choice D. At pH of 7, the amino group on a peptide is ionized with a charge of positive 1. The carboxyl group is also ionized with a charge of negative 1. Since there are two carboxyl groups and only one amino group, the net ccharge on the peptide is negative 1 (Choice D). 183. The correct answer is Choice D. The respiratory minute volume of the lung is defined as the total amount of new air entering into the respiratory passages each minute. It can be calculated by the tidal volume times the respiratory rate: RMV = tidal volume x respiratory rate. Changing the tidal volume into liters and multiplying the respiratory rate: RMV = (0.41) x (18/min.) We get a respiratory minute volume of 7.2 liters/minute or Choice D. 184, The correct answer is Choice A. Of the following combinations, only Choice A is not correctly matched. ACTH or adrenocorticotropin is a large polypeptide hormone secreted by the anterior pituitary. ACTH is primarily responsible for the control and regulation of adrenocortical secretions, especially cortisol 185, The correct answer is Choice A. Gastrin (Choice A) causes activation of the pyloric pump along with relaxation of the pylorus, and contraction of esophageal sphincter. It is a hormone released by the antral mucosa of the stomach. Secretin (Choice B) is also a hormone of the digestive tact. It is formed by the epithelial cells of the duodendum and its primary function is to stimulate pancreatic secretion of sodium bicarbonate. Pepsinogen (Choice C) is an inactive proenzyme formed and secreted by the chief cells of the gastric mucosa. When it comes into contact with hydrochloric acid, it becomes active enzyme pepsin. ‘Acetylcholine (Choice D) is a neurotransmitter synthesized in the cytoplasm of synaptic terminals, Cholecystokinin (Choice E) secreted by the duodenal and upper jejunal mucosa is chiefly responsible for the stimulation of gallbladder contraction. 186. The correct answer is Choice D. Essentially, an animal is in nitrogen balance when its nitrogen intake equals its output. An animal may be in negative nitrogen balance when its output exceeds that of intake (Choice D). ‘When the urine is nitrogen-free (Choice A), i's an indication of nitrogen in balance. Similarly, when nitrogen intake equals output (Choice B), the nitrogen is in balance. ‘When the nitrogen intake exceeds that of output (Choice C). the animal is in positive nitrogen balance. ‘When new tissue is being synthesized (Choice E), the nitrogen balance is undisturbed. 2 «as developed byBiochemistry/Physiology Released 1997 187. The correct answer is Choice E. Glucosura or glucose in the urine may be a result of low insulin level (Choice A) leading to decreased glucose utilization and an increase in blood glucose. It can also be attributed to high blood sugar level (Choice B) with excess glucose excreted through the urine. Impaired tubular reabsorption (Choice C) may also cause glucosuria with incomplete reabsorption of glucose from glomerular filtrate. Conversely, a high glomerular filtration rate (Choice D) may also lead to glucosuria With unmatched rate of tubular reabsorption of glucose. High renal threshold for glucose (Choice E), however, will not result in glucosuria. Glucose will only appear in the urine ‘when the threshold for glucose is exceeded and if the threshold is high, glucosuria is unlikely 188. The correct answer is Choice A. In theory, if a substance is completely removed from the blood during one pass through the kidney, then the amount of substance excreted in the urine should be the same as the amount present in the blood plasma. In other words, a completely cleared substance has its clearance rate equal to that of renal plasma flow (Choice A). Choices B, C, D, and E do not describe conditions presented in this question. 189. The correct answer is choice C. A marked drop in arterial blood concentration of oxygen will not directly influence the respiratory center in the brain, but will strongly stimulate the peripheral chemoreceptor system. This system is made up of special ‘chemical receptors located in several areas outside the brain of which the aortic and carotid bodies (Choice C) are the most important. ‘The aortic bodies are found along the arch of the aorta and the carotid bodies are placed bilaterally in the bifurcation of the common carotid arteries. Choices A, B,D and E are not directly affected by a drop of oxygen tension below normal. 190. The correct answer is Choice B. Oxygen tension is highest in the pulmonary vein (Choice B). Pulmonary veins contains blood that is richly oxygenated by the lungs on its way to the left atrium of the heart. The vein is unusual as veins are normally oxygen poor. ‘The aorta (Choice A) receives oxygenated blood from the left ventricle and distributes it to various parts of the body. Though the oxygen tension in the aorta is high, it is not as oxygen rich as the pulmonary vein. Pulmonary artery (Choice C) receives oxygen poor blood from the right ventricle on its way to the lungs. Coronary artery and vein (Choices D and E) provide local circulation to the heart muscle itself. They also do not have the greatest oxygen concentrations in the body. 191. The correct answer is Choice E. Amino acids are the basic building blocks of proteins. They are classified into two separate ‘groups, the essential and the nonessential amino acids. The nonessential group includes amino acids that the body can synthesize. The essential amino acid group include ones that the body either cannot synthesize or are synthesized in amounts too small to meet the needs of the body. These amino acids must be supplied in the diet. The following isa list of essential amino acids: 1 ‘Threonine 6.——_Phenylalanine 2. Lysine 7. Leucine 3. Methionine «8, Tryptophan 4. Arginine 9. Isoleucine 5S. Valine 10. Histidine . (Of the choices listed, Choice E (Iryptophan, methionine, isoleucine) contains only essential amino acids. 192, The correct answer is Choice C. Glomerular filtration is the first step in urine formation, Large amounts of fluid from the blood enters the glomerular capillaries and are selectively filtered resulting in a filtrate that is essentially protein-free and devoid of cellular components. Glomerular filtration is primarily regulated by the glomerular capillary hydrostatic pressure (Choice C), An increase in glomerular capillary hydrostatic pressure will also cause an increase in filtration rate ofthe glomerulus and vice versa, Choices A, B, and D do not directly control glomerular filtration. 193. ‘The correct answer is Choice C. Inulin is a polysaccharide molecule found in the roots of certain plants. It is freely filtered and is not reabsorbed or secreted by the blood renal tubules. Inulin is often administered intravenously to measure glomerular filtration rate of an individual. If a freely filtered substance has plasma clearance less than that of inulin, there is net reabsorption of the substance in the tubules (Choice C). ‘A substance bound to protein (Choice A) is not fully filtered so its clearance can't be compared with inulin, When there is a net secretion of the substance in the tubules (Choices B and E), the plasma clearance of the substance would be higher than inulin. ‘When there is neither secretion or reabsorption in the tubules (Choice D), the plasma clearance of the substance would equal that of inulin. | “karan 2 'NDB-I 194, The correct answer is Choice D. The posterior pituitary gland secretes two important hormones, oxytocin and antidiuretic hormone. Antidiuretic hormones control and regulate the concentration of water in the body fluids. A hypoactvity ofthe posterior pituitary gland resulting in a deficiency of antidiuretic hormone will lead to diabetes insipidus (Choice D). In this condition. the kidneys excrete larger amounts of dilute urine causing dehydration and increased concentration of sodium chloride in the extracellular fluid Dwarfism (Choice A) is caused by deficiency of anterior pituitary secretion of GH (growth hormone) and not posterior pituitary secretion. * Cretinism (Choice B) is caused by extreme hypothyroidism during fetal life, infancy, and childhood. ‘Acromegaly (Choice C) is caused by an excessively active anterior pituitary gland, and excess GH in adulthood. 195, The correct answer is Choice D. 25-hydroxy cholecalciferol is an active metabolite of vitamin D. Of the compounds listed, 2-hydroxy cholecalciferol is most immediately derived from 7-dehydro-cholesterol (Choice D). 7-dehydro-cholesterol, a normal substance found in the skin, is converted to cholecalciferol by ultraviolet rays from the sun. Cholecalciferol or vitamin D3 is the direct precursor of 25-hydroxy cholecaliferl Choices A, B, Cand E will ot directly convert to 25-hydroxy cholecaciferol. 196. _ The correct answer is Choice E. In a complete heart block or a third degree block, the impulses from the atria are no longer transmitted to the ventricles. The ventricles have “escaped” control from the aria. In this instance, dissociation of the P wave and the QRS complex (Choice E) can be detected on the electrocardiogram. Moreover, there is no relationship between the P wave and the QRS complex since the ventricles are beating at their own rate, Choices A, B, C and D do not characterize a complete heart block on the ECG. 197, The correct answer is Choice A. Cardiac output is simply the volume of blood pumped by the heart each minute. It is expressed as a product of the volume of blood pumped in each beat (stroke volume), and the number of heart beats per minute (heart rate). CO = [STROKE VOLUME] x [HEART RATE] So the correct answer is choice A. 198. The correct answer is Choice B, Carbon dioxide in the blood stream reacts with water to form carbonic acid. Carbonic acid then dissociates into hydrogen and bicarbonate ions (Choice B). This is the form most of CO takes on in the blood stream. CO2 has potent effect on controlling respiratory drive via the route outlined above because hydrogen ions directly stimulate the sensor neurons in the chemosensitive area of the respiratory center. Choices A, C, D and E are not the correct answers. 199, ‘The correct answer is Choice A. Choline is a small hydrophilic compound essential in the formation of lecithin. It makes up the nitrogenous base in the lecithin molecule. In turn, lecithin isthe principal emulsifier of fat and lipids in bile. Lecithin breaks down fat globules into small sizes enabling lipases to continue in the digestion of fat. A deficiency of choline, therefore, can cause abnormalities in the metabolism of fat or lipids (Choice A) by inhibiting the formation of lecithin, Deficiency of choline in the diet will not effect metabolism of substances in Choices B, C, D or E. 200. The correct answer is Choice C. The enterogastric reflex is initiated when food is present in the small intestine. It inhibits stomach secretion and decreases motility of the stomach (Choice C) at the same time. The enterogastric reflex is a control mechanism for slowing down stomach emptying when the intestines are already filled. Choices A, B, D and E are not functions of the enterogastic reflex. a a5 developed by i 2 manePart | 2 December 1985 2. 3 4 “The km value of an enzyme is numerically 6. equal to 1. half the maximum velocity expressed in mol 2. velocity ofa reaction divided by Substrate concentration 3. substrate concentation in molester necessary to achieve half the maximum ‘elocity of a reaction, 4. maximum velocity divided by half the 7. substrate concentration in moles necessary to achieve maximum velocity ‘The physiologically active form of vitamin D produced in the kidney is 1. 1,25 enzyme + product complex. and K3, which is the reaction ‘enzyme-substrate complex —> enzyme + substrate. K1, K2 and K3 cannot be measured empirically. Michaelis-Menten formulated an expression for the rate of all ofthe above reactions, which is as follows V= Vou X the ial substrate concentration K, + the initial substrate concentration, where Via the maximum velocity at extremely high concentrations of substrate, and K, = K+ K2 KI This equation assumes a steady state; that is, the concentration of the enzyme-substrate complex is constant, and K, = a substrate concentration at 1/2 Vay. Itis a concentration, not a constant, and must be determined experimentally after the determination Of Vas and the changing substrate concentrations, so again the correct choice is #3. 2. The correct choice is #1, 1,25- dihydroxycholecaleiferol. The synthesis of vitamin D involves intially the irradiation of 7- dehydrocholesteol by UV light: 7 Fe"*. Remember from general chemistry a reduction isthe gain of electrons. land oxidation isthe loss of electrons. When an ion is reduced it gains a negative charge, and thus its oxidation state becomes more negative. Likewise, when an ion is oxidized it loses negative charge, and therefore its oxidation state becomes more positive. In this question we have a variety of reactions to choose from. In choice #1 we are adding water across the double bond for a hydroxylation reaction. The oxidation state of each carbon remains the same in the reactants and products. In choice #2 we have the dissociation of a carboxylic acid, R-COOH, into the anion, R-COO and a hydronium ion, H+. We have no change in oxidation states here Choice #3, we have the formation of an alkene, C=C from an alkane, CH2-CH2. Again, a change in oxidation state js not occurring here. In choice #4 we have Cu" —> Cu” + I electron - Well, we have a change in oxidation state on Cu+' to Cus*. However, we have a loss of one electron, Consequently, the oxidation # becomes more positive, from +1 to +2. This is an oxidation reaction. ‘And finally choice #5, Fe""* + | electron ~> Fe" is a reduction, since Fe+3 gains one unit of negative charge, going from Fe+3 10 Fet2, for a reduction. So again, the correct choice is 5. 4. The correct choice is #3. The cleavage of beta- hydroxy-beta methylglutaryl-CoA. Acetoacetate is the major ketone body synthesized by the liver hepatocytes. First, acetate from acetyl CoA forms a dimer, acetoacetic acid. The CoA- acetoacetate bond cleavage is energetically unfavorable, so beta-hydroxy-beta-methylglutaryl-CoA. or HMG-CoA, a 6-carbon intermediate must first be formed. Acetyl-CoA can now be moved in the liver to generate acetoacetate. Other ketone bodies are beta-hydroxy-butyric acid and acetone. Too much acetoacetate and beta-hydroxy-butyrate in body serum is termed Ketonemia. The liver may overproduce ketone bodies during starvation. Severe carbohydrate deficiency will decrease the amount of acetyl-CoA and thus citrate, a TCA intermediate, will decrease. A decrease in citrate inhibits acetyl-CoA carboxylase, which, as you may recall, is the rate-limiting enzyme of fatty acid synthesis, blocking another metabolic step in acetyl-CoA metabolism. The buildup of acetyl-CoA forces its conversion into ketone bodies. So again, the correct choice is #3, the cleavage of beta-hydroxy-beta-methylglutaryl-CoA. 7 «as developed byBiochemistry/Physiology Released 1987 5. The correct choice is #5, oxaloacetic acid and alpha-Ketoglutaric acid. You must be familiar with the TCA cycle. Let me rephrase that. You must know the TCA cycle. The cycle takes place in the mitochondria and plays an essential role in the metabolism of carbohydrates, fatty acids and amino acids. Its intermediates are involved in the synthesis of amino acids and porphyrins. Most importantly, though, itis a major site of energy production. Let's quickly go through the cycle, mentioning sites of energy production. Acetate is joined to oxaloacetate by citrate synthase, producing citrate. Citrate synthase isthe rate-limiting enzyme ofthis cycle. Citrate is dehydrated by aconitate hydratase to form cis-aconitae. Itis then rehydrated to isoctrate by the same ‘enzyme. Isocitrate dehydrogenase oxidizes isocitat, yielding alpha-ketoglutarate, CO2 and NADH. This is a rate-limiting step. ‘Alpha-ketoglutarate is converted to succinyl-CoA by alphe-Ketoglutarate dehydrogenase. NADH is produced. Succinyl-CoA then forms succinate by succinyl-CoA synthetase. In this cleavage GDP —> GTP. Succinate is converted to fumarate via succinate 7, due to its high concentration of HCO3. This helps prevent dental caries by neutralizing any acid produced by bacteria in the oral cavity. Saliva also has elevated concentrations of potassium, amylase, lysozyme, IgA and lactoferrin. ‘The stimulation of parasympathetics and the release of acetylcholine increases the volume of saliva and the concentration of the bicarbonate ion. Stimuli for salivation includes conditioned reflexes, the taste of acid and other tastes, smell, nausea and mechanical stimulation of the oral cavity. So again, the correct choice is #4, bicarbonate. 26. The correct choice is #1. a genetic mutation. This genetic mutation, as you may recognize, leads to the sickle cell trait. Sickle cell anemia is a chronic hemolytic disease that is genetically transmitted. This mutation leads to elongation and sickling of the red blood corpuscles. It is prevalent inthe black population with an incidence of approximately 4 per 1000. Patients with sickle cell anemia are homozygous for an abnormal gene on one of the autosomal chromosomes. Offspring receiving the abnormal gene from ‘one parent, but normal alleles from the other parent, develop sickle cel wait. These heterozygotes are not usually symptomatic. This trait occurs in 10% of blacks. The mutation results in a single amino acid alteration in the beta chain of hemoglobin, leaving a hhemoglobin $ form and a high concentration of deoxygenated hemoglobin S, encourages the sickling of cells. This frequency of sickle cell anemia is as high as 40% in Africa. This high incidence of the sickle cell gene is due tothe protection conferred against malaria, Which is a very prevalent infection in Africa. So again, the correct choice to question 26 is #1, a genetic mutation. 27. The correct answer is #2, at the postsynaptic ganglionic sympathetic nerve endings. Norepinephrine is the tansmitter in postganglionic neurons of the autonomic nervous system. In the central nervous system norepinephrine-containing neurons are prominent in the locus ceruleus, which projects diffusely to the cortex, cerebellum and spinal cord and is involved in alerting mechanisms. Sympathetic postganglionic fibers usually store norepinephrine as their neurotransmitter. However, there are always exceptions to a rule. Sympathetic postganglionic neurons to sweat glands and to some of those causing dilatation of blood vessels in skeletal muscles are ofien cholinergic neurons. Again, the correct answer is #2, at postganglionic sympathetic nerve endings. 28. The correct choice is #4, associated with transferrin. Iron is carried in the plasma of blood by transferrin and is stored in the liver as a complex with ferritin, another protein. Therefore, choice 3 is incorrect. Iron does exist in other forms in the body. However, the most abundant form in human blood plasma is carried as transferrin. So again, the correct choice is #4, 29. The correct choice is #3, hypothalamus. ‘The hypothalamus has a multitude of functions. It centrally maintains the homeostasis of the body by integrating autonomic, somatic and endocrine systems. ‘Temperature regulation involves both posterior hypothalamus and anterior hypothalamus. The posterior hypothalamus responds to cold by producing shivering, vasoconstriction of skin vessels, piloerection and discharge of catecholamines. The anterior hypothalamus responds to excessive heat through sweating, panting and vasodilatation of skin vessels, ‘The receptors monitoring body temperature seem to be located primarily in the anterior or preoptic area of the hypothalamus. Other functions of the hypothalamus include the release of corticotropin, thyrotropin, ‘gonadotropin, somatastatin, prolactin and growth hormone releasing factors. These releasing factors in turn regulate the release of the above hormones from the anterior lobe of the pituitary. So again, the correct choice is #3, hypothalamus. 30. The correct choice is #5, closure of the aortic valves. Let's discuss the heart sounds. SI, or the first heart sound, is synchronous with mitral and tricuspid valve closure. Its intensity isa clinically useful sign. S1 intensity varies inversely with the P- R interval on the ECG. The shorter the P-R interval the louder $1. In mitral stenosis the absence of a loud S1 is an important sigt suggesting a rigid, heavily-calcified and immobile mitral valve. The second heart sound is called S2. Iti synchronous with aortic and pulmonary valve closure. Its intensity also is a clinically useful sign. The third heart sound, S3, or ventricular gallop, occurs in early diastole. It represents vibrations of the left ventricular structures and blood mass as the rapid inflow of blood is limited to the left ventricular diastolic expansion. $3 is a normal sound in children and young adults. In adults, however, over the age of 30 or 35 years, it represents significant global ventricular dysfunction and is frequently associated with ventricular dilatation, It can also be present in severe anemia, thyrotoxicosis and mitral regurgitation. ‘The fourth heart sound is $4. This is atrial gallop. It occurs after atrial contraction and before S1. Again, the correct choice is #5, closure of the aortic valves. 31. The correct choice is #4, testosterone. Testosterone is the primary sex steroid produced by the Leydig cells of the testes. Its effects are as follows: stimulates sex drive, maintains secondary sexual characteristics, stimulates growth and secretory activities of the accessory sex glands, maintains spermatogenesis. It is also responsible for embryogenesis of male ducts, systems and external genitalia and subsequent maturation at the time of puberty. Descent of the testes into the scrotum from the abdominal cavity at birth is under control of testosterone. It also promotes the growth of many bodily tissues through anabolic effects. The action of testosterone on androgen-sensitive tissues appears to be mediated by conversion of testosterone to dihydrotestosterone by the target cell. Dihydrotestosterone is the active hormone in the prostate, epididymis and on the tissues to promote growth. The action is mediated by induction of RNA and protein synthesis via androgen receptors, similar to the effects of other steroids on other steroid receptors. Testosterone can also be converted to estradiol in the testes and peripherally. Again, the correct choice is #4, testosterone. 20 «as developed byee Biochemistry/Physiology Released 1987 32, The correct choice is #3, increased potassium permeability. A neuron is refractory to stimulation at two phases during and following the action potential because of the changes in ion conductances. The absolute refractory period at the peak and first half of the falling phase of the action potential is a period during which a second stimulus, no matter how strong, cannot initiate another impulse. Because of the sodium pump inactivation a second stimulus cannot again elevate the sodium conductance as is required for the beginning of a second action potential. Furthermore, potassium conductance is still elevated through the falling phase, causing an ‘outward potassium which would neutralize the effect of an inward sodium on the state of polarization. ‘The relative refractory period immediately following the absolute refractory period is the phase in which the sodium inactivation is ending and the potassium conductance is diminishing and reaching a rest value. At this point a stronger than normal stimulus can initiate another action potential, Following termination of the action potential the membrane is in a state of hyperpolarization, since the membrane i further away from the threshold level of depolarization necessary to cause the next action potential initiation. So again, the correct choice is #3, increased potassium permeability. ‘The correct choice is #1, hypothalamus. The autonomic nervous system is defined as the efferent or motor neurons to the viscera, cardiac and smooth muscle and glands. It functions to adjust the amplitude of visceral activity and coordinate activities of different viscera. The central nervous system centers are the hypothalamus and brainstem, especially the reticular formation. They contain the controlling neurons, cell bodies which are the sites of autonomic regulation. For other functions of the hypothalamus, please refer to question #29. 34, The correct choice is #3, adaptation. This question is best explained by looking at the sensory receptors in the somatic Sensory system, Sensory receptors are organs, in a sense, which give us our contact with the external environment. ‘The information we receive comes not only from the external world but also from within our bodies. Sensory systems can be divided into three categories, based onthe source ofthe signals: (1) exteroceptive (2) proprioceptive and (3) interoceptive. The somatic sensory system is involved with the stimuli that affect the body surface or deep tissues. Four submodalities of the somatic sensory system are (A) touch and pressure (B) positon sense (C) thermal regulation and (D) pain sensation. Let's look at the mechanoreceptors as the example of how mediation ofthese submodalities and adaptation can occur. There are rapidly adapting mechanoreceptors which respond only atthe onset and termination ofa stimulus. For example, the pacinian corpuscles in the subcutaneous tissue of your feet will initially respond when you put your shoes on, but after awhile they rapidly adapt, and you no longer feel the shoes on your fet. Likewise, they are stimulaied upon removal of the shoes. Thus, some sense organs when stimulated continuously by a constant stimulus may gradually lose their ability to continue to respond, and this phenomenon is best known as adaptation, for the correct choice of #3. 35. The corect choice is #4, pH = pKa when an acid is half-neutralized. The Henderson-Hasselbalch equation enables you to understand the relationship between the pH, or (-)log(hydronium ions in solution] and the ratio of the acid to base in the solution. The ‘Henderson-Hasselbalch equation is as follows: pH = pK, + log (anion|/[undissociated acid] in moles/. Knowing the proportion of an anion to undissociated acid in moles/l and the pK, of the acid, H,, the pH can easily be calculated from this equation. You can see that when the concentration of the anion equals the concentration of the undissociated acid ‘we have a one-half neutralized acid. When the numerator of a fraction is equal to the denominator the fraction is equal to 1. The log of |as you may remember from basic trigonometry, is equal to 0. Plugging this in to the Henderson-Hasselbalch equation, we have pH pK, + log 1. or pH = pK, + 0, so the pH = pK, when the acid is half neutralized, or choice #4. 36. The correct choice is #5, decreased venous return: The autonomic nervous system plays a major role in controlling the circulation, regulating the cardiac output, vascular resistance and venous capacitance. Nervous control mechanisms respond quickly and powerfully, allowing for rapid adjustments in different parts of the circulation. ‘The nervous control of circulation involves central Control, sympathetic control and parasympathetic control, baroreceptor control and chemoreceptor regulation. The baroreceptors are situated in the carotid sinus and aortic arch, the heart and lungs. Upon stretching of the atria the nerve endings are activated, secondary to an increase in blood pressure. The greater the stretch the greater the frequency of firing. A fall in blood pressure produces a decrease in frequency which leads to sympathetically mediated vasoconstriction and an increase in the heart rate. Increase in blood pressure will stretch atrial walls, leading to an increase in the baroreceptor firing, resulting in a decrease in sympathetic tone and a vagally mediated decrease in blood pressure. In the absence of compensatory changes a drop in blood pressure results from a decreased venous return, oF the correct choice of #5. 37. The correct choice is #4, induction of dimerization by way of covalent bonds between adjacent thymidine groups. DNA is not indestructible and can easily be damaged and altered by chemical and physical means. If our bodies allowed the altered DNA to remain, death or mutations of the cells would surely occur. One of the common ways DNA is damaged or altered is atthe bases. The bases ‘may be changed or deleted. Also, phosphodiester bonds can be altered. Double-stranded DNA enables the DNA to be repaired, When U-V light bombards DNA, adjacent thymidine residues on a DNA strand are known to cross-link covalently. Replication is therefore blocked due to a change in the double-stranded DNA conformation. After this dimerization, the defect is corrected in the body by KAPLAN 2NDB-1 excising the defect, followed by repairing the excised area with U-V-specific endonuclease, DNA polymerase-I and a 5'3-exonuclease. ‘Also, DNA ligase is involved. Skin cancer is caused by a defective repair of DNA in xeroderma pigmentosum. So the correct choice is #4 38. Thecomrect choice is #3, alpha-D-glucopyranoside-beta-D-fructofuranoside. Sucrose is a disaccharide derived from an alpha- —lucocytic linkage of the anomeric carbons of fructose and glucose. Sucrose is therefore nota reducing sugar. Sucrose is spit into ‘glucose and fructose by the enzyme sucrase. Sucrose is synthesized by activated intermediate UDP sugars. Sucrose is synthesized by the transfer of glucose from the activated UDP glucose to fructose-6-phosphate to form sucrose-6-phosphate, which is then hydrolyzed to sucrose. Again, the corect choice is #3. 39, The correct choice is #3, acts as coenzyme in transamination reactions. Pyridoxal phosphate, which is derived from ytidoxine is the prosthetic group of all transaminase reactions. Without substrate pyridoxal phosphate aldehyde groups form a Schiff base linkage with the epsilon amino group of a specific lysine residue at the active site. As alpha amino groups of amino acid substrates are added, the epsilon amino group of the active site of lysine is displaced. The amino pyridoxal phosphate Schiff base bond is a tight noncovalent union. The mechanism for the reaction involves the aldamine to ketamine, then hydrolysis to pyridoxamine phosphate and alpha-keto acid. Other transformations catalyzed by pcyridoxal phosphates include decarboxylations, deaminations, racimizations and aldol cleavages. These are just a few. So again, the correct choice is #3, acts as coenzyme in transamination reactions. 40. The correct answer is #3, oxygen that can be transported by hemoglobin. Carbon monoxide combines with ferromyoglobin and ferrohemoglobin, interfering with oxygen transport. Heme has a high affinity for carbon monoxide. Myoglobin and hemoglobin have less affinity than the isolated heme. However, they still bind. These proteins decrease the affinity of carbon monoxide to the hheme-protein complex by sterically hindering the binding of carbon monoxide. More specifically, the myoglobin and hemoglobin change the geometry of the binding of carbon monoxide from that of the protein-oxygen binding and in doing so weakens the interaction of carbon monoxide with the heme, optimizing O2 binding. Nevertheless, carbon monoxide has a greater affinity for binding than oxygen, and this fact decreases the amount of oxygen that can be transported by hemoglobin. So again, the correct choice is #3, oxygen that can be transported by hemoglobin, 41. The correct choice is #2, efferent arteriolar constriction. The filtration fraction is defined as the glomerular filtration raterenal plasma flow. The filtration fraction is the fraction of inflowing plasma that is filtered across the glomerulus. In man, filtration fraction is approximately 0.2; that is, 1/5 of the inflowing plasma is filtered. Extrinsic regulation is achieved by sympathetic innervation of blood vessels. Sympathetic output to both afferent and efferent arteriole enables fine control ofthe glomerular filtration rate and thus, the filtration fraction. For example, renal plasma flow could be decreased more than the glomerular filtration rate, thus. increasing the filtration fraction, which is equal to the glomerular filtration rate/renal plasma flow. ‘The renal vasculature is also sensitive to epinephrine and norepinephrine, ADH and serotonin, all of which can constrict renal vessels when given in pharmacological doses. So again, the correct choice is #2. 42. The correct choice is #3, hydrophobic aromatic nitrogen bases are held close to each other. This is a good time to discuss the structure of deoxyribonucleic acid. DNA is made up of purine and pyrimidine bases, which carry the genetic code, and sugar and phosphate groups which contribute to its structure. The backbone of DNA consists of deoxyriboses linked by phosphodiester bridges. ‘The base sequence may vary. The two purines are adenine and guanine. The two pyrimidines are thymine and cytosine, Structurally, the hydrophobic aromatic nitrogenous bases occupy the inner portion of the helix, held close to each other, and the phosphate and deoxyribose units are on the outside of the helix. The base planes are perpendicular to the axis of the helix. The two chains are held together by hydrogen bonds between pairs of bases. Adenine pairs with thymidine and guanine with cytosine. ‘The sequence of the bases carries the genetic information. So again, the correct choice is #3, hydrophobic aromatic nitrogen bases are held close to each other. 43, The correct choice to question 43 is #3, vitamin A. Rhodopsin is a photosensitive molecule in rods. It is made up of opsin and 11-cis-retinal. The precursor of 11-cis-retinal is Il-trans-retinol, or vitamin A. Vitamin A is an essential vitamin; that is, it cannot be synthesized in mammals. ‘The all-trans-retinol is converted to 1-cis-retinal by retinol dehydrogenase, followed by an isomerization between the 11th and 12th carbon double bonds, from trans to cis configuration by retinal isomerase, If vitamin A is, deficient in the human it will lead to night blindness and eventual degeneration of the rods. So the correct choice is #3, vitamin A. 44, The correct choice is #2. peptide bond. ‘The formation ofa peptide chain involves the removal of water between the carboxy] ‘groups of one amino acid and the amino group ofa second amino acid. ‘The formation of a peptide bond is not energetically favorable, and thus an input of energy is necessary. Each amino acid residue has an alpha-amino and alpha-carboxyl group. In reading a polypeptide chain you start wit the amino terminal residue and move from lft to right, ending with the carboxy terminal amino acid 2 “as developed by "AR AAPA RPA PPR RAPABiochemistry/Physiology Released 1987 residue. An example of a dipeptide, then, in reading from left to right would be NH3-CH-R1-COO-NH-CH-R2-COO’. So again, the ‘correct choice is #2, a peptide bond. 45, The correct answer is #2, inhibit bone resorption. Normal levels of calcium are 0.5 millimolar, 5 milliequivalents, 100 mg/ml. About 50% of calcium is ionized, while the other partis bound to albumin or complexed to phosphate. Hypocalcemia will lead to tetany and seizures. Hypercalcemia will lead to renal calcification and decreased cardiac contractility. Calcitonin is secreted by the thyroid glands, parafollicular or C-cells in response to high calcium levels. It depresses blood calcium by inhibiting bone resorption. It also prevents the action of parathyroid hormone or osteolysis by inhibiting osteolytic and osteoclastic osteolysis and reducing the number of osteoclasts. It is a rapidly acting hormone. It also increases mitochondrial calcium and mitochondrial granulation. Calcitonin is cyclic AMP. Mediated, it may act on receptors separate from parathyroid hormone. In the kidney calcitonin decreases calcium resorption by increasing calcium secretion into distal convoluted tubules. Calcitonin increases the net calcium ion uptake by distal tubule kidney cells from peritubular capillaries, so more is secreted into the tubular fluid. Again, the ‘correct choice to question 45 is #2, inhibit bone resorption. 46. The correct choice is #4, secretion continues even when the pressure within the salivary duct is higher than the blood pressure. Saliva is secreted by three pairs of glands: the parotid, the submaxillary and sublinguals. These glands receive sympathetic input from the superior cervical ganglion, and parasympathetic input via the cranial nerves VII, IX and X. The function of saliva is to lubricate food, keeping the mouth moist, improving dental health and digestion of starch and neutralization of acids. Saliva is always hhypotonic to serum. Sodium and chloride concentrations are high at high secretory rates and are affected by hydration and mineralocorticoids. Saliva is actively secreted. Sodium is actively resorbed via the sodium-potassium-ATPase system. Potassium is secreted and resorbed into the acinus and excreted in the tubule with bicarbonate. It is actively secreted when pressure within the salivary duct is greater than the blood pressure. Saliva will still flow. This further supports the belief that saliva secretion is an active process. Again, the correct choice is #4. 47. The correct choice is #3, xanthine oxidase. In humans purines are degraded to urate. Nucleotidases degrade nucleosides via hydrolysis. Nucleosides are cleaved to free bases and ribose-1-phosphate. This is catalyzed by nucleoside phosphorylases. The ribose- {phosphate undergoes isomerization to ribose-S-phosphate by phosphoribomutase. The degradation of AMP leads eventually to hypoxanthine. Xanthine oxidase, a flavoprotein, will oxidize hypoxanthine to xanthine and then to urate. Hydrogen peroxide is formed in this reaction, which quickly goes to water and oxygen Via catalase. Excessive urate production will lead to gout. In gout sodium urate crystals will precipitate in the serum, causing a very painful clinical presentation. Again, the correct choice is #3, santhine oxidase. 48, The correct choice is #5, reciprocal inhibition. The somatesthetic system includes different modalities such as touch, pressure, temperature and pain. The proprioceptive modalities include muscle length, tension and stretch velocity. The kinesthetic ‘modalities include joint position and joint movement. In this question we are considering the joint receptors. Several types of joint receptors mentioned above are in use during the movement ofa joint. Stretch receptors in this example are being activated as the joint is moved, which will send afferent information to the higher centers of the brain to thus inhibit the extensor muscles. This is a protection of the joint and is termed reciprocal inhibition, or the correct choice of #5. 49. The correct choice is #3, carbon dioxide is incorporated into acetyl-coenzyme A, forming malonyl-coenzyme A, an intermediate in the synthetic process. Synthesis of fatty acids takes place in the cytosol. It begins with the committed step, the carboxylation of acetyl-CoA to form malonyl-CoA. The enzyme is acetyl-CoA-carboxylase, which contains biotin, Acetyl-CoA- carboxylase is the rate-limiting enzyme of fatty acid synthesis. Acetate and malonates are transferred from the CoA to acyl carrier protein. Acetate is then transferred to a synthase enzyme. Acetyl-S-synthase condenses with malony|-S-ACP, generating acetylacyl-S- ACP, giving off carbon dioxide. In fatty acid biosynthesis NADPH is used from the hexose monophosphate shunt for the reduction of beta-ketal groups of acetoacetyl-S-ACP forming beta-hydroxylbutyryl-S-ACP. The beta-hydroxyl group of beta-hydroxylbutyryl-S- ACP is eventually removed via hydratase, forming crotonyl-S-ACP. The double bond is then saturated, yielding butyryl-S-ACP.. ‘Butyrate is then transferred from ACP to the synthase enzyme, condensing with malonyl-S-ACP. Eventually, we will form palmityl- $-ACP. The thio bond will be cleaved, forming palmitic acid and ACP-SH. Each turn of this cycle uses 7 moles of ATP. It is strongly advisable to get a biochemistry textbook and look atthe structures of these molecules and familiarize yourself with fatty acid biosynthesis. So again, the correct choice to question #49 is #3, carbon dioxide is incorporated into acetyl-coenzyme A, forming ‘malonyl-coenzyme A, an intermediate in the synthetic process. $0. The correct choice is #4, greater than the clearance of inulin. Clearance from plasma water of a given substance, ox, is that volume of plasma, or virtual volume, from which the substance is cleared completely by the kidneys per unit time in minutes. The clearance volume is that amount of plasma that must be cleared completely of a substance to supply the excreted mass of the substance ‘pet minute. Since the concentration of renal venous plasma is lowered, the clearance can be visualized as keeping the concentration constant and removing all of a substance from a given volume, the clearance volume. Inulin is nearly completely filterable at the ‘KAPLAN 3NDB-1 ‘glomerulus. It is not bound to plasma proteins and is not resorbed or secreted by the renal tubule walls. If a substance is completely filtered, not resorbed, and is secreted it will obviously have a clearance greater than that of inulin, since it is being secreted. Inulin is not being secreted. So again, the correct choice is #4, greater than the clearance of inulin 51. The correct choice is #5, oxidative phosphorylation. Oxidative phosphorylation is necessary for all cells that derive energy vvia aerobic oxidation. Mitochondria, the powerhouses of the cell, are the locations of the oxidative phosphorylation and electron transport enzymes. The mitochondria have two membranes, the inner membrane and the outer membrane. ‘The inner membrane contains cytochromes b, c, cl, a and a3, and the FATP-ase associated with the mechanism of oxidative phosphorylation. Proof has been established that electron transport from NADH to oxygen is the main source of energy used for the completed phosphorylation of, ADP, so the correct answer is #5, oxidative phosphorylation. 52. The correct choice is #2, both require phosphopantothenic acid. Phosphopantothenic acid is a precursor of coenzyme A. Coenzyme A is required in both fatty acid biosynthesis and fatty acid breakdown. Pantothenic acid is phosphorylated by ATP with the enzyme pantothenate kinase, The product is 4'-pantothenic acid. Then, in the presence of CTP and cystine and the enzyme phosphopantothenol cysteine synthetase 4'-phosphopantothenol cysteine is formed. A decarboxylation follows, leaving 4'- phosphopantothene. Adenylation follows, yielding dephospho-CoA, and finally, with the addition of one mole of ATP, the product CoA. So again, the correct choice is #2, both require phosphopanthothenic acid. 53. The correct answer is #2, mixing food with digestive secretions. Gastric motility is produced by the longitudinal and circular ‘muscles, with a unique oblique layer. There is an excitatory wave which occurs with the basal electric rhythm pacemaker in the greater curvature and moves to the pylorus. ‘This determines the rate of peristaltic contraction. ‘The magnitude of the contraction is governed by characteristics of muscle cells themselves and is modulated by the myenteric and submucosal plexus. It is modified by sympathetic ‘output and vagal input. They function in grinding and mixing the food. The contraction of the stomach and shape of the stomach permit the mixing of the food. In the smal intestine segmentation originates near the duodenum bulb. Segmentation moves distally ‘at 20 cm/sec. So again, the correct choice is #2, mixing food with digestive secretions. 54. The correct choice is #3, the membranes. The cell membrane is selectively permeable and has many transmembrane proteins ‘whose functions are still being investigated. Some transmembrane proteins may function as channels for transport of materials into and out of the phosopho-lipid bilayer. All of the other choices listed here are subcellular structures and not composed primarily of lipid. ‘The cytoplasm contains these subcellular structures and is confined by the membrane. So again, the correct choice is #3. 55. The correct choice is 41, itis a function of the base composition. Studying the kinetics of the reassociation of double- stranded DNA that has been denatured with heat has revealed that DNA contains repeated base sequences. The melting temperature of DNA, or Ty defined as the temperature at which double-stranded DNA will form two single strands of DNA. ‘The kinetics of reassociation of the DNA can be measured at 260 nanometers and, by plotting the fraction of single-stranded molecules present versus log concentration (time in seconds), the kinetics of the reassociation may be depicted, The faster the reassociation the greater the ‘number of repetitive sequences of DNA. So again, the correct choice is #1 56. The correct choice is #2, contraction of some fibers. Muscle cells are specialized for contraction. An action potential is transmitted along their cell membranes which, in tur, activates the contractile mechanism. There are three types of muscles. Skeletal muscle is striated, under voluntary control and is rapidly acting. Smooth muscle is not striated. It is located in internal organs, is nonvoluntary or involuntary, which means having inherent rhythmic contractile activity and is slow-acting. Cardiac muscle, which is the third type of muscle is striated but has some characteristics of smooth muscle including inherent rhythmicity. Muscle fibers are single muscle cells. They contain myofibrils, and the myofilament constitutes each of the myofibrils. The thick filament of myosin and the thin filament of tropomyosin and troponin make up the biochemical composition of myofilaments. After the release of acetylcholine atthe neuromuscular junction by the action potential it reacts with the receptors at the muscle end plate, and the muscle cell membrane depolarizes. Threshold is reached when a membrane is depolarized sufficiently initiating an action potential along the ‘muscle cell membrane. Each muscle fiber has its own threshold, so therefore a submaximal direct stimulus to a skeletal muscle causes ‘contraction of some fibers, since different fibers make up a muscle. So again, the correct choice is #2. 57. The correct choice is #1, 0.75. The R.Q. or respiratory quotient is defined as the volume of carbon dioxide produced/volume Of oxygen consumed. This is a fairly straightforward problem, since it is not even necessary to convert the units of volume into the ‘same units, since both oxygen and carbon dioxide are in liters. So in this case we have a man producing 3 liters of carbon dioxide and consuming 4 liters of oxygen. Our R.Q. is equal to CO2 produced/O2 consumed, or 3 liters/4 liters. Liters canceling out, we are left with 3/4 or 0.75 for the correct choice of #1 58. The correct choice is #5, cholecystokinin. The primary role of the gallbladder is bile storage for release during meals when the gallbladder is relaxed. The sphincter of Oddi has low resistance. Approximately 50% of bile is stored, while the remainder enters 7 ‘as developed by PEER BPR RRR RRR RRR RRR RRBiochemistry/Physiology Released 1987 the duodenum, Contraction begins approximately a half an hour after meals. Contraction is stimulated by acetylcholine (that’s the vagocephalic phase of digestion), Hormones which stimulate contraction include cholecystokinin, or CCK, secretin and gastrin, Contraction, however, is seldom complete, being from 51% to 99% emptying. The gallbladder wall absorbs water and also it absorbs electrolytes. It concentrates cholesterol and absorbs sodium by the electrogenic pump. It also allows for the passive movement of chloride and the passive movement of water, The secretory product, bile, contains water, phospholipid, cholesterol, bile acids and bilirubin. 59. The correct choice is 5, thickening of the alveolar membrane. The assumption that alveolar partial pressure, or PAo:. equals fend capillary partial pressure is not strictly true. That is, equilibrium in the alveoli is not complete. The result is an alveolar atrial oxygen gradient. If there isa diffusion disturbance such as thickened alveolar capillary barriers or when we have pulmonary blood flow which is faster, or a low oxygen mixture is inspired, the alveolar arterial oxygen gradient is exaggerated. Equilibrium is approached less and less, and p02 falls. So again, the correct choice is #5, thickening of the alveolar membrane. 60. The correct choice is #1, the liver. Nitrogen is excreted predominantly in the form of urea in urine. Urea is formed in the liver, brain and also the kidney, but mainly in the liver via the urea cycle. Let us review this very important cycle. CO2 and NH3 + H20 + 2ATP via carbamoylphosphate synthetase form the unstable carbamoylphosphate. Carbamoylphosphate combines with ‘ornithine, via ornithine carbamoyltransferase to form citrulline. Citrulline and aspartate and ATP form arginosuccinate, then fumarate and arginine, via arginosuccinate lyase. Arginine is then hydrolyzed via arginase to form the urea, NHy-CO-NH? and Hz. The net reaction of the urea cycle is (CO? + 2NH3 + 3ATP + 3H20— urea + 2ADP + AMP + dinorganic phosphates. So again, the correct choice is #1, the liver. 61. The correct choice is #1, during diabetes mellitus. Before we answer this question it is important you understand the ‘mechanism of insulin action, Insulin increases the maximum velocity of carrier-mediated glucose transport increased energy-dependent transport of ino acid, increased movement of potassium, leads to hyperpolarization of cells. In adipose tissue it increases the affinity of carriers for glucose. In the liver it may increase amino acid transport, but it is important that you understand that it has no effect on glucose transport in the liver. Insulin causes a decrease in the cyclic AMP levels, which affects enzymes that catalyze reactions involving gluconeogenesis and glycogen breakdown. Insulin increases ribosomal RNA activity, therefore increasing protein synthesis. Glucose is the most important signal promoting insulin secretion by the beta cells of the pancreas. Arginine also stimulates the secretion of insulin. Diabetes mellitus type I, or absent insulinopenia, is a state of inadequate glucose utilization. Inadequate levels of insulin lead to an inability to remove excess glucose from the blood. There is a severe lack of ability to store foodstuffs as glycogen, fat and protein. The response is lke starvation, so that there is an increase in gluconeogenesis and, therefore, an increase in the concentration of glucose. Loss of glucose in the urine osmotically brings with it the loss of water. With it comes dehydration. So the correct choice of #61 is #1 62. The correct choice is #1, hyperventilation. Alveolar ventilation is adequate for oxygenation when it matches the oxygen with its supply. Hypoventilation leads to a buildup of pCO2 and a decrease in pO2. The buildup of pCO? leads to an acidotic state in the blood, and since it is caused by a respiratory abnormality; that is, hypoventilation, itis referred to as respiratory acidosis. Likewise, hyperventilation leads to a decrease in pCO? and an increase in pO2 for an alkaline blood pH. This is called respiratory alkalosis. Drugs which depress the respiratory center in the medulla, such as barbiturates, will cause an acidosis. Also, some drugs may induce a hyperventilatory state, thus may induce a respiratory alkalosis. So again, the correct choice to question #62 is #1, hyperventilation. 63. The correct choice is #5, acetylcholine esterase. Acetylcholine is synthesized, then stored, released upon arrival of an action potential and then interacts with receptors of the postsynaptic membrane. Then the transmitter is removed from the synaptic cleft by acetylcholine esterase. Acetylcholine is used by motor neurons of the spinal cord and at the nerve-muscle junction. It is also the transmitter for all autonomic preganglionic neurons and of parasympathetic postganglionic neurons. Acetylcholine is located also in the brain, and itis thought to be highly concentrated in the substantia innominata region of the basal ganglia. ‘The receptor of acetylcholine determines if it will be an excitatory or an inhibitory action. Once a transmitter bonds to the receptor it must be disposed of in order to end the signal. This can be done through diffusion, enzymatic degradation or reuptake by the presynaptic cel. Reuptake is the most common method. However, the best choice here is via acetylcholine esterase. So again, the correct choice to question #63 is #5. 64. The correct choice is #1, atonic. This is a simple definition-type problem. An atonic muscle will be flaccid. The muscle will be freely movable, and lies without tone. This occurs with lower motor neuron lesions; that is, the destruction of the alpha motor neurons. Spasticity is a hypertonus state of the affected muscles. This is due to a release of the tonic inhibition of the brainstem, facilitory information which leads to gamma motor neuron excitation. ‘Thus, hyperactivity of the gamma fibers causes ‘exaggerated response to stretch of muscle spindles. Hypotonia is simply a decrease in alpha motor neuron stimulation; however, not a ‘complete destruction. So therefore we have partial tone loss. So again, the correct choice to question #64 is #1, atonic. KAPLAN 3NDB-1 68. The correct choice is #2, a carbon atom with four different groups attached to it. A good example of an asymmetric carbon is the alpha carbon of an amino acid. The amino acid must not, however, be glycine, since glycine amino acids have an alpha carbon ‘with two hydrogens attached to it. Asymmetric means that no matter how you look at it, you cannot find a plane of symmetry in the molecule. Also, asymmetric carbons are optically active; that is, they rotate the plane of polarized light to either the right or the left, clockwise or counterclockwise, The carbon is also referred to as chiral. An achiral carbon is a carbon atom with at least two substituents identical. The alpha carbon of the amino acid glycine, again, is a good example an achiral carbon, since it has two hydrogens on it as well as the COO- and the NH3. So again, the correct choice to question #65 is #2. 66. The correct choice is #4, increased concentration of colloids in plasma diminishes the formation of filtrate. The functional aspects of filtration can help you understand this question. Number 1: The smaller the molecular size of the solute in relation to the pore diameter the greater the likelihood of entering the pore being filtered. These pores are the highly fenestrated endothelium of the ‘glomerular capillary. Molecules larger than the pore diameter of 1000 A are hindered sterically. An increase in the molecular sieving diminishes the formation of filtrate. Molecular sieving refers to the decrease in concentration of a solute from plasma water to glomerular filtrate. The sieving coefficient equals the filtrate concentration in the Bowman's space/concentration in plasmal water. With a decrease in filtration small solutes passing freely have a coefficient of 1, $0 again, the correct choice is #4. 67. The correct choice is #1, after translation. Collagen is a protein, and itis produced in the rough endoplasmic reticulum. Each unit of collagen is composed of three protein strands, with carbohydrates attached. Each collagen unit consists of three tropocollagen, units which assemble in a quarter stagger to form a collagen fiber. Post-translational modification of collagen occurs when hydroxylation of proline and lysine occurs. So the correct choice is #1 68. The correct choice is #4, hyaluronidase. Hyaluronidase is a proteolytic enzyme which acts on hyaluronic acid. Ground substance is produced by connective tissue cells and contains large proteins with complex carbohydrate chains attached, The carbohydrates act to hold the ground substance together by twisting and coiling. So, in summary, ground substance is made up of proteins with carbohydrates attached. Hyaluronic acid is one such protein. Hyaluronidase will depolymerize the ground substance, since the ground substance is made up of hyaluronic acid. So again, the correct choice is #4. 69, The comect choice is #5, from polyunsaturated fatty acids. Prostaglandin synthesis occurs in cell membranes, utilizing polyunsaturated fatty acids. A prostaglandin is a 20-carbon fatty acid which has contained in its structure a $-carbon ring. The prostaglandins are hormone fine tuners. They are, therefore, not hormones. Some prostaglandins are PGEL, which functions in the breakdown of fat; PGE2, which induces delivery, playing a key role in parturition. PGF2-alpha is another prostaglandin. This functions by decreasing the secretion of progesterone. Prostaglandin synthetase is a key enzyme in prostaglandin synthesis. Another name for this enzyme is cyclooxygenase, since it is involved inthe formation of the five-membered ring of this 20-carbon compound. The reason I mention cyclooxygenase is that itis important to know that aspirin inhibits the formation of prostaglandins by inhibiting the cyclooxygenase. Prostaglandins exacerbate the inflammation reaction. So again, the correct choice is #5, from polyunsaturated fatty acids 70. The correct choice is #5, prolonged exposure to a cold environment. There are wo forms of thyroid hormone, T3, triiodothyronine and T4,thyroxin. ‘The thyroid hormones travel inthe blood, largely bound to plasma proteins in equilibrium with free hormones. Most of the T3 and TS is bound to thyroxine binding globulin. T3 is more active, but present at much lower plasma levels than T4, Under thyroid stimulating hormone stimulation the apical membrane of the thyroid follicles undergo marked evelopment of the microvilli projecting ino the colloid. The epithelial cell microvilli engulf peripheral colloid from the periphery of the follicles. Phagocytic vacuoles containing colloids fuse with lysosomes, and lysosomal proteases break down the thyroglobulin {nto small peptides, which include T3 and T4. Thyroid hormones are essential to survival in the cold. Normal animals quickly adapt to increase their oxygen consumption, catecholamines and increase muscular activity. These are the direct agents of the adaptation, and ‘T3 and TS are permissive to the actions of catecholamines. So again, the correct choice to question #70 is 5, prolonged exposure to a cold environment. 71. The correct choice is #2, decreases. Severe exercise will increase the demands on the muscle to a point where it must rely on glycolysis for the energy. Lactic acid, as a result, will be produced. This produces an acidotic state. Acidosis will increase ‘ventilation, along with increasing the number of open capillaries, o increase surface area. An increase in the cardiac output causes an increase in the capillary blood flow. All of these factors tend to decrease the concentration of the lactic acid in the blood and return it to its normal pre-exercise conditions. So again, the correct choice to #71 is 2. 72. The correct choice is #4, vitamin K. Vitamin K can be supplied to humans by the normal action of intestinal flora. Vitamin K is a key factor in the synthesis of prothrombin. In the absence of vitamin K or in the presence of dicumarol or warfarin prothrombin is not produced. Prothrombin binds to calcium, and in the presence of these antagonists of vitamin K it does not bind 10 calcium, Prothrombin, via activated factor X is converted into thrombin, This is modified by factor V. When calcium binds to 26 ‘as developed by