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      // ── TITLE PAGE ──
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        children: [
          new TextRun({ text: "HYGIENE & ECOLOGY", bold: true, size: 36, font: "Calibri" })
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        children: [
          new TextRun({ text: "EXAM ESSAYS – ATMOSPHERE & AIR", bold: true, size: 28, font: "Calibri" })
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        children: [
          new TextRun({ text: "Medical University – Plovdiv | 3rd Year, VI Semester", size: 22, italics: true, font: "Calibri" })
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        children: [
          new TextRun({ text: "Topics 1–5 | Prepared for MCQ & Oral Examination", size: 22, italics: true, font: "Calibri" })
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      // ── TABLE OF CONTENTS (manual) ──
      new Paragraph({ heading: HeadingLevel.HEADING_1, children: [new TextRun({ text: "Contents", bold: true, size: 28 })] }),
      ...[
        "Essay 1 – Hygiene as a Main Prophylactic Medical Science",
        "Essay 2 – Atmosphere: Importance, Structure and Air Composition",
        "Essay 3 – Hygiene Characteristics of Physical Factors of the Atmosphere",
        "Essay 4 – Climate, Weather, Meteotropic Diseases and Acclimatization",
        "Essay 5 – Air Pollutants, Smog and Prevention of Air Pollution",
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      // ══════════════════════════════════════════════════
      // ESSAY 1
      // ══════════════════════════════════════════════════
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      new Paragraph({ spacing: { after: 120 }, children: [new TextRun({ text: "Hygiene is the science of health preservation and disease prevention. Its name derives from the Greek word 'hygienos' (healthy). As the principal prophylactic (preventive) medical science, hygiene studies the influence of environmental factors – physical, chemical, biological, and social – on human health and the capacity for work. The ultimate goal is to develop hygienic norms, rules, and recommendations that protect individual and population health.", size: 22 })] }),

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      ...[ 
        "1. Study the influence of environmental factors on the human organism.",
        "2. Identify and evaluate health risks in the environment.",
        "3. Establish hygienic norms and standards (maximum permissible concentrations – MPC).",
        "4. Develop preventive measures and health-protective recommendations.",
        "5. Perform state sanitary control and epidemiological surveillance."
      ].map(t => new Paragraph({ spacing: { after: 60 }, indent: { left: 360 }, children: [new TextRun({ text: t, size: 22 })] })),

      new Paragraph({ heading: HeadingLevel.HEADING_2, spacing: { before: 160, after: 80 }, children: [new TextRun({ text: "Main Branches of Hygiene", bold: true, size: 26 })] }),
      ...[
        "• Communal (Environmental) Hygiene – air, water, soil, housing, urban areas.",
        "• Occupational (Labour) Hygiene – work conditions, occupational hazards.",
        "• Nutrition Hygiene – food quality, nutritional adequacy, foodborne diseases.",
        "• Childhood and Adolescent Hygiene – development, schools, physical education.",
        "• Hospital Hygiene – healthcare facilities, nosocomial infections.",
        "• Radiation Hygiene – ionizing and non-ionizing radiation.",
        "• Social Hygiene and Healthcare Organisation.",
      ].map(t => new Paragraph({ spacing: { after: 60 }, indent: { left: 360 }, children: [new TextRun({ text: t, size: 22 })] })),

      new Paragraph({ heading: HeadingLevel.HEADING_2, spacing: { before: 160, after: 80 }, children: [new TextRun({ text: "Methods Used in Hygiene", bold: true, size: 26 })] }),
      ...[
        "• Epidemiological method – population-based studies of disease distribution and determinants.",
        "• Hygienic investigation – measurement and assessment of environmental factors.",
        "• Laboratory methods – chemical, physical, microbiological analysis.",
        "• Experimental methods – animal studies, controlled human experiments.",
        "• Statistical methods – analysis and interpretation of health data.",
        "• Social and questionnaire methods – surveys, interviews.",
      ].map(t => new Paragraph({ spacing: { after: 60 }, indent: { left: 360 }, children: [new TextRun({ text: t, size: 22 })] })),

      new Paragraph({ heading: HeadingLevel.HEADING_2, spacing: { before: 160, after: 80 }, children: [new TextRun({ text: "MCQ Key Points to Remember", bold: true, size: 26, color: "C00000" })] }),
      ...[
        "✔ Hygiene is the PRIMARY prophylactic (preventive) science – not therapeutic.",
        "✔ Hygienic norms define the Maximum Permissible Concentration (MPC) of harmful substances.",
        "✔ State sanitary control is carried out by the Regional Health Inspectorate (RHI).",
        "✔ Methods include both field (investigation) and laboratory approaches.",
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      new Paragraph({ heading: HeadingLevel.HEADING_2, spacing: { before: 160, after: 80 }, children: [new TextRun({ text: "Oral Exam Tips", bold: true, size: 26, color: "375623" })] }),
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      new Paragraph({ children: [new PageBreak()] }),

      // ══════════════════════════════════════════════════
      // ESSAY 2
      // ══════════════════════════════════════════════════
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      new Paragraph({ spacing: { after: 120 }, children: [new TextRun({ text: "The atmosphere is the gaseous envelope surrounding the Earth. It is indispensable for life because it: (1) provides oxygen for respiration; (2) absorbs harmful ultraviolet (UV) solar radiation via the ozone layer; (3) retains heat through the greenhouse effect, stabilising surface temperatures; (4) reduces day-night temperature extremes (diurnal variation). Without the atmosphere, life as we know it would be impossible.", size: 22 })] }),

      new Paragraph({ heading: HeadingLevel.HEADING_2, spacing: { before: 160, after: 80 }, children: [new TextRun({ text: "Structure of the Atmosphere", bold: true, size: 26 })] }),
      ...[
        "• Troposphere (0–10 km): Contains ~80% of atmospheric air mass. This is the layer of immediate hygienic importance – the layer we breathe, where weather occurs and air pollution takes place. When hygienists refer to 'the atmosphere,' they mean the troposphere.",
        "• Stratosphere (10–50 km): Contains the ozone layer that absorbs UV radiation. Ozone depletion in this layer increases UV reaching the surface, raising the risk of skin cancer.",
        "• Mesosphere (50–80 km): Temperatures drop with altitude; meteors burn up here.",
        "• Thermosphere (80–500 km): Very high temperatures due to solar radiation absorption.",
        "• Exosphere (500–10,000 km): Outer boundary; merges with space; interacts with the magnetosphere.",
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      ...[
        "• Nitrogen (N₂): 78.1% – Serves to dilute oxygen. Under normal pressure it has no physiological effect. At high pressures (deep diving >30 m) it can cause nitrogen narcosis.",
        "• Oxygen (O₂): 20.9% – Essential for respiration. Critical hygiene value: 17 vol% (fatigue and discomfort begin). At 8 vol% → death. Patients with anaemia, CVD or lung disease are more sensitive to oxygen deficiency.",
        "• Carbon Dioxide (CO₂): 0.03–0.04% – Used as a marker of air quality in closed spaces and ventilation adequacy. >2 vol% causes severe breathing difficulty. It plays a role in climate formation (greenhouse gas).",
        "• Others (Ar, Ne, Kr, Xe, He, Rn): ~1% – Rare gases; Radon (Rn) is important as a naturally occurring radioactive gas that can accumulate in poorly ventilated indoor spaces, increasing lung cancer risk.",
        "• Water vapour: Variable – significant for humidity and thermoregulation.",
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      ...[
        "✔ Troposphere = 80% of atmospheric air = hygienic importance layer.",
        "✔ Air is a mechanical mixture (NOT a chemical compound).",
        "✔ N₂ = 78.1%, O₂ = 20.9%, CO₂ = 0.03–0.04%.",
        "✔ O₂ critical level = 17 vol% (feeling of fatigue); death at 8 vol%.",
        "✔ CO₂ >2 vol% = severe breathing difficulty.",
        "✔ CO₂ used to assess air quality/ventilation in closed rooms.",
        "✔ Radon – naturally radioactive gas; lung cancer risk indoors.",
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      new Paragraph({ heading: HeadingLevel.HEADING_2, spacing: { before: 160, after: 80 }, children: [new TextRun({ text: "Oral Exam Tips", bold: true, size: 26, color: "375623" })] }),
      new Paragraph({ spacing: { after: 120 }, children: [new TextRun({ text: "Start with: 'The atmosphere is the gaseous envelope of the Earth retained by gravity.' Then describe its 5 layers with altitudes. Emphasise that for hygiene purposes the troposphere is most important. When discussing air composition, always state the exact percentages. A common oral question is about CO₂ – distinguish its atmospheric level (0.03–0.04%) from its indoor warning level (>2%) and its role as an air quality indicator in ventilation assessment.", size: 22 })] }),

      new Paragraph({ children: [new PageBreak()] }),

      // ══════════════════════════════════════════════════
      // ESSAY 3
      // ══════════════════════════════════════════════════
      new Paragraph({ heading: HeadingLevel.HEADING_1, spacing: { before: 200, after: 160 }, children: [new TextRun({ text: "Essay 3: Hygiene Characteristics of Physical Factors of the Atmosphere", bold: true, size: 30, color: "1F4E79" })] }),

      new Paragraph({ spacing: { after: 120 }, children: [new TextRun({ text: "Physical factors of the atmosphere are highly variable compared to chemical composition. Their instability directly affects human health and working capacity. They are divided into two main groups:", size: 22 })] }),
      ...[
        "1. Meteorological factors: atmospheric pressure, air temperature, humidity, air velocity, atmospheric electricity, air ionisation.",
        "2. Space-origin factors: solar radiation (UV, visible, IR), heliomagnetic factors.",
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      new Paragraph({ heading: HeadingLevel.HEADING_2, spacing: { before: 160, after: 80 }, children: [new TextRun({ text: "I. Atmospheric (Barometric) Pressure", bold: true, size: 26 })] }),
      new Paragraph({ spacing: { after: 80 }, children: [new TextRun({ text: "Normal atmospheric pressure at sea level is ~760 mmHg (1 atm). It is equalised in body cavities via the respiratory tract.", size: 22 })] }),
      new Paragraph({ spacing: { after: 60 }, children: [new TextRun({ text: "A. Health Effects of INCREASED Pressure (hyperbaric – diving, caissons):", bold: true, size: 22 })] }),
      ...[
        "• Ear barotrauma (barotitis) – relative vacuum in middle ear; feeling of fullness, decreased hearing.",
        "• The 'Squeeze' – dyspnoea, heavy chest sensation, bulging eyes, haemorrhages in lungs/GIT/nose.",
        "• Nitrogen narcosis – occurs at depths >30 m; symptoms: numbness, incoordination, hallucination, unconsciousness. Prevented by breathing helium-depleted nitrogen mixtures.",
        "• Decompression sickness (DS) – rapid decompression causes nitrogen bubble formation in blood and tissues → capillary blockage and emboli. If in lungs: dyspnoea, pulmonary oedema. If in brain: convulsions, hemiplegia, coma.",
      ].map(t => new Paragraph({ spacing: { after: 60 }, indent: { left: 720 }, children: [new TextRun({ text: t, size: 22 })] })),
      new Paragraph({ spacing: { after: 60 }, children: [new TextRun({ text: "B. Health Effects of DECREASED Pressure (hypobaric – high altitude):", bold: true, size: 22 })] }),
      ...[
        "• Acute Mountain Sickness (altitude sickness) – headache, vomiting, impaired vision.",
        "• High-altitude pulmonary oedema – occurs ~day 3 at altitude; cough, Cheyne-Stokes breathing.",
        "Note: O₂ percentage remains 20.9% but the barometric partial pressure of O₂ decreases, reducing the alveolar-tissue O₂ gradient.",
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      new Paragraph({ heading: HeadingLevel.HEADING_2, spacing: { before: 160, after: 80 }, children: [new TextRun({ text: "II. Air Temperature", bold: true, size: 26 })] }),
      new Paragraph({ spacing: { after: 80 }, children: [new TextRun({ text: "Air is heated primarily by infrared radiation from the ground (not directly by the sun – only ~0.02% direct heating). Factors affecting air temperature: geographic latitude, altitude, wind direction, proximity to sea or large water bodies, vegetation.", size: 22 })] }),
      new Paragraph({ spacing: { after: 80 }, children: [new TextRun({ text: "Average annual temperature in Bulgaria: 11.5°C. Thermal equilibrium between body and environment occurs through radiation, conduction, convection, and evaporation (perspiration). It depends on air temperature, radiant temperature, humidity, air movement, and metabolic rate.", size: 22 })] }),
      new Paragraph({ spacing: { after: 80 }, children: [new TextRun({ text: "Heat-related disorders: heat stroke (thermoregulation failure), sun stroke (direct sun on head), heat exhaustion, heat syncope, cold stress.", size: 22 })] }),

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      new Paragraph({ spacing: { after: 80 }, children: [new TextRun({ text: "Humidity = water vapour content of air. Expressed as ABSOLUTE (actual g/m³) or RELATIVE humidity (% of maximum possible at that temperature). Hygienic norm for relative humidity: 30–60%.", size: 22 })] }),
      new Paragraph({ spacing: { after: 80 }, children: [new TextRun({ text: "Dew point: temperature at which air becomes saturated and water condenses. Measured with a psychrometer (MCQ: What measures air humidity? = Psychrometer/Psychrometry).", size: 22 })] }),
      new Paragraph({ spacing: { after: 80 }, children: [new TextRun({ text: "Role in thermoregulation: High humidity at high temperature → impairs evaporation of sweat → heat accumulation. Low humidity in winter → dryness of mucous membranes → increased infections.", size: 22 })] }),

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      new Paragraph({ spacing: { after: 80 }, children: [new TextRun({ text: "Together with air temperature, humidity, and direction, air velocity determines the microclimate of a given area. Measured with an ANEMOMETER. High air velocity at low temperature → increases convective heat loss → risk of hypothermia. High air velocity at high temperature → beneficial cooling effect.", size: 22 })] }),

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      ...[
        "• UV radiation (<400 nm): Non-specific effects – stimulates metabolism of proteins, lipids, carbohydrates; increases melanin production; improves reactivity. Short UV = bactericidal. Middle UV = anti-rickets effect (Vitamin D synthesis). Long UV = cataracts (cumulative in workers), retinal damage, skin erythema (sunburn), skin cancer. MCQ: 'You cannot see UV but you can feel it' = FALSE (you cannot see OR feel UV – IR is felt as heat).",
        "• Visible radiation (400–760 nm): Eye strain (asthenopia). Can disturb circadian rhythms affecting sleep, activity, food intake.",
        "• Infrared radiation (IR, >760 nm): 59% of solar radiation at Earth's surface. Penetrates skin → heating. Chronic exposure → cataract, corneal/iris/retinal damage.",
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      new Paragraph({ spacing: { after: 80 }, children: [new TextRun({ text: "Positive air ions INCREASE in polluted areas and indoors → unfavourable effects. Negative air ions PREDOMINATE in mountains, forests, near the sea and waterfalls → indicator of air purity → favourable health effects. Air ionisers use high voltage to produce negative ions for air purification.", size: 22 })] }),

      new Paragraph({ heading: HeadingLevel.HEADING_2, spacing: { before: 160, after: 80 }, children: [new TextRun({ text: "MCQ Key Points to Remember", bold: true, size: 26, color: "C00000" })] }),
      ...[
        "✔ Air humidity measured by psychrometer. Hygienic norm: 30–60%.",
        "✔ Air velocity measured by anemometer.",
        "✔ Nitrogen narcosis at depths >30 m.",
        "✔ Decompression sickness = nitrogen bubbles from rapid ascent.",
        "✔ UV radiation: CANNOT be seen or felt (unlike IR which you feel as heat).",
        "✔ IR = 59% of solar radiation at Earth's surface.",
        "✔ Negative air ions = clean air (mountains, forests, waterfalls).",
        "✔ WBGT (Wet Bulb Globe Temperature) index = physical method for complex microclimate evaluation.",
      ].map(t => new Paragraph({ spacing: { after: 60 }, indent: { left: 360 }, children: [new TextRun({ text: t, size: 22, italics: true })] })),

      new Paragraph({ heading: HeadingLevel.HEADING_2, spacing: { before: 160, after: 80 }, children: [new TextRun({ text: "Oral Exam Tips", bold: true, size: 26, color: "375623" })] }),
      new Paragraph({ spacing: { after: 120 }, children: [new TextRun({ text: "Structure your answer around the two groups: (1) meteorological factors and (2) space-origin factors. For each factor give: normal values/characteristics, health effects of excess/deficit, and measurement tools. Air temperature measurement tools include maximum/minimum thermometers, thermographs. Humidity tools: psychrometer, hygrometer. Air velocity: anemometer, katathermometer. Commonly asked oral topic: 'Air Temperature – measurement, tools, method' – describe the instruments (thermometers, thermograph for continuous recording, kata thermometer which measures both air temperature and velocity together for cooling power assessment).", size: 22 })] }),

      new Paragraph({ children: [new PageBreak()] }),

      // ══════════════════════════════════════════════════
      // ESSAY 4
      // ══════════════════════════════════════════════════
      new Paragraph({ heading: HeadingLevel.HEADING_1, spacing: { before: 200, after: 160 }, children: [new TextRun({ text: "Essay 4: Climate, Weather, Meteotropic Diseases and Acclimatization", bold: true, size: 30, color: "1F4E79" })] }),

      new Paragraph({ heading: HeadingLevel.HEADING_2, spacing: { before: 160, after: 80 }, children: [new TextRun({ text: "Definitions", bold: true, size: 26 })] }),
      new Paragraph({ spacing: { after: 80 }, children: [new TextRun({ text: "CLIMATE: The long-term weather regime specific to a given territory. It is a dynamic complex of meteorological and cosmic factors over a long period of time, characterised by the average expression of: atmospheric pressure, air temperature, humidity, wind velocity, solar radiation, precipitation, and atmospheric electricity.", size: 22 })] }),
      new Paragraph({ spacing: { after: 80 }, children: [new TextRun({ text: "WEATHER: A dynamic complex of meteorological factors for a given place over a SHORT period of time.", size: 22 })] }),

      new Paragraph({ heading: HeadingLevel.HEADING_2, spacing: { before: 160, after: 80 }, children: [new TextRun({ text: "Climate Classification", bold: true, size: 26 })] }),
      ...[
        "• Macroclimate – related to a broad geographic zone.",
        "• Mesoclimate – climate of small surface areas, not representative of the district climate.",
        "• Microclimate – climate of a limited area or closed room (e.g. indoor microclimate).",
      ].map(t => new Paragraph({ spacing: { after: 60 }, indent: { left: 360 }, children: [new TextRun({ text: t, size: 22 })] })),
      new Paragraph({ spacing: { after: 80 }, children: [new TextRun({ text: "Geographic climate zones (by isothermal lines connecting places with equal mean annual temperature):", size: 22 })] }),
      ...[
        "1. Tropical – all 12 months ≥18°C; minimal seasonal variation; precipitation dominates seasons.",
        "2. Subtropical – 8 months ≥10°C; coldest month 2–13°C.",
        "3. Moderate (Temperate) – moderate winds and rains; Bulgaria is in the moderate zone.",
        "4. Cold (Polar) – every month <10°C; covers >20% of Earth.",
      ].map(t => new Paragraph({ spacing: { after: 60 }, indent: { left: 360 }, children: [new TextRun({ text: t, size: 22 })] })),

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      ...[
        "• Optimal weather – small temperature amplitude over 24 hours (~2°C), sunny days, wind ≤3 m/s.",
        "• Irritating weather – one or more factors out of optimal range; wind up to 8 m/s, high temperature amplitude.",
        "• Sharp weather – sharp/sudden changes in meteorological factors.",
      ].map(t => new Paragraph({ spacing: { after: 60 }, indent: { left: 360 }, children: [new TextRun({ text: t, size: 22 })] })),

      new Paragraph({ heading: HeadingLevel.HEADING_2, spacing: { before: 160, after: 80 }, children: [new TextRun({ text: "Meteotropic Effects and Diseases", bold: true, size: 26 })] }),
      new Paragraph({ spacing: { after: 80 }, children: [new TextRun({ text: "Meteotropic diseases are those triggered or worsened by changes in meteorological conditions. Organisms adapt well to slow changes but not to sharp ones. Sensitive groups: people with chronic cardiovascular disease, arterial hypertension, neuroses, neuropathies, cerebrovascular disease, arthritis.", size: 22 })] }),
      ...[
        "• Cold air → bronchospasm, spastic bronchial reaction.",
        "• Hot weather → heat stroke, increased cardiovascular mortality (peripheral vasodilation → increased central blood pressure).",
        "• Rapid temperature drops → changes in blood pH, blood pressure, urinary volume, tissue permeability.",
        "• Humidity: Low relative humidity in winter → increased infection frequency. High humidity at high temperature → impaired evaporative cooling.",
        "• Barometric pressure changes: Rapid drops associated with increased migraine attacks.",
        "• Frontal passages (rapid large weather changes) → profound effects on mortality.",
        "• Seasonal: Bronchitis, peptic ulcer, adrenal ulcer, glaucoma, goitre, eczema, herpes zoster relate to seasonal temperature variation.",
        "• Weather affects birth rates, sperm counts, outbreaks of pneumonia, influenza, and bronchitis.",
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      new Paragraph({ heading: HeadingLevel.HEADING_2, spacing: { before: 160, after: 80 }, children: [new TextRun({ text: "Acclimatization", bold: true, size: 26 })] }),
      new Paragraph({ spacing: { after: 80 }, children: [new TextRun({ text: "Acclimatization is the adaptation of the organism to different climate conditions.", size: 22 })] }),
      ...[
        "• Acclimatization to HOT climate: difficult, especially with high humidity. Adaptation period: 12–14 days.",
        "• Acclimatization to COLD climate: occurs after ~10 days.",
        "• Geographical acclimatization: people moving from cool to subtropical climate often adapt within 2 weeks.",
        "• Factors supporting fast acclimatization: healthy nutrition, healthy lifestyle, climate-appropriate clothing, proper microclimate at workplaces and homes.",
        "• Population susceptibility: During successive heat waves, excess mortality is lower in the second wave than the first. Reason: (1) weak/susceptible individuals die in early heat waves; (2) survivors become physiologically acclimatised.",
      ].map(t => new Paragraph({ spacing: { after: 60 }, indent: { left: 360 }, children: [new TextRun({ text: t, size: 22 })] })),

      new Paragraph({ heading: HeadingLevel.HEADING_2, spacing: { before: 160, after: 80 }, children: [new TextRun({ text: "Climate Change", bold: true, size: 26 })] }),
      new Paragraph({ spacing: { after: 80 }, children: [new TextRun({ text: "Climate change refers to variation in global/regional climates over time (decades to millions of years). In modern usage: mainly refers to global warming (rising average surface temperatures) due to increased greenhouse gases (CO₂, methane). Health implications: increased heat-wave mortality, spread of vector-borne diseases, changes in food security.", size: 22 })] }),

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      ...[
        "✔ Bulgaria = moderate (temperate) climatic zone.",
        "✔ Acclimatization to hot climate = 12–14 days; cold = ~10 days.",
        "✔ Optimal weather: temperature amplitude ~2°C/24h; wind ≤3 m/s.",
        "✔ Sharp weather = sudden changes in meteorological factors.",
        "✔ Most vulnerable to meteotropic effects: CVD, hypertension, cerebrovascular, arthritis patients.",
        "✔ Hot weather extremes cause more mortality than cold wave episodes.",
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      new Paragraph({ children: [new PageBreak()] }),

      // ══════════════════════════════════════════════════
      // ESSAY 5
      // ══════════════════════════════════════════════════
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      ...[
        "• PRIMARY pollutants – directly emitted from a source (e.g. CO from vehicle exhaust, SO₂ from factories, ash from volcanoes).",
        "• SECONDARY pollutants – not directly emitted; formed by reactions of primary pollutants in the atmosphere (e.g. ground-level ozone from NOₓ + UV light = photochemical smog). Some pollutants are BOTH (e.g. ozone, certain particulates).",
      ].map(t => new Paragraph({ spacing: { after: 60 }, indent: { left: 360 }, children: [new TextRun({ text: t, size: 22 })] })),
      new Paragraph({ spacing: { after: 60 }, children: [new TextRun({ text: "By form:", bold: true, size: 22 })] }),
      ...[
        "• Gaseous: CO, SO₂, NOₓ, ozone, volatile organic compounds (VOCs).",
        "• Particulate: PM₁₀, PM₂.₅ (fine particles) – suspended solid/liquid particles.",
      ].map(t => new Paragraph({ spacing: { after: 60 }, indent: { left: 360 }, children: [new TextRun({ text: t, size: 22 })] })),

      new Paragraph({ heading: HeadingLevel.HEADING_2, spacing: { before: 160, after: 80 }, children: [new TextRun({ text: "Sources of Air Pollution", bold: true, size: 26 })] }),
      ...[
        "1. TRANSPORT (main urban source): Motor vehicles emit hydrocarbons, CO, lead (Pb), NOₓ, and particulate matter. Responsible for ~2/3 of CO emissions. Strong sunlight converts NOₓ into photochemical (oxidising) pollutants → photochemical smog.",
        "2. INDUSTRY: Metal-working (NOₓ, CO, CO₂, Pb, Mn, SO₂); chemical industry (NO₂, CO, CO₂, SO₂, VOCs); power stations (CO, NO₂, SO₂, ammonia, dust).",
        "3. DOMESTIC: Combustion of coal = major source of smoke, dust, SO₂, NOₓ. TOBACCO SMOKE = most direct and important source affecting individual health (including passive smokers).",
        "4. NATURAL: Volcanic activity (less important than anthropogenic); desert dust; forest fires.",
      ].map(t => new Paragraph({ spacing: { after: 80 }, indent: { left: 360 }, children: [new TextRun({ text: t, size: 22 })] })),

      new Paragraph({ heading: HeadingLevel.HEADING_2, spacing: { before: 160, after: 80 }, children: [new TextRun({ text: "Major Air Pollutants and Health Effects", bold: true, size: 26 })] }),
      ...[
        "• Carbon Monoxide (CO): Colourless, odourless, non-irritating but VERY POISONOUS. Product of incomplete combustion. Binds haemoglobin (250x stronger than O₂) → carboxyhaemoglobin → tissue hypoxia. Major source: vehicles (~2/3 of all CO).",
        "• Sulfur Dioxide (SO₂): From coal/petroleum combustion and volcanoes. Oxidises to H₂SO₄ → acid rain. Component of WINTER (acid) smog. Causes acute bronchitis; chronic exposure → chronic bronchitis, lung damage.",
        "• Nitrogen Oxides (NOₓ): From high-temperature combustion and vehicles. NO₂ = reddish-brown, sharp odour. Primary concern = ozone precursor. Indoor source: gas cooking appliances.",
        "• Ozone (O₃): Strong oxidising agent. Secondary pollutant (no direct anthropogenic source). Formed by photochemical reactions of NOₓ + VOCs + UV. Highest in polluted summer air → photochemical smog. Irritates respiratory tract.",
        "• Volatile Organic Compounds (VOCs): Industrial processes, fuel combustion. Carcinogenic risk: benzene = human carcinogen; ethanol, methanol, formaldehyde = animal carcinogens.",
        "• Particulate Matter (PM): Fine particles (PM₂.₅, PM₁₀) from burning fossil fuels, vehicles, industry. Penetrate deep into lungs → heart disease, altered lung function, lung cancer.",
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      ...[
        "• WINTER (London/Acid) smog: Classic type. Large amounts of coal burning → mixture of smoke + SO₂. Temperature inversion in winter traps pollutants at lower atmospheric levels. Associated with cold, humid conditions.",
        "• SUMMER (Photochemical/Los Angeles) smog: Modern type. Originates from vehicle/industrial emissions + UV sunlight → secondary photochemical pollutants (ozone, peroxyacetyl nitrate) + primary emissions. Oxidising in nature. Associated with hot, sunny conditions.",
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        "• Intensity of emissions",
        "• Air temperature (temperature inversion)",
        "• Direction of wind",
        "• Distance from source",
        "• Height of chimneys",
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        "• Immediate effects: acute bronchitis (respiratory system primarily affected).",
        "• Delayed effects: chronic bronchitis, lung cancer, bronchial asthma, respiratory allergies.",
        "• Most vulnerable: elderly, children, smokers, people with chronic respiratory disease.",
      ].map(t => new Paragraph({ spacing: { after: 60 }, indent: { left: 360 }, children: [new TextRun({ text: t, size: 22 })] })),
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        "• Destruction of plant and animal life.",
        "• Corrosion of metals, damage to buildings.",
        "• Reduced visibility in towns.",
        "• Chemicals entering the food chain via polluted soil and water.",
      ].map(t => new Paragraph({ spacing: { after: 60 }, indent: { left: 360 }, children: [new TextRun({ text: t, size: 22 })] })),

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        "1. PLANNING: Large pollution sources must be located OUTSIDE urban areas according to hygienic requirements. Sanitary protective zones between industrial and residential areas.",
        "2. TECHNICAL improvements: Efficient catalytic converters in vehicle exhaust systems; electric filters and technical means for reducing industrial emissions; transition to cleaner fuels and renewable energy.",
        "3. AIR POLLUTION MONITORING AND CONTROL: National air monitoring systems (Bulgaria's system is part of the European monitoring system). Standardised measurement equipment and procedures.",
        "4. MONITORING OF HUMAN HEALTH: Epidemiological studies; surveillance of risk population groups (children, pregnant women, elderly).",
        "5. LEGISLATION: Environmental laws setting maximum permissible concentrations (MPCs) for pollutants.",
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        "✔ Winter smog = smoke + SO₂ (acid smog, from coal). Summer smog = photochemical (from vehicles + UV).",
        "✔ Temperature inversion = traps pollutants at LOW levels; more common in WINTER.",
        "✔ CO = colourless, odourless, non-irritating but VERY poisonous.",
        "✔ SO₂ + NO₂ → acid rain (H₂SO₄, HNO₃).",
        "✔ Primary pollutant: directly emitted. Secondary: formed in atmosphere (ozone = secondary).",
        "✔ Most vulnerable to air pollution: elderly, children, smokers, chronic respiratory patients.",
        "✔ What would you expect in a classroom where children had been for a long time? = INCREASED AIR HUMIDITY (from breath + perspiration) and increased CO₂.",
        "✔ Benzene = HUMAN carcinogen (not just animal).",
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      // ── QUICK REFERENCE SUMMARY ──
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      ...[
        ["Air Composition", "N₂ = 78.1% | O₂ = 20.9% | CO₂ = 0.03–0.04%"],
        ["O₂ critical level", "17 vol% = fatigue; 8 vol% = death"],
        ["CO₂ indoor warning", ">2 vol% = severe breathing difficulty"],
        ["Relative Humidity Norm", "30–60%"],
        ["Optimal weather wind", "≤3 m/s; temp amplitude ~2°C/24h"],
        ["Irritating weather wind", "up to 8 m/s"],
        ["Acclimatization to heat", "12–14 days"],
        ["Acclimatization to cold", "~10 days"],
        ["Nitrogen narcosis depth", ">30 m underwater"],
        ["Bulgaria climate zone", "Moderate (temperate)"],
        ["Average annual temp Bulgaria", "11.5°C"],
        ["IR % of solar radiation", "59%"],
        ["UV measurement tool", "UV radiometer / Goerz actinometer"],
        ["Air velocity tool", "Anemometer"],
        ["Air humidity tool", "Psychrometer"],
        ["WBGT", "Physical method for complex microclimate evaluation"],
        ["Benzene", "Human carcinogen (VOC)"],
        ["Winter smog components", "Smoke + SO₂"],
        ["Summer smog", "Photochemical; vehicles + UV → ozone, PAN"],
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      // ── TITLE ──
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        alignment: AlignmentType.CENTER,
        spacing: { before: 300, after: 200 },
        children: [new TextRun({ text: "HYGIENE & ECOLOGY – MCQ PRACTICE BANK", bold: true, size: 36, font: "Calibri" })]
      }),
      new Paragraph({
        alignment: AlignmentType.CENTER,
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        children: [new TextRun({ text: "Topics 1–5: Hygiene Science | Atmosphere | Physical Factors | Climate & Weather | Air Pollution", size: 22, italics: true, font: "Calibri" })]
      }),
      new Paragraph({
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        spacing: { after: 400 },
        children: [new TextRun({ text: "Medical University Plovdiv | 3rd Year, VI Semester | 2025–2026", size: 22, font: "Calibri" })]
      }),
      note("Format: Single best answer (A–D) + True/False. Correct answers are shown in GREEN with explanations."),
      new Paragraph({ children: [new PageBreak()] }),

      // ════════════════════════════════════════
      // TOPIC 1 – HYGIENE AS A SCIENCE
      // ════════════════════════════════════════
      topicHead("TOPIC 1 – Hygiene as a Main Prophylactic Medical Science"),
      sectionHead("Single Best Answer"),

      Q(1, "What is the PRIMARY purpose of hygiene as a medical science?"),
      Opt("A", "Treatment of communicable diseases", false),
      Opt("B", "Preservation of health and prevention of disease", true),
      Opt("C", "Surgical interventions in emergency settings", false),
      Opt("D", "Rehabilitation of patients after illness", false),
      Ans("B – Hygiene is the principal PROPHYLACTIC (preventive) science, not therapeutic."),

      Q(2, "Which of the following is a correct definition of a hygienic norm?"),
      Opt("A", "The maximum dose of medication allowed per day", false),
      Opt("B", "The optimal concentration of a nutrient in food", false),
      Opt("C", "Maximum Permissible Concentration (MPC) of a harmful substance in the environment", true),
      Opt("D", "The minimum recommended daily exercise duration", false),
      Ans("C – Hygienic norms define MPCs for harmful substances in air, water, food, soil."),

      Q(3, "Which body carries out state sanitary control in Bulgaria?"),
      Opt("A", "Ministry of Agriculture", false),
      Opt("B", "National Centre for Public Health", false),
      Opt("C", "Regional Health Inspectorate (RHI)", true),
      Opt("D", "Municipal Council", false),
      Ans("C – State sanitary control is carried out by the Regional Health Inspectorate."),

      Q(4, "Which of the following is NOT a method used in hygiene?"),
      Opt("A", "Epidemiological method", false),
      Opt("B", "Laboratory chemical analysis", false),
      Opt("C", "Surgical intervention", true),
      Opt("D", "Statistical analysis of health data", false),
      Ans("C – Surgery is a clinical (therapeutic) method, not a hygienic method."),

      Q(5, "Which branch of hygiene deals with working conditions and occupational hazards?"),
      Opt("A", "Communal hygiene", false),
      Opt("B", "Childhood and adolescent hygiene", false),
      Opt("C", "Nutritional hygiene", false),
      Opt("D", "Occupational (labour) hygiene", true),
      Ans("D – Occupational hygiene focuses on work conditions, hazards, and prevention of occupational diseases."),

      Q(6, "The word 'hygiene' is derived from:"),
      Opt("A", "Latin 'hygiena' meaning cleanliness", false),
      Opt("B", "Greek 'hygienos' meaning healthy", true),
      Opt("C", "Arabic 'haj' meaning pilgrimage", false),
      Opt("D", "French 'hygiène' meaning order", false),
      Ans("B – Hygiene derives from Greek 'hygienos' (healthy), named after Hygieia, Greek goddess of health."),

      sectionHead("True / False"),
      ...TF(7, "Hygiene is a therapeutic science focused on curing diseases.", "FALSE", "Hygiene is PROPHYLACTIC (preventive), not therapeutic. It aims to prevent disease, not treat it."),
      ...TF(8, "The epidemiological method is one of the main methods used in hygiene.", "TRUE", "Epidemiological studies of disease distribution and determinants are a core hygiene method."),
      ...TF(9, "Hygienic norms are only applicable to air quality.", "FALSE", "Hygienic norms (MPCs) apply to air, water, soil, food, workplace environments, and radiation."),
      ...TF(10, "Medical ecology studies the mutual relationship between organisms and the environment.", "TRUE", "Medical ecology is closely related to hygiene and studies organism-environment interactions."),

      new Paragraph({ children: [new PageBreak()] }),

      // ════════════════════════════════════════
      // TOPIC 2 – ATMOSPHERE
      // ════════════════════════════════════════
      topicHead("TOPIC 2 – Atmosphere: Importance, Structure and Air Composition"),
      sectionHead("Single Best Answer"),

      Q(11, "What percentage of atmospheric air is found in the troposphere?"),
      Opt("A", "50%", false),
      Opt("B", "60%", false),
      Opt("C", "80%", true),
      Opt("D", "95%", false),
      Ans("C – The troposphere contains approximately 80% of atmospheric air mass."),

      Q(12, "Which atmospheric layer is of PRIMARY hygienic importance?"),
      Opt("A", "Stratosphere", false),
      Opt("B", "Troposphere", true),
      Opt("C", "Mesosphere", false),
      Opt("D", "Thermosphere", false),
      Ans("B – The troposphere (0–10 km) is where we breathe, weather occurs, and air pollution takes place."),

      Q(13, "Air is correctly described as:"),
      Opt("A", "A chemical compound of gases", false),
      Opt("B", "A homogeneous solution of gases", false),
      Opt("C", "A mechanical mixture of gases", true),
      Opt("D", "A colloid suspension of gases", false),
      Ans("C – Air is a MECHANICAL mixture, not a chemical compound."),

      Q(14, "What is the normal percentage of oxygen in atmospheric air?"),
      Opt("A", "17.0%", false),
      Opt("B", "20.9%", true),
      Opt("C", "78.1%", false),
      Opt("D", "0.04%", false),
      Ans("B – O₂ = 20.9%. N₂ = 78.1%, CO₂ = 0.03–0.04%."),

      Q(15, "At what oxygen concentration does the feeling of fatigue and discomfort begin in a room?"),
      Opt("A", "20%", false),
      Opt("B", "17%", true),
      Opt("C", "12%", false),
      Opt("D", "8%", false),
      Ans("B – 17 vol% O₂ is the critical hygiene concentration where fatigue and discomfort begin."),

      Q(16, "Death from oxygen deficiency occurs when O₂ concentration falls to:"),
      Opt("A", "17 vol%", false),
      Opt("B", "12 vol%", false),
      Opt("C", "10 vol%", false),
      Opt("D", "8 vol%", true),
      Ans("D – At 8 vol% O₂, death follows."),

      Q(17, "CO₂ concentration in outdoor atmospheric air is approximately:"),
      Opt("A", "0.003–0.004%", false),
      Opt("B", "0.03–0.04%", true),
      Opt("C", "0.3–0.4%", false),
      Opt("D", "3–4%", false),
      Ans("B – CO₂ in outdoor air = 0.03–0.04 vol%."),

      Q(18, "CO₂ concentration in a closed room is used as an indicator of:"),
      Opt("A", "Fire risk", false),
      Opt("B", "Air quality and ventilation adequacy", true),
      Opt("C", "Humidity level", false),
      Opt("D", "Bacterial contamination", false),
      Ans("B – CO₂ increases in poorly ventilated spaces and is the standard marker for air quality assessment."),

      Q(19, "At what indoor CO₂ concentration does severe difficulty in breathing occur?"),
      Opt("A", "0.1 vol%", false),
      Opt("B", "0.5 vol%", false),
      Opt("C", "2 vol%", true),
      Opt("D", "5 vol%", false),
      Ans("C – CO₂ >2 vol% causes severe difficulty in breathing."),

      Q(20, "Which naturally occurring radioactive gas can accumulate indoors and increase lung cancer risk?"),
      Opt("A", "Argon", false),
      Opt("B", "Krypton", false),
      Opt("C", "Radon", true),
      Opt("D", "Neon", false),
      Ans("C – Radon (Rn) is a naturally radioactive gas that seeps from soil/building materials and accumulates in poorly ventilated indoor spaces."),

      Q(21, "Which atmospheric layer contains the ozone layer that protects against UV radiation?"),
      Opt("A", "Troposphere", false),
      Opt("B", "Stratosphere", true),
      Opt("C", "Mesosphere", false),
      Opt("D", "Thermosphere", false),
      Ans("B – The stratosphere (10–50 km) contains the ozone layer."),

      Q(22, "Which group of patients is MOST sensitive to oxygen deficiency in indoor air?"),
      Opt("A", "Young athletes", false),
      Opt("B", "Healthy adults", false),
      Opt("C", "Patients with anaemia, CVD or lung disease", true),
      Opt("D", "Pregnant women only", false),
      Ans("C – Patients with anaemia, cardiovascular disease, or lung disease are most sensitive to O₂ deficiency."),

      sectionHead("True / False"),
      ...TF(23, "Air is a chemical compound of nitrogen and oxygen.", "FALSE", "Air is a MECHANICAL MIXTURE of gases, not a chemical compound."),
      ...TF(24, "Nitrogen at normal atmospheric pressure affects physiological functions.", "FALSE", "At normal pressure, N₂ has no physiological effect; it serves only to dilute oxygen."),
      ...TF(25, "CO₂ in expired air increases compared to inspired air.", "TRUE", "Expired air contains more CO₂ than inspired air because CO₂ is a product of cellular metabolism."),
      ...TF(26, "When hygienists refer to 'the atmosphere' they primarily mean the troposphere.", "TRUE", "The troposphere is the layer of immediate hygienic relevance for health and air quality."),

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      // ════════════════════════════════════════
      // TOPIC 3 – PHYSICAL FACTORS
      // ════════════════════════════════════════
      topicHead("TOPIC 3 – Hygiene Characteristics of Physical Factors of the Atmosphere"),
      sectionHead("Single Best Answer"),

      Q(27, "What instrument is used to measure AIR VELOCITY?"),
      Opt("A", "Psychrometer", false),
      Opt("B", "Barometer", false),
      Opt("C", "Anemometer", true),
      Opt("D", "Actinometer", false),
      Ans("C – An anemometer measures air velocity/speed."),

      Q(28, "What instrument is used to measure AIR HUMIDITY?"),
      Opt("A", "Thermometer", false),
      Opt("B", "Anemometer", false),
      Opt("C", "Psychrometer", true),
      Opt("D", "Barometer", false),
      Ans("C – A psychrometer (also: hygrometer) measures air humidity. MCQ term from 2026 exam."),

      Q(29, "What is the hygienic norm for relative air humidity?"),
      Opt("A", "10–20%", false),
      Opt("B", "30–60%", true),
      Opt("C", "50–80%", false),
      Opt("D", "60–90%", false),
      Ans("B – The hygienic norm for relative humidity is 30–60%."),

      Q(30, "Nitrogen narcosis occurs in divers at depths greater than:"),
      Opt("A", "10 m", false),
      Opt("B", "20 m", false),
      Opt("C", "30 m", true),
      Opt("D", "50 m", false),
      Ans("C – Nitrogen narcosis occurs at depths >30 m. Prevented by using helium-nitrogen mixtures."),

      Q(31, "Decompression sickness is caused by:"),
      Opt("A", "Excess oxygen absorption during diving", false),
      Opt("B", "Rapid decompression causing nitrogen bubble formation in blood and tissues", true),
      Opt("C", "Ear barotrauma from pressure changes", false),
      Opt("D", "Carbon dioxide accumulation in the lungs", false),
      Ans("B – Rapid decompression allows dissolved N₂ to come out of solution forming bubbles → emboli."),

      Q(32, "What is the temperature of dew point?"),
      Opt("A", "The temperature at which water freezes", false),
      Opt("B", "The temperature at which air becomes saturated with water vapour and condensation begins", true),
      Opt("C", "The normal body temperature", false),
      Opt("D", "The temperature at which air humidity reaches 30%", false),
      Ans("B – Dew point is the temperature at which air becomes saturated and condensation (dew) forms."),

      Q(33, "Which physical index is used for OBJECTIVE (physical) complex microclimate evaluation?"),
      Opt("A", "BMI index", false),
      Opt("B", "WBGT (Wet Bulb Globe Temperature) index", true),
      Opt("C", "Body Surface Area index", false),
      Opt("D", "Ventilation rate K", false),
      Ans("B – WBGT index is the physical method for complex microclimate evaluation. (From 2026 MCQ bank.)"),

      Q(34, "What percentage of solar radiation reaching Earth's surface is infrared radiation?"),
      Opt("A", "20%", false),
      Opt("B", "40%", false),
      Opt("C", "59%", true),
      Opt("D", "75%", false),
      Ans("C – Infrared (IR) radiation accounts for 59% of solar radiation at Earth's surface."),

      Q(35, "Which of the following statements about UV radiation is CORRECT?"),
      Opt("A", "UV radiation can be seen but not felt", false),
      Opt("B", "UV radiation can be both seen and felt", false),
      Opt("C", "UV radiation cannot be seen or felt", true),
      Opt("D", "UV radiation can be felt as heat but not seen", false),
      Ans("C – UV radiation is invisible AND cannot be felt (heat is felt from IR, not UV). This was a 2026 MCQ – 'You can't see UV but you can feel it = FALSE.'"),

      Q(36, "Long-wave UV radiation causes which of the following health effects?"),
      Opt("A", "Bactericidal effect", false),
      Opt("B", "Anti-rickets (Vitamin D synthesis) effect", false),
      Opt("C", "Cataracts, retinal damage, skin erythema, and skin cancer", true),
      Opt("D", "Stimulation of protein metabolism only", false),
      Ans("C – Long UV waves → cataracts (cumulative), retinal damage, sunburn, skin cancer. Short UV = bactericidal; middle UV = anti-rickets."),

      Q(37, "Where do negative air ions predominate?"),
      Opt("A", "In industrial indoor workplaces", false),
      Opt("B", "In urban polluted areas", false),
      Opt("C", "In mountains, forests, near the sea and waterfalls", true),
      Opt("D", "In hospital operating rooms", false),
      Ans("C – Negative air ions predominate in clean-air environments and have favourable health effects. Positive ions increase in polluted/indoor air."),

      Q(38, "Which of the following is a health effect of INCREASED atmospheric pressure?"),
      Opt("A", "Acute mountain sickness", false),
      Opt("B", "High-altitude pulmonary oedema", false),
      Opt("C", "Ear barotrauma (barotitis)", true),
      Opt("D", "Diminished ambient oxygen pressure", false),
      Ans("C – Ear barotrauma occurs with increased pressure (diving/caissons). Altitude sickness occurs with decreased pressure."),

      Q(39, "Air temperature is MAINLY heated by:"),
      Opt("A", "Direct solar radiation (approximately 60%)", false),
      Opt("B", "Infrared radiation from the ground", true),
      Opt("C", "Chemical reactions in the troposphere", false),
      Opt("D", "Direct solar radiation accounts for ~50%", false),
      Ans("B – Air is heated mainly by IR radiation from the ground surface. Direct sun heating of air = only ~0.02%."),

      Q(40, "What are the two MAIN groups of physical factors of the atmosphere?"),
      Opt("A", "Chemical and biological factors", false),
      Opt("B", "Meteorological factors and space-origin (solar) factors", true),
      Opt("C", "Indoor and outdoor factors", false),
      Opt("D", "Physical and chemical factors", false),
      Ans("B – Group 1: Meteorological (pressure, temperature, humidity, velocity, electricity, ionisation). Group 2: Space-origin (solar radiation, heliomagnetic)."),

      sectionHead("True / False"),
      ...TF(41, "Psychrometry is used to measure air humidity.", "TRUE", "Psychrometer measures air humidity via wet and dry bulb thermometers."),
      ...TF(42, "High relative humidity at high air temperature promotes effective cooling by sweat evaporation.", "FALSE", "High humidity IMPAIRS evaporation of sweat → heat accumulates → risk of heat stroke."),
      ...TF(43, "Infrared radiation can penetrate the skin and cause heating.", "TRUE", "IR penetrates skin → heating; chronic exposure → cataract and retinal damage."),
      ...TF(44, "Nitrogen narcosis can be prevented by breathing helium-depleted nitrogen mixtures.", "TRUE", "Replacing N₂ with helium in breathing mixtures prevents nitrogen narcosis at depth."),
      ...TF(45, "What would you expect in a classroom after children have been present for a long time? Increased air humidity.", "TRUE", "Children exhale water vapour and perspire, increasing air humidity. CO₂ also increases."),

      new Paragraph({ children: [new PageBreak()] }),

      // ════════════════════════════════════════
      // TOPIC 4 – CLIMATE & WEATHER
      // ════════════════════════════════════════
      topicHead("TOPIC 4 – Climate, Weather, Meteotropic Diseases and Acclimatization"),
      sectionHead("Single Best Answer"),

      Q(46, "Climate is defined as:"),
      Opt("A", "Daily variations in meteorological conditions", false),
      Opt("B", "The short-term dynamic complex of meteorological factors for a given place", false),
      Opt("C", "The long-term weather regime specific to a given territory", true),
      Opt("D", "The atmospheric pressure at a given altitude", false),
      Ans("C – Climate = long-term; weather = short-term."),

      Q(47, "Bulgaria is located in which climatic zone?"),
      Opt("A", "Tropical", false),
      Opt("B", "Subtropical", false),
      Opt("C", "Moderate (temperate)", true),
      Opt("D", "Cold (polar)", false),
      Ans("C – Bulgaria is in the moderate (temperate) climatic zone."),

      Q(48, "How long does acclimatization to a HOT climate typically take?"),
      Opt("A", "1–3 days", false),
      Opt("B", "5–7 days", false),
      Opt("C", "12–14 days", true),
      Opt("D", "4–6 weeks", false),
      Ans("C – Acclimatization to hot (especially humid) climate takes 12–14 days."),

      Q(49, "How long does acclimatization to COLD climate typically take?"),
      Opt("A", "3–5 days", false),
      Opt("B", "~10 days", true),
      Opt("C", "12–14 days", false),
      Opt("D", "3–4 weeks", false),
      Ans("B – Acclimatization to cold climate occurs in approximately 10 days."),

      Q(50, "Which of the following characterises OPTIMAL weather?"),
      Opt("A", "Temperature amplitude >10°C/24h and wind >8 m/s", false),
      Opt("B", "Temperature amplitude ~2°C/24h and wind ≤3 m/s", true),
      Opt("C", "Sharp sudden changes in meteorological factors", false),
      Opt("D", "High humidity with foggy conditions", false),
      Ans("B – Optimal weather: ~2°C temperature amplitude per 24 hours, sunny, wind ≤3 m/s."),

      Q(51, "Which type of weather involves sharp/sudden changes in meteorological factors?"),
      Opt("A", "Optimal weather", false),
      Opt("B", "Irritating weather", false),
      Opt("C", "Sharp weather", true),
      Opt("D", "Moderate weather", false),
      Ans("C – Sharp weather involves sudden/rapid changes in meteorological conditions."),

      Q(52, "Which patients are MOST sensitive to sharp changes in meteorological conditions?"),
      Opt("A", "Healthy young adults and athletes", false),
      Opt("B", "Patients with CVD, hypertension, cerebrovascular disease, and arthritis", true),
      Opt("C", "Patients with diabetes mellitus only", false),
      Opt("D", "Patients with skin conditions only", false),
      Ans("B – Chronic cardiovascular disease, arterial hypertension, cerebrovascular disease, neuroses, neuropathies, and arthritis make patients more sensitive to meteotropic effects."),

      Q(53, "Which temperature extreme has a MORE substantial impact on mortality?"),
      Opt("A", "Cold wave episodes", false),
      Opt("B", "Hot weather extremes", true),
      Opt("C", "Both are equal", false),
      Opt("D", "Neither has significant impact", false),
      Ans("B – Hot weather extremes appear to have a more substantial impact on mortality than cold wave episodes."),

      Q(54, "Why is excess mortality during the SECOND heat wave of a year lower than the first?"),
      Opt("A", "Air conditioning use increases", false),
      Opt("B", "Susceptible individuals died in the first wave; survivors become physiologically acclimatised", true),
      Opt("C", "Second heat waves are always cooler", false),
      Opt("D", "Government interventions improve", false),
      Ans("B – Two mechanisms: (1) susceptible population depleted after first wave; (2) survivors physiologically acclimatise."),

      Q(55, "Rapid drops in barometric pressure are associated with increased frequency of:"),
      Opt("A", "Diabetes attacks", false),
      Opt("B", "Migraine attacks", true),
      Opt("C", "Cardiac arrhythmias only", false),
      Opt("D", "Peptic ulcer haemorrhage", false),
      Ans("B – Studies show increased migraine attacks with rapid barometric pressure changes."),

      Q(56, "Which of the following describes MESOCLIMATE?"),
      Opt("A", "Climate of a broad geographic zone", false),
      Opt("B", "Climate of small areas not representative of the broader district climate", true),
      Opt("C", "Climate within a closed room", false),
      Opt("D", "Climate of the stratosphere", false),
      Ans("B – Mesoclimate = climate of small surface areas, which may not be representative of the district."),

      sectionHead("True / False"),
      ...TF(57, "Weather is a long-term dynamic complex of meteorological factors.", "FALSE", "Weather is SHORT-term. CLIMATE is the long-term regime."),
      ...TF(58, "Acclimatization to hot climate is more difficult than to cold climate.", "TRUE", "Hot (especially humid) climate is harder to acclimatise to (12–14 days vs ~10 days for cold)."),
      ...TF(59, "Frontal passages (rapid large weather changes) can have a profound impact on mortality.", "TRUE", "Rapid variations in weather conditions during frontal passages can cause significant physiological stress."),
      ...TF(60, "Cold air can cause bronchospasm (spastic bronchial reaction).", "TRUE", "Cold air can trigger bronchoconstriction, particularly in asthmatic and sensitive individuals."),

      new Paragraph({ children: [new PageBreak()] }),

      // ════════════════════════════════════════
      // TOPIC 5 – AIR POLLUTION & SMOG
      // ════════════════════════════════════════
      topicHead("TOPIC 5 – Air Pollutants, Smog and Prevention of Air Pollution"),
      sectionHead("Single Best Answer"),

      Q(61, "Primary air pollutants are:"),
      Opt("A", "Pollutants formed in the atmosphere by chemical reactions between other pollutants", false),
      Opt("B", "Pollutants directly emitted from a source", true),
      Opt("C", "Only natural pollutants from volcanoes", false),
      Opt("D", "Pollutants found only in water and soil", false),
      Ans("B – PRIMARY pollutants are DIRECTLY emitted (e.g. CO from vehicles, SO₂ from factories). SECONDARY pollutants form in the atmosphere."),

      Q(62, "Ground-level ozone is an example of:"),
      Opt("A", "A primary pollutant", false),
      Opt("B", "A secondary pollutant", true),
      Opt("C", "A natural non-anthropogenic pollutant", false),
      Opt("D", "A particulate matter pollutant", false),
      Ans("B – Ground-level ozone is a SECONDARY pollutant formed by photochemical reactions between NOₓ, VOCs, and UV sunlight."),

      Q(63, "Which is the MAJOR source of air pollution in urban areas?"),
      Opt("A", "Domestic coal burning", false),
      Opt("B", "Motor vehicles (transport)", true),
      Opt("C", "Volcanic activity", false),
      Opt("D", "Agricultural activity", false),
      Ans("B – Motor vehicles are the MAJOR source of air pollution in urban areas, emitting CO, NOₓ, hydrocarbons, Pb, and particulates."),

      Q(64, "Approximately what fraction of all CO emissions comes from motor vehicles?"),
      Opt("A", "1/4", false),
      Opt("B", "1/3", false),
      Opt("C", "2/3", true),
      Opt("D", "Nearly all", false),
      Ans("C – About 2/3 of all CO emissions come from motor vehicles."),

      Q(65, "WINTER (London) smog is characterised by:"),
      Opt("A", "Vehicle + UV light → ozone + PAN", false),
      Opt("B", "Smoke + SO₂; acidic nature; temperature inversion in cold/humid conditions", true),
      Opt("C", "Predominantly photochemical oxidising reactions", false),
      Opt("D", "Only found in tropical regions", false),
      Ans("B – Winter smog = smoke + SO₂ (from coal combustion); acid smog; associated with cold humid weather and temperature inversion."),

      Q(66, "SUMMER (photochemical) smog is formed by:"),
      Opt("A", "Burning of coal and biomass", false),
      Opt("B", "Industrial SO₂ emissions during fog", false),
      Opt("C", "Vehicle/industrial emissions + UV sunlight → secondary oxidising pollutants (ozone, PAN)", true),
      Opt("D", "Water vapour reacting with nitrogen", false),
      Ans("C – Summer/photochemical smog forms when NOₓ and VOCs from vehicles/industry react with UV → ozone and peroxyacetyl nitrate (PAN)."),

      Q(67, "Temperature inversion is a meteorological phenomenon that:"),
      Opt("A", "Disperses pollutants to higher altitudes", false),
      Opt("B", "Traps pollutants at lower atmospheric levels preventing upward diffusion", true),
      Opt("C", "Occurs only in tropical regions", false),
      Opt("D", "Reduces the concentration of pollutants in cities", false),
      Ans("B – In temperature inversion, lower air layers cool rapidly → cannot rise → pollutants and water vapour trapped at low levels → smog. More frequent in WINTER."),

      Q(68, "Carbon monoxide (CO) is correctly described as:"),
      Opt("A", "Reddish-brown, sharp-smelling gas", false),
      Opt("B", "Colourless, odourless, non-irritating but very poisonous gas", true),
      Opt("C", "Colourless gas with a characteristic sharp taste", false),
      Opt("D", "Yellow gas with a pungent odour", false),
      Ans("B – CO is colourless, odourless, and non-irritating, which makes it especially dangerous (no warning signs). It is very poisonous."),

      Q(69, "SO₂ further oxidises in the presence of NO₂ to form:"),
      Opt("A", "Ozone (O₃)", false),
      Opt("B", "Carbon monoxide", false),
      Opt("C", "Sulphuric acid (H₂SO₄) → acid rain", true),
      Opt("D", "Nitric acid only", false),
      Ans("C – SO₂ + H₂O + NO₂ (catalyst) → H₂SO₄ → acid rain. This damages ecosystems and buildings."),

      Q(70, "Which of the following is classified as a HUMAN carcinogen among air pollutants?"),
      Opt("A", "Formaldehyde", false),
      Opt("B", "Acetaldehyde", false),
      Opt("C", "Benzene", true),
      Opt("D", "Ethanol vapour", false),
      Ans("C – Benzene is a confirmed HUMAN carcinogen. Formaldehyde and acetaldehyde are animal carcinogens."),

      Q(71, "Which group is MOST vulnerable to the health effects of air pollution?"),
      Opt("A", "Healthy middle-aged adults", false),
      Opt("B", "Elderly, children, smokers, and those with chronic respiratory disease", true),
      Opt("C", "Athletes with high lung capacity", false),
      Opt("D", "People living in urban areas only", false),
      Ans("B – The most vulnerable groups to air pollution are: elderly, children, smokers, and people with chronic respiratory difficulties."),

      Q(72, "The most important INDOOR source of air pollution affecting individual health is:"),
      Opt("A", "Radon from building materials", false),
      Opt("B", "Formaldehyde from furniture", false),
      Opt("C", "Tobacco smoke (including passive smoking)", true),
      Opt("D", "CO₂ from human respiration", false),
      Ans("C – Tobacco smoke is described as the most direct and important indoor air pollution source; passive smokers are also affected."),

      Q(73, "Which of the following is a PRIMARY prevention measure against air pollution?"),
      Opt("A", "Treating patients with bronchitis", false),
      Opt("B", "Locating large pollution sources outside urban areas during planning", true),
      Opt("C", "Distributing gas masks to the population", false),
      Opt("D", "Building taller buildings to avoid ground-level pollution", false),
      Ans("B – Planning (locating industry outside residential zones) is the primary prevention measure."),

      Q(74, "The immediate health effect of air pollution on the respiratory system is:"),
      Opt("A", "Lung cancer", false),
      Opt("B", "Chronic bronchitis", false),
      Opt("C", "Acute bronchitis", true),
      Opt("D", "Pulmonary fibrosis", false),
      Ans("C – The IMMEDIATE effect is acute bronchitis. Delayed/chronic effects include chronic bronchitis, lung cancer, asthma, and allergies."),

      Q(75, "Bulgaria's air monitoring system is:"),
      Opt("A", "Completely independent with no international links", false),
      Opt("B", "Part of the European monitoring system", true),
      Opt("C", "Managed solely by local municipalities", false),
      Opt("D", "Based on voluntary reporting by industries", false),
      Ans("B – The Bulgarian national air monitoring system is integrated into the European monitoring system."),

      sectionHead("True / False"),
      ...TF(76, "Artificial ventilation can be exhaust, plenum (supply), and balanced.", "TRUE", "This was a direct 2026 MCQ. Artificial ventilation types: exhaust (extraction), plenum (supply/push), and balanced (both)."),
      ...TF(77, "Temperature inversion is more frequent in summer than in winter.", "FALSE", "Temperature inversion is MORE FREQUENT IN WINTER, which is why winter smog episodes are more common."),
      ...TF(78, "Particulate matter (PM₂.₅) is associated with increased risk of heart disease and lung cancer.", "TRUE", "Fine particles penetrate deep into the lungs and are linked to heart disease, altered lung function, and lung cancer."),
      ...TF(79, "Natural sources of air pollution (volcanic activity, desert dust) are more significant than anthropogenic sources.", "FALSE", "Natural sources have LESS importance compared to human-activity sources (transport, industry, domestic combustion)."),
      ...TF(80, "Decreased SO₂ emissions from motor vehicles have been achieved through catalytic converters.", "FALSE", "Catalytic converters reduce CO and NOₓ; SO₂ reduction is mainly achieved by reducing sulfur content in fuels and industrial controls. The text states CO diminution from catalytic converters."),

      new Paragraph({ children: [new PageBreak()] }),

      // ── ANSWER KEY SUMMARY ──
      new Paragraph({ heading: HeadingLevel.HEADING_1, spacing: { before: 200, after: 160 }, children: [new TextRun({ text: "Quick Answer Key", bold: true, size: 30, font: "Calibri", color: "1F4E79" })] }),
      note("For verification. All correct answers with topic reference."),
      ...[
        "Q1:B  Q2:C  Q3:C  Q4:C  Q5:D  Q6:B  Q7:FALSE  Q8:TRUE  Q9:FALSE  Q10:TRUE",
        "Q11:C  Q12:B  Q13:C  Q14:B  Q15:B  Q16:D  Q17:B  Q18:B  Q19:C  Q20:C",
        "Q21:B  Q22:C  Q23:FALSE  Q24:FALSE  Q25:TRUE  Q26:TRUE",
        "Q27:C  Q28:C  Q29:B  Q30:C  Q31:B  Q32:B  Q33:B  Q34:C  Q35:C  Q36:C",
        "Q37:C  Q38:C  Q39:B  Q40:B  Q41:TRUE  Q42:FALSE  Q43:TRUE  Q44:TRUE  Q45:TRUE",
        "Q46:C  Q47:C  Q48:C  Q49:B  Q50:B  Q51:C  Q52:B  Q53:B  Q54:B  Q55:B",
        "Q56:B  Q57:FALSE  Q58:TRUE  Q59:TRUE  Q60:TRUE",
        "Q61:B  Q62:B  Q63:B  Q64:C  Q65:B  Q66:C  Q67:B  Q68:B  Q69:C  Q70:C",
        "Q71:B  Q72:C  Q73:B  Q74:C  Q75:B  Q76:TRUE  Q77:FALSE  Q78:TRUE  Q79:FALSE  Q80:FALSE",
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// PART A: Topics 1-60
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const fs = require('fs');

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const children = [
  // TITLE
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    children: [new TextRun({ text: "HYGIENE & ECOLOGY — COMPLETE MCQ BANK", bold: true, size: 36, font: "Calibri" })] }),
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    children: [new TextRun({ text: "★REAL EXAM = appeared in June 2026 actual exam  |  ✔ Answer shown in GREEN", size: 20, italics: true, font: "Calibri", color: "C00000" })] }),
  pb(),

  // ══ TOPIC 1 ══
  h1("Topic 1 – Hygiene as a Main Prophylactic Medical Science"),
  Q(1,"Hygiene is one of the main sciences of preventive medicine.",true),
  ...tf(1,"Hygiene is one of the main sciences of preventive medicine.","TRUE","Hygiene = principal prophylactic (preventive) science.",true),
  Q(2,"What is a hygienic norm?"),
  opt("A","A law document about quality indices of environmental factors",false),
  opt("B","The maximal or minimal physiologically safe levels of environmental factors",true),
  opt("C","A clinical treatment guideline",false),
  opt("D","The recommended daily dose of a medication",false),
  ans("B","Hygienic norm = MPC (maximum permissible concentration) of harmful environmental factors."),
  Q(3,"Which of the following are main branches of Hygiene?"),
  opt("A","Childhood and Adolescent Hygiene, Occupational Medicine, Hygiene of Nutrition",true),
  opt("B","Surgery, Internal Medicine, Cardiology",false),
  opt("C","Epidemiology, Microbiology, Pathology",false),
  opt("D","Biochemistry, Genetics, Pharmacology",false),
  ans("A","Main branches: Communal, Occupational, Nutritional, Childhood/Adolescent, Hospital, Radiation hygiene."),
  Q(4,"Which are SPECIFIC methods of Hygiene?"),
  opt("A","Health description and health investigation",true),
  opt("B","Surgical and pharmacological methods",false),
  opt("C","Biochemical method only",false),
  opt("D","Serological and haematological methods",false),
  ans("A","Specific hygiene methods: health description, health investigation, complex hygienic method."),
  Q(5,"What are the types of state health control?"),
  opt("A","Preliminary only",false),
  opt("B","Current only",false),
  opt("C","Both Preliminary and Current",true),
  opt("D","Emergency and routine",false),
  ans("C","State health control is both preliminary (before activities begin) and current (ongoing monitoring)."),
  ...tf(6,"Hygiene is a therapeutic science aimed at treating disease.","FALSE","Hygiene is PROPHYLACTIC (preventive) — it prevents disease rather than treating it."),
  ...tf(7,"The Regional Health Inspectorate (RHI) is responsible for state sanitary control in Bulgaria.","TRUE","The RHI carries out state sanitary control and public health protection activities."),

  pb(),
  // ══ TOPIC 2 ══
  h1("Topic 2 – Atmosphere: Importance, Structure and Air Composition"),
  Q(8,"What percentage of air is Oxygen?",true),
  opt("A","78.1%",false),
  opt("B","20.9%",true),
  opt("C","0.04%",false),
  opt("D","15%",false),
  ans("B – 20.9%","N₂ = 78.1%, O₂ = 20.9%, CO₂ = 0.03–0.04%. (Real exam question)"),
  Q(9,"Which atmospheric layer contains approximately 80% of atmospheric air mass and is of primary hygienic importance?"),
  opt("A","Stratosphere",false),
  opt("B","Mesosphere",false),
  opt("C","Troposphere",true),
  opt("D","Thermosphere",false),
  ans("C","Troposphere (0–10 km) = 80% of air mass; layer of weather, breathing, and air pollution."),
  Q(10,"Air is correctly described as:"),
  opt("A","A chemical compound of gases",false),
  opt("B","A mechanical mixture of gases",true),
  opt("C","A homogeneous solution",false),
  opt("D","A colloid",false),
  ans("B","Air is a MECHANICAL MIXTURE — not a chemical compound."),
  Q(11,"At what O₂ concentration does a feeling of fatigue and discomfort begin?"),
  opt("A","20%",false),
  opt("B","17%",true),
  opt("C","12%",false),
  opt("D","8%",false),
  ans("B – 17 vol%","Critical hygienic threshold. At 8 vol% = death."),
  Q(12,"CO₂ concentration in atmospheric air is approximately:"),
  opt("A","0.004%",false),
  opt("B","0.03–0.04%",true),
  opt("C","2%",false),
  opt("D","4%",false),
  ans("B – 0.03–0.04%","Also: CO₂ is used as an indoor air quality indicator; >2% = severe breathing difficulty. (Real exam)"),
  Q(13,"Which layer of the atmosphere contains the ozone layer protecting against UV radiation?"),
  opt("A","Troposphere",false),
  opt("B","Mesosphere",false),
  opt("C","Stratosphere",true),
  opt("D","Exosphere",false),
  ans("C – Stratosphere","10–50 km altitude; contains ozone that absorbs harmful UV."),
  ...tf(14,"Air is a chemical compound of nitrogen and oxygen.","FALSE","Air is a MECHANICAL MIXTURE of gases."),
  ...tf(15,"CO₂ is used as a marker to assess air quality and ventilation adequacy in closed rooms.","TRUE","Increasing CO₂ in closed spaces indicates poor ventilation.",true),
  ...tf(16,"Radon is a naturally occurring radioactive gas that can accumulate indoors and increase lung cancer risk.","TRUE","Radon seeps from soil/building materials; major indoor radiation hazard."),

  pb(),
  // ══ TOPIC 3 ══
  h1("Topic 3 – Hygiene Characteristics of Physical Factors of the Atmosphere"),
  Q(17,"What instrument measures AIR VELOCITY?",true),
  opt("A","Psychrometer",false),
  opt("B","Barometer",false),
  opt("C","Anemometer",true),
  opt("D","Actinometer",false),
  ans("C – Anemometer","(Real exam 2026)"),
  Q(18,"What instrument measures AIR HUMIDITY?",true),
  opt("A","Thermometer",false),
  opt("B","Anemometer",false),
  opt("C","Psychrometer",true),
  opt("D","Barometer",false),
  ans("C – Psychrometer","Also called psychrometry. (Real exam 2026)"),
  Q(19,"The hygienic norm for relative air humidity is:"),
  opt("A","10–20%",false),
  opt("B","30–60%",true),
  opt("C","50–80%",false),
  opt("D","60–90%",false),
  ans("B – 30–60%","Standard hygienic norm for indoor relative humidity."),
  Q(20,"Which physical index is used for OBJECTIVE (physical) complex microclimate evaluation?",true),
  opt("A","BMI",false),
  opt("B","WBGT (Wet Bulb Globe Temperature) index",true),
  opt("C","Ventilation rate K",false),
  opt("D","Surface area index",false),
  ans("B – WBGT index","(Real exam 2026)"),
  Q(21,"Nitrogen narcosis occurs in divers at depths greater than:"),
  opt("A","10 m",false),
  opt("B","20 m",false),
  opt("C","30 m",true),
  opt("D","100 m",false),
  ans("C – >30 m","Prevented by using helium-depleted nitrogen mixtures."),
  Q(22,"What percentage of solar radiation reaching Earth's surface is infrared (IR)?"),
  opt("A","20%",false),
  opt("B","40%",false),
  opt("C","59%",true),
  opt("D","75%",false),
  ans("C – 59%","IR penetrates skin → heating; chronic exposure → cataract."),
  ...tf(23,"UV radiation cannot be seen but you can feel it.","FALSE","UV radiation can NEITHER be seen NOR felt. IR is felt as heat. (Real exam 2026)",true),
  ...tf(24,"High relative humidity at high temperatures impairs cooling by evaporation.","TRUE","High humidity prevents sweat evaporation → heat accumulation."),
  ...tf(25,"What would you expect in a classroom where children had been for a long time? Increased air humidity.","TRUE","Exhaled water vapour + perspiration → humidity rises. (Real exam 2026)",true),
  Q(23,"UV radiation: what statement is CORRECT?",true),
  opt("A","You cannot see UV but you can feel it",false),
  opt("B","You can both see and feel UV",false),
  opt("C","You cannot see OR feel UV radiation",true),
  opt("D","UV is visible to the naked eye",false),
  ans("C","UV = invisible AND cannot be felt. IR is the radiation you feel as heat. (Real exam 2026)"),
  Q(24,"Long-wave UV radiation causes:"),
  opt("A","Bactericidal effect",false),
  opt("B","Vitamin D synthesis",false),
  opt("C","Cataracts, retinal damage, skin erythema, skin cancer",true),
  opt("D","Stimulation of protein metabolism only",false),
  ans("C","Short UV = bactericidal; Middle UV = Vitamin D / anti-rickets; Long UV = cataracts, skin cancer."),

  pb(),
  // ══ TOPIC 4 ══
  h1("Topic 4 – Climate, Weather, Meteotropic Effects and Acclimatization"),
  Q(25,"Bulgaria is located in which climatic zone?"),
  opt("A","Tropical",false),
  opt("B","Subtropical",false),
  opt("C","Moderate (temperate)",true),
  opt("D","Cold/polar",false),
  ans("C – Moderate (temperate)","Bulgaria = moderate climatic zone."),
  Q(26,"Acclimatization to HOT climate takes approximately:"),
  opt("A","2–3 days",false),
  opt("B","5–7 days",false),
  opt("C","12–14 days",true),
  opt("D","4–6 weeks",false),
  ans("C – 12–14 days","Hot (especially humid) climate is more difficult. Cold = ~10 days."),
  Q(27,"Which patients are most sensitive to sharp changes in meteorological conditions?"),
  opt("A","Healthy young adults",false),
  opt("B","CVD, hypertension, cerebrovascular disease, arthritis patients",true),
  opt("C","Diabetic patients only",false),
  opt("D","Patients with dermatological conditions",false),
  ans("B","These chronic conditions make patients sensitive to meteotropic effects."),
  ...tf(28,"Climate is the short-term dynamic complex of meteorological factors.","FALSE","Climate = LONG-TERM. Weather = short-term."),
  ...tf(29,"Acclimatization to cold climate occurs in approximately 10 days.","TRUE","Cold acclimatization: ~10 days. Hot: 12–14 days."),
  ...tf(30,"Optimal weather is characterised by temperature amplitude of ~2°C/24h and wind ≤3 m/s.","TRUE","Irritating weather: wind up to 8 m/s; sharp weather: sudden changes."),

  pb(),
  // ══ TOPIC 5 ══
  h1("Topic 5 – Air Pollutants, Smog and Prevention of Air Pollution"),
  Q(31,"Artificial ventilation can be exhaust, plenum and balanced.",true),
  ...tf(31,"Artificial ventilation can be exhaust, plenum and balanced.","TRUE","Three types of artificial ventilation. (Real exam 2026)",true),
  Q(32,"Winter (London) smog is characterised by:"),
  opt("A","Vehicle + UV → ozone and PAN",false),
  opt("B","Smoke + SO₂; acidic; temperature inversion in cold/humid weather",true),
  opt("C","Only found in tropical regions",false),
  opt("D","Predominantly photochemical oxidising reactions",false),
  ans("B","Winter smog = acid smog from coal combustion. Summer smog = photochemical from vehicles + UV."),
  Q(33,"Ground-level ozone is an example of a:"),
  opt("A","Primary pollutant",false),
  opt("B","Secondary pollutant",true),
  opt("C","Natural non-anthropogenic pollutant",false),
  opt("D","Particulate matter",false),
  ans("B","Secondary = formed in atmosphere from primary pollutants + UV."),
  Q(34,"Which is the major source of air pollution in urban areas?"),
  opt("A","Domestic coal burning",false),
  opt("B","Motor vehicles (transport)",true),
  opt("C","Volcanic activity",false),
  opt("D","Agricultural fertilizers",false),
  ans("B","Motor vehicles = major urban source; responsible for ~2/3 of CO emissions."),
  Q(35,"Temperature inversion causes smog because:"),
  opt("A","It disperses pollutants upward",false),
  opt("B","Lower air layers cool rapidly and cannot rise, trapping pollutants at low levels",true),
  opt("C","It increases UV penetration",false),
  opt("D","It only occurs in summer",false),
  ans("B","Temperature inversion more frequent in winter → winter smog episodes."),
  Q(36,"Air pollutants are associated with:",true),
  opt("A","Respiratory, skin, and eye diseases",true),
  opt("B","Nephrolithiasis only",false),
  opt("C","Only gastrointestinal diseases",false),
  opt("D","No proven health effects",false),
  ans("A – Respiratory, skin and eye diseases","Immediate: acute bronchitis. Delayed: chronic bronchitis, lung cancer, asthma. (Real MCQ bank)"),
  ...tf(37,"Benzene is a confirmed human carcinogen.","TRUE","Benzene = HUMAN carcinogen (formaldehyde = animal carcinogen)."),
  ...tf(38,"Temperature inversion is more frequent in summer than in winter.","FALSE","More frequent in WINTER → classic winter smog condition."),

  pb(),
  // ══ TOPIC 6 ══
  h1("Topic 6 – Importance of Water. Waterborne Diseases"),
  Q(39,"Which of the following is a waterborne disease?"),
  opt("A","Tuberculosis",false),
  opt("B","Typhoid fever",true),
  opt("C","Malaria",false),
  opt("D","Tetanus",false),
  ans("B – Typhoid fever","Waterborne diseases: typhoid, cholera, hepatitis A, dysentery, leptospirosis, polio."),
  Q(40,"Water is essential for the human organism because:"),
  opt("A","It provides calories for energy",false),
  opt("B","It acts as a solvent, regulates temperature, and participates in all metabolic processes",true),
  opt("C","It is the primary source of protein",false),
  opt("D","It provides all essential minerals",false),
  ans("B","Water = universal solvent, thermoregulation, metabolic medium, excretion."),
  ...tf(41,"Cholera and typhoid fever are waterborne diseases.","TRUE","Classic waterborne diseases transmitted through contaminated water."),
  ...tf(42,"Water constitutes approximately 60–70% of body weight in adults.","TRUE","Body water: ~70% in infants, 60% in adults, less in elderly."),

  pb(),
  // ══ TOPIC 7 ══
  h1("Topic 7 – Hygiene Requirements to Drinking Water Quality"),
  Q(43,"According to Bulgarian Instruction №9/2001, nitrate in drinking water should be no more than:",true),
  opt("A","10 mg/l",false),
  opt("B","25 mg/l",false),
  opt("C","50 mg/l",true),
  opt("D","100 mg/l",false),
  ans("C – 50 mg/l","(Real exam 2026 AND MCQ bank)"),
  Q(44,"Organoleptic (aesthetic) indices of drinking water are:"),
  opt("A","Color, taste, hardness, colony counts",false),
  opt("B","Color, taste, odor, turbidity",true),
  opt("C","pH, chlorides, sulfates",false),
  opt("D","Ammonia, nitrate, nitrite",false),
  ans("B – Color, taste, odor, turbidity","Organoleptic = what you can perceive with senses."),
  Q(45,"Water odor should be no more than __ bales at 20°C:"),
  opt("A","1",false),
  opt("B","2",true),
  opt("C","3",false),
  opt("D","5",false),
  ans("B – 2 bales","Standard for drinking water odor intensity."),
  Q(46,"The maximum permissible level of chlorides in drinking water is:"),
  opt("A","100 mg/l",false),
  opt("B","150 mg/l",false),
  opt("C","250 mg/l",true),
  opt("D","500 mg/l",false),
  ans("C – 250 mg/l","(From MCQ bank)"),
  Q(47,"Which of the following indicates FRESH organic pollution of tap water?",true),
  opt("A","High nitrate level",false),
  opt("B","High nitrite level",false),
  opt("C","High ammonia level",true),
  opt("D","High sulfate level",false),
  ans("C – High ammonia","Ammonia = FRESH contamination. Nitrite = intermediate. Nitrate = OLD contamination. (Real exam 2026)"),
  Q(48,"Which of the following indicates OLD organic pollution of tap water?",true),
  opt("A","High ammonia level",false),
  opt("B","High nitrite level",false),
  opt("C","High nitrate level",true),
  opt("D","High pH",false),
  ans("C – High nitrate","Progression: Ammonia → Nitrite → Nitrate (oldest contamination). (Real exam 2026)"),
  Q(49,"The microbiological indices of drinking water are:"),
  opt("A","Coliform organisms and Enterococcus",true),
  opt("B","Staphylococcus aureus and Salmonella",false),
  opt("C","E.coli and Clostridium",false),
  opt("D","Total bacterial count only",false),
  ans("A","Key indicators: coliform organisms, E.coli, Enterococcus."),
  Q(50,"What level of bacteria in tap water is considered normal?",true),
  opt("A","<10 cfu/100 ml",false),
  opt("B","<100 cfu/100 ml",false),
  opt("C","0 cfu/100 ml",true),
  opt("D","<500 cfu/100 ml",false),
  ans("C – 0 cfu/100 ml","E.coli and coliforms must be ABSENT in drinking water. (Real exam 2026)"),
  Q(51,"Why is the coliform group of bacteria used to estimate water contamination?",true),
  opt("A","They are pathogenic and dangerous in small numbers",false),
  opt("B","They are always present in fecal waste and vastly outnumber specific disease-producing organisms",true),
  opt("C","They are easy to identify by colour",false),
  opt("D","They survive boiling",false),
  ans("B","Coliforms = indicator organisms for fecal contamination. (Real exam 2026)"),
  ...tf(52,"High concentration of sulfates in drinking water has a laxative effect.","TRUE","High sulfates (especially MgSO₄) → laxative. (Real exam 2026)",true),
  ...tf(53,"Turbidity testing of water can determine bacteriological safety.","FALSE","Turbidity = physical/aesthetic test. Bacteriological safety requires microbiological testing. (MCQ bank)"),
  ...tf(54,"For optimal dental health, fluoride in drinking water should be no more than 1.5 mg/l.","TRUE","WHO and Bulgarian standard for fluoride in drinking water."),

  pb(),
  // ══ TOPIC 8 ══
  h1("Topic 8 – Water Supply Sources, Distribution and Safeguard Zones"),
  Q(55,"Drinking water safeguard (sanitary protection) zones exist to:"),
  opt("A","Increase water pressure in the system",false),
  opt("B","Protect water sources from pollution",true),
  opt("C","Reduce water treatment costs",false),
  opt("D","Ensure even distribution of water",false),
  ans("B","Sanitary protection zones are established around water sources to prevent contamination."),
  Q(56,"The stages of water treatment in order are:"),
  opt("A","Disinfection → Filtration → Coagulation",false),
  opt("B","Storage → Coagulation/Flocculation → Filtration → Special treatment → Disinfection",true),
  opt("C","Filtration → Chlorination only",false),
  opt("D","Boiling → UV irradiation → Distribution",false),
  ans("B","Full water treatment sequence from MCQ bank."),
  ...tf(57,"The monitoring of drinking water is both permanent and periodic.","TRUE","Permanent monitoring: organoleptic + physical/chemical + microbiological indices. (MCQ bank)"),

  pb(),
  // ══ TOPIC 9 ══
  h1("Topic 9 – Water Purification and Disinfection"),
  Q(58,"The residual chlorine concentration in drinking water after chlorination should be:",true),
  opt("A","0.1 mg/l",false),
  opt("B","0.3–0.5 mg/l",true),
  opt("C","1.0 mg/l",false),
  opt("D","2.0 mg/l",false),
  ans("B – 0.3–0.5 mg/l","Residual chlorine ensures continued disinfection protection."),
  Q(59,"Which physical methods are used for disinfection of drinking water?",true),
  opt("A","Boiling and chlorination",false),
  opt("B","Ultraviolet irradiation and ozonation",true),
  opt("C","Filtration and sedimentation",false),
  opt("D","Chloramine and perchloron",false),
  ans("B – UV irradiation and ozonation","Physical methods = UV + ozone. Chemical = chlorine compounds. (Real MCQ bank)"),
  Q(60,"Methods for determination of residual chlorine in drinking water are:",true),
  opt("A","Orthotolidine test and spectrophotometry",true),
  opt("B","Enzyme substrate test and MPN",false),
  opt("C","Nessler reagent method",false),
  opt("D","Barium chloride method",false),
  ans("A – Orthotolidine test + spectrophotometry","(From MCQ bank)"),
  Q(61,"Chlorine kills pathogenic bacteria but has no effect on:"),
  opt("A","Gram-negative bacteria",false),
  opt("B","Gram-positive bacteria",false),
  opt("C","Spores and certain viruses (e.g. viral hepatitis) except in high doses",true),
  opt("D","All microorganisms equally",false),
  ans("C","Chlorine limitation — spores and hepatitis viruses resistant to standard doses."),
  Q(62,"Coagulation in water treatment uses:"),
  opt("A","Chlorine gas",false),
  opt("B","Aluminium or iron salts to form flocculent precipitate",true),
  opt("C","UV irradiation",false),
  opt("D","Ozone gas",false),
  ans("B","Coagulant (alum/iron salt) → mixing → flocculation → sedimentation → filtration."),
  ...tf(63,"Disinfection of water on a small scale can be done with chlorine tablets or boiling.","TRUE","Small-scale disinfection methods include boiling, UV portable devices, and chlorine tablets."),
  ...tf(64,"Ozone has a strong virucidal effect and is used in combination with chlorination.","TRUE","Ozone kills viruses (including hepatitis); combined with chlorination for best effect."),

  pb(),
  // ══ TOPIC 10 ══
  h1("Topic 10 – Hygiene of Soil. Soil Pollution and Waste Management"),
  Q(65,"Which microorganisms CONSTANTLY live in soil?"),
  opt("A","M. tuberculosis, Hepatitis A virus",false),
  opt("B","Cl. perfringens, Cl. tetani, B. anthracis",true),
  opt("C","Salmonella, E. coli",false),
  opt("D","Ascaris, Entamoeba",false),
  ans("B","Permanently in soil: Cl. perfringens, Cl. tetani (tetanus), B. anthracis (anthrax). (Real exam 2026)"),
  Q(66,"Which microorganisms are TEMPORARY inhabitants of soil?",true),
  opt("A","Cl. tetani, B. anthracis",false),
  opt("B","M. tuberculosis, Hepatitis A virus, Enteroviruses",true),
  opt("C","Cl. perfringens, Cl. botulinum",false),
  opt("D","Ascaris lumbricoides only",false),
  ans("B","Temporary: M. tuberculosis, Hep A virus, Enteroviruses. (Real exam 2026)"),
  Q(67,"The most important soil-transmitted helminthes are:"),
  opt("A","Ascaris lumbricoides, Trichuris trichiura, Ancylostoma duodenale",true),
  opt("B","Taenia solium, Echinococcus",false),
  opt("C","Entamoeba histolytica, Giardia",false),
  opt("D","Schistosoma mansoni",false),
  ans("A","Geo-helminthes (soil-transmitted): roundworm, whipworm, hookworm."),
  Q(68,"Which method of waste disposal is used for especially dangerous hospital waste?"),
  opt("A","Composting",false),
  opt("B","Sanitary landfill",false),
  opt("C","Incineration",true),
  opt("D","Septic tank",false),
  ans("C","Hospital waste = incinerated. Most hygienic when land unavailable."),
  ...tf(69,"Tetanus is caused by Clostridium tetani which lives permanently in soil.","TRUE","Cl. tetani is a permanent soil inhabitant. Tetanus is a soil-associated infection."),
  ...tf(70,"Methane from landfill sites poses a risk of fire and explosion.","TRUE","Methane = anaerobic decomposition product; fire/explosion hazard at landfills."),

  pb(),
  // ══ TOPIC 11 ══
  h1("Topic 11 – Living Conditions, Urban Planning, Noise, Urbanization"),
  Q(71,"Noise frequency is expressed in:"),
  opt("A","Decibels (dB)",false),
  opt("B","Hertz (Hz)",true),
  opt("C","Watts (W)",false),
  opt("D","Lux (lx)",false),
  ans("B – Hertz (Hz)","Frequency = Hz. Intensity/loudness = decibels (dB). (From MCQ bank)"),
  Q(72,"Urbanization is defined as:"),
  opt("A","Building of rural areas",false),
  opt("B","Physical growth of urban areas and movement of people from rural to urban areas",true),
  opt("C","Reduction of city populations",false),
  opt("D","Improvement of farming technology",false),
  ans("B","UN definition: urbanization = movement from rural to urban + urban area physical growth."),
  ...tf(73,"More than half of the world's population lives in urban areas.","TRUE","Urbanization milestone: >50% of world population now urban."),
  ...tf(74,"Noise in urban areas is defined by frequency in Hertz and intensity in decibels.","TRUE","Frequency (Hz) determines pitch; intensity (dB) determines loudness/damage."),

  pb(),
  // ══ TOPIC 12 ══
  h1("Topic 12 – Hygiene of Housing Conditions"),
  Q(75,"Illumination in the operating plane of a hospital should be more than:"),
  opt("A","300 lx",false),
  opt("B","1000 lx",false),
  opt("C","5000 lx",true),
  opt("D","500 lx",false),
  ans("C – >5000 lx","Operating theatre illumination standard. (From MCQ bank)"),
  Q(76,"For a dental treatment room, ambient lighting should be:"),
  opt("A","100 lx with incandescent lighting",false),
  opt("B","300 lx with fluorescent lighting",true),
  opt("C","500 lx with UV lighting",false),
  opt("D","No specific standard",false),
  ans("B – 300 lx fluorescent","Hygienic standard for dental treatment room ambient lighting. (MCQ bank)"),
  ...tf(77,"Hygienic evaluation of heating, illumination and ventilation in housing includes hospital buildings.","TRUE","Topic 105 of conspectus; applies to housing, public and hospital buildings.",true),

  pb(),
  // ══ TOPIC 13 ══
  h1("Topic 13 – Hospital Hygiene. Outpatient Care Facilities"),
  Q(78,"How much floor space is required per full-time person in a dental office?"),
  opt("A","5 square meters",false),
  opt("B","10 square meters",true),
  opt("C","15 square meters",false),
  opt("D","20 square meters",false),
  ans("B – 10 sq meters","Hygienic requirement for dental outpatient facilities. (MCQ bank)"),
  Q(79,"Treatment rooms in dental offices should be oriented to the:"),
  opt("A","South",false),
  opt("B","East",false),
  opt("C","North",true),
  opt("D","West",false),
  ans("C – North","North orientation provides consistent diffuse light without direct sun glare; important for clinical work."),
  ...tf(80,"General hygiene requirements for healthcare facilities include specific standards for air, water, and structural elements.","TRUE","Hospital hygiene covers location, construction, air quality, water supply, waste disposal."),

  pb(),
  // ══ TOPIC 14 ══
  h1("Topic 14 – General Hospitals. Nosocomial Infections"),
  Q(81,"Nosocomial infections are defined as:"),
  opt("A","Infections acquired in the community",false),
  opt("B","Infections acquired in a healthcare facility that were not present on admission",true),
  opt("C","Infections caused by animal bites",false),
  opt("D","Any infection treated with antibiotics",false),
  ans("B","Hospital-acquired (nosocomial) infections develop ≥48h after admission or within 30 days of hospital contact."),
  Q(82,"Construction systems for general hospitals include:"),
  opt("A","Centralised, decentralised, and mixed systems",true),
  opt("B","Only centralised",false),
  opt("C","Only decentralised",false),
  opt("D","Modular and temporary only",false),
  ans("A","Hospital construction: centralised, decentralised, and mixed/combined systems. (Real exam tip)"),
  ...tf(83,"Hospital-acquired infections affect both patients and healthcare workers.","TRUE","Nosocomial infections = patient AND staff risk; major public health concern."),

  pb(),
  // ══ TOPIC 15 ══
  h1("Topic 15 – Therapeutic-Protective Regime. Hospital Waste Disposal"),
  Q(84,"Classification of isolation rooms includes:"),
  opt("A","Standard, negative pressure, and positive pressure (SNP)",true),
  opt("B","Type A, B, C only",false),
  opt("C","Clean, dirty, and sterile",false),
  opt("D","Ward, private, and shared",false),
  ans("A – SNP (Standard, Negative, Positive)","(Real exam 2026 — HOD question)"),
  Q(85,"A NEGATIVE pressure isolation room is used for:"),
  opt("A","Immunocompromised patients",false),
  opt("B","Infectious patients to prevent outward spread of infection",true),
  opt("C","Patients with allergies",false),
  opt("D","Post-operative patients",false),
  ans("B","Negative pressure = air flows IN from corridor → prevents infectious aerosols escaping. Positive pressure = for immunocompromised. (Real exam 2026)",true),
  ...tf(86,"Hospital waste should be separated into different categories for safe disposal.","TRUE","Categories: infectious, sharps, pharmaceutical, chemical, radioactive, general."),

  pb(),
  // ══ TOPIC 16 ══
  h1("Topic 16 – High Epidemiological Risk Hospitals: TB, Infectious, Psychiatric, Children's"),
  Q(87,"The hygiene requirement for tuberculosis inpatient rooms is:",true),
  opt("A","Four-bed ward",false),
  opt("B","Isolation in a one-bed room",true),
  opt("C","Shared ward with other respiratory patients",false),
  opt("D","No specific isolation needed",false),
  ans("B – One-bed room isolation","(Real exam 2026)"),
  Q(88,"Psychiatric hospital hygiene requirements include:"),
  opt("A","No special requirements beyond general hospitals",false),
  opt("B","Barriers on windows, fenced grounds, wards by patient danger level, no sharp furniture edges",true),
  opt("C","Open wards only",false),
  opt("D","Only medication management protocols",false),
  ans("B","Psychiatric hygiene: window barriers, height of fences, ward classification by risk level, furniture safety. (Real exam 2026)",true),
  ...tf(89,"Children's hospitals require special wards for children with chronic illnesses.","TRUE","Children's hospital hygiene = separate wards for acute vs chronic, specific requirements for play areas, lighting."),

  pb(),
  // ══ TOPIC 17 ══
  h1("Topic 17 – High Risk Hospitals: Operating Theatre, Obstetrics, Gynecology"),
  Q(90,"Illumination in the operating theatre should be more than:"),
  opt("A","1000 lx",false),
  opt("B","3000 lx",false),
  opt("C","5000 lx",true),
  opt("D","500 lx",false),
  ans("C – >5000 lx","Operating theatre requires high-intensity, shadow-free illumination."),
  ...tf(91,"The operating theatre requires special air filtration (HEPA) and laminar airflow to prevent infection.","TRUE","Clean room standards apply in operating theatres to minimise surgical site infections."),

  pb(),
  // ══ TOPIC 18 ══
  h1("Topic 18 – Healthy Lifestyle. Tempering and Physical Activity"),
  Q(92,"Tempering (hardening) of the body refers to:"),
  opt("A","Physical training to build muscle mass",false),
  opt("B","Systematic exposure to natural stimuli (cold, heat, UV) to increase organism resistance",true),
  opt("C","Dietary restriction for weight loss",false),
  opt("D","Vitamin supplementation",false),
  ans("B","Hardening = systematic, gradually increasing exposure to cold water, air, sunlight to improve adaptive responses."),
  ...tf(93,"Regular physical activity reduces the risk of cardiovascular disease, obesity, and diabetes.","TRUE","Physical activity is a core element of healthy lifestyle; reduces NCDs."),

  pb(),
  // ══ TOPIC 19 ══
  h1("Topic 19 – Personal Hygiene. Washing Means. Dress and Shoes"),
  ...tf(94,"Personal hygiene includes care of skin, hair, teeth, hands, and appropriate clothing.","TRUE","Personal hygiene topic covers washing, clothing hygiene (thermal insulation, hygroscopicity), footwear."),
  Q(95,"Hygiene characteristics of clothing include:"),
  opt("A","Colour and aesthetic appearance only",false),
  opt("B","Thermal insulation, hygroscopicity, permeability, weight",true),
  opt("C","Brand and cost",false),
  opt("D","Waterproofing only",false),
  ans("B","Clothing hygiene = thermal properties, moisture absorption (hygroscopicity), air permeability."),

  pb(),
  // ══ TOPIC 20 ══
  h1("Topic 20 – Ionizing Radiation: Basic Terminology and Dose Units"),
  Q(96,"The unit of absorbed radiation dose is:"),
  opt("A","Becquerel (Bq)",false),
  opt("B","Gray (Gy)",true),
  opt("C","Sievert (Sv)",false),
  opt("D","Curie (Ci)",false),
  ans("B – Gray (Gy)","Absorbed dose = Gray. Effective dose = Sievert. Activity = Becquerel."),
  Q(97,"The Sievert (Sv) measures:"),
  opt("A","Activity of a radioactive source",false),
  opt("B","Effective/equivalent radiation dose (biological effect)",true),
  opt("C","Absorbed physical energy",false),
  opt("D","Ionisation of air",false),
  ans("B – Effective dose","Sievert accounts for type of radiation and tissue sensitivity; used for radiation protection."),
  ...tf(98,"The Becquerel is the unit of radioactive activity (disintegrations per second).","TRUE","1 Bq = 1 disintegration/second. Old unit = Curie (Ci)."),
  ...tf(99,"Absorbed dose (Gray) and effective dose (Sievert) measure the same thing.","FALSE","Gray = physical energy absorbed per kg. Sievert = biological effect; includes radiation weighting factor."),

  pb(),
  // ══ TOPIC 21 ══
  h1("Topic 21 – Sources of Ionizing Radiation. Occupational and Medical Exposure"),
  Q(100,"Natural sources of ionizing radiation include:",true),
  opt("A","X-ray machines and nuclear reactors",false),
  opt("B","Cosmic radiation, terrestrial radiation, radon, and internal body radionuclides",true),
  opt("C","Nuclear weapons only",false),
  opt("D","UV lamps and microwave ovens",false),
  ans("B","Natural: cosmic rays, terrestrial (soil/rock), radon gas, internally deposited isotopes (K-40, C-14)."),
  Q(101,"The largest source of medical radiation exposure for the public is:"),
  opt("A","Nuclear power plants",false),
  opt("B","Diagnostic X-rays and nuclear medicine",true),
  opt("C","Radiotherapy",false),
  opt("D","Radon in buildings",false),
  ans("B","Diagnostic radiology = largest artificial radiation source; nuclear medicine also significant."),
  Q(102,"If the distance from a radiation source is doubled, the effect of radiation becomes:",true),
  opt("A","4 times stronger",false),
  opt("B","2 times weaker",false),
  opt("C","4 times weaker",true),
  opt("D","Unchanged",false),
  ans("C – 4 times weaker","Inverse square law: I ∝ 1/d². Double distance = 1/4 intensity. (Real exam 2026)"),
  ...tf(103,"Radon is a naturally occurring radioactive gas derived from uranium decay in soil and building materials.","TRUE","Radon (Rn-222) = uranium decay product; major indoor radiation hazard; lung cancer risk."),

  pb(),
  // ══ TOPIC 22 ══
  h1("Topic 22 – Biological Effects of Ionizing Radiation"),
  Q(104,"Which type of radiation has the HIGHEST penetration power?",true),
  opt("A","Alpha",false),
  opt("B","Beta",false),
  opt("C","Gamma/X-rays",true),
  opt("D","Neutron",false),
  ans("C – Gamma/X-rays","Penetration: Alpha < Beta < Gamma/X-ray. Ionisation: Alpha > Beta > Gamma. (Real exam 2026)"),
  Q(105,"Which type of radiation has the HIGHEST ionising power?",true),
  opt("A","Gamma",false),
  opt("B","X-rays",false),
  opt("C","Alpha",true),
  opt("D","Beta",false),
  ans("C – Alpha","Alpha most ionising but least penetrating. (Real exam 2026)"),
  Q(106,"Beta radiation spilled on a lab coat would cause:"),
  opt("A","Internal contamination only",false),
  opt("B","External contamination",true),
  opt("C","Both internal and external contamination",false),
  opt("D","No contamination",false),
  ans("B – External contamination","Beta particles cannot penetrate deeply; lab coat = external contamination. (Real exam 2026)",true),
  Q(107,"The difference between gamma rays and X-rays is:"),
  opt("A","Gamma comes from nuclear decay; X-rays from electron transitions",true),
  opt("B","X-rays penetrate deeper than gamma",false),
  opt("C","Gamma is non-ionising; X-rays are ionising",false),
  opt("D","They are completely identical in origin",false),
  ans("A","Gamma = emitted from nucleus during radioactive decay. X-rays = produced by electrons outside nucleus. (Real exam 2026)",true),
  ...tf(108,"Low dose radiation is permitted during pregnancy, hence no changes are needed for foetal dose.","FALSE","BOTH statements incorrect. Low dose radiation is NOT permitted in pregnancy; foetal dose must be minimised. (Real exam 2026)",true),

  pb(),
  // ══ TOPIC 23 ══
  h1("Topic 23 – Risk and Control of Ionizing Radiation"),
  Q(109,"Monitoring of ionizing radiation exposure in occupational settings includes:",true),
  opt("A","Visual inspection only",false),
  opt("B","Individual dosimeters for all workers; health check-ups every 6 months",true),
  opt("C","Annual blood tests only",false),
  opt("D","Environmental monitoring only",false),
  ans("B","Every worker must have individual dosimeter; medical check-ups every 6 months. (Real exam 2026)"),
  Q(110,"The three main principles of radiation protection are:"),
  opt("A","Time, distance, shielding",true),
  opt("B","Ventilation, PPE, vaccination",false),
  opt("C","Filtration, dilution, substitution",false),
  opt("D","Rotation, rest, rehydration",false),
  ans("A","Time (reduce exposure time), Distance (increase from source), Shielding (barriers/lead)."),
  ...tf(111,"Lead shielding is the most effective protection against gamma and X-ray radiation.","TRUE","Lead = standard shielding for gamma/X-rays in radiology and nuclear medicine."),
  ...tf(112,"Decontamination of radioactive contamination of the skin is done by washing with soap and water.","TRUE","First step in decontamination: thorough washing with soap and water. (Real exam 2026)",true),

  pb(),
  // ══ TOPIC 24 ══
  h1("Topic 24 – Hygiene of Nutrition: Proteins"),
  Q(113,"The daily energy provided by 1g of protein is:"),
  opt("A","4 kcal",true),
  opt("B","7 kcal",false),
  opt("C","9 kcal",false),
  opt("D","2 kcal",false),
  ans("A – 4 kcal","Protein = 4 kcal/g. Carbohydrates = 4 kcal/g. Fat = 9 kcal/g. (Real exam 2026)",true),
  Q(114,"Complete proteins containing all essential amino acids are found in:"),
  opt("A","Vegetables only",false),
  opt("B","Animal products: meat, fish, eggs, milk",true),
  opt("C","Pulses only",false),
  opt("D","Cereals and grains",false),
  ans("B","Animal proteins = complete (all essential AAs). Plant proteins often incomplete."),
  Q(115,"The recommended percentage of proteins in daily diet is:"),
  opt("A","5–10%",false),
  opt("B","10–15%",true),
  opt("C","20–30%",false),
  opt("D","30–40%",false),
  ans("B – 10–15%","Protein: 10–15% of daily energy. Fat: 20–35%. Carbs: 55–60%."),
  ...tf(116,"Animal proteins have higher biological value than plant proteins due to their essential amino acid profile.","TRUE","Biological value = proportion of absorbed protein retained for body functions."),

  pb(),
  // ══ TOPIC 25 ══
  h1("Topic 25 – Fats: Physiological Importance, Sources and Needs"),
  Q(117,"The daily recommended energy range of total fat is:",true),
  opt("A","10–15%",false),
  opt("B","15–20%",false),
  opt("C","20–35%",true),
  opt("D","40–50%",false),
  ans("C – 20–35%","WHO recommendation: dietary fat = 20–35% of total energy. (Real exam 2026 + MCQ bank)"),
  Q(118,"Which of the following statements about fats is INCORRECT?",true),
  opt("A","Unsaturated fats are healthier than saturated fats",false),
  opt("B","Saturated fats should predominate over unsaturated fats",true),
  opt("C","1g of fat provides approximately 9 kcal",false),
  opt("D","Polyunsaturated fats include omega-3 and omega-6 fatty acids",false),
  ans("B – INCORRECT statement","Saturated fats should NOT predominate. Unsaturated fats (especially PUFA) are recommended. (Real exam 2026)",true),
  Q(119,"Which type of fat is present in HEALTHY diets?"),
  opt("A","Saturated fat predominantly",false),
  opt("B","Trans fats",false),
  opt("C","Mono- and polyunsaturated fats",true),
  opt("D","Cholesterol-rich animal fats",false),
  ans("C","Mono-unsaturated (olive oil) and polyunsaturated (omega-3, omega-6) = healthy fats. (MCQ bank)"),
  ...tf(120,"Fat and water are the main energy sources in the body.","FALSE","Main energy sources are CARBOHYDRATES and FATS. Water provides no calories. (Real exam 2026)",true),
  ...tf(121,"Polyunsaturated fats reduce energy expenditure.","FALSE","PUFA do NOT reduce energy expenditure. (Real exam 2026)",true),

  pb(),
  // ══ TOPIC 26 ══
  h1("Topic 26 – Carbohydrates: Physiological Importance and Dietary Fibre"),
  Q(122,"Excellent sources of complex carbohydrates are:",true),
  opt("A","Bread, rice, potatoes",true),
  opt("B","Sugar and honey only",false),
  opt("C","Meat and fish",false),
  opt("D","Oils and fats",false),
  ans("A – Bread, rice, potatoes","Complex carbs = polysaccharides. (Real MCQ bank)"),
  Q(123,"What does dietary fibre help to prevent?"),
  opt("A","Muscle weakness",false),
  opt("B","Constipation",true),
  opt("C","High blood pressure (primarily)",false),
  opt("D","Anaemia",false),
  ans("B – Constipation","Fibre also reduces cholesterol, colorectal cancer risk, and controls blood glucose. (MCQ bank)"),
  Q(124,"Calculate the energy from: 5g carbohydrates + 10g fat + 5g protein:",true),
  opt("A","100 kcal",false),
  opt("B","115 kcal",false),
  opt("C","130 kcal",true),
  opt("D","150 kcal",false),
  ans("C – 130 kcal","5×4 + 10×9 + 5×4 = 20+90+20 = 130 kcal. (Real exam 2026)"),
  ...tf(125,"The recommended percentage of carbohydrates in the daily diet is 55–60%.","TRUE","Macronutrient balance: CHO 55–60%, Fat 20–35%, Protein 10–15%."),

  pb(),
  // ══ TOPIC 27 ══
  h1("Topic 27 – Vitamins: Physiological Importance, Sources and Needs"),
  Q(126,"Which food is rich in Vitamin C?",true),
  opt("A","Eggs",false),
  opt("B","Oily fish",false),
  opt("C","Peppers and broccoli",true),
  opt("D","Cereals and milk",false),
  ans("C – Peppers and broccoli","Vitamin C (ascorbic acid) highest in: peppers, broccoli, citrus fruits, kiwi. (Real MCQ bank)"),
  Q(127,"Which of the following does NOT increase the need for Vitamin D?",true),
  opt("A","Dark skin pigmentation",false),
  opt("B","Limited sun exposure",false),
  opt("C","Religious practices (covering skin)",false),
  opt("D","Religious practices was the INCORRECT answer in exam",true),
  ans("D – Answer: Religious practices","All the others DO increase Vitamin D need. Religious practices covering skin do increase need, but this was the exam answer. Context: dark skin, limited sun, old age, malabsorption increase D need. (Real exam 2026)"),
  note("Note: The 2026 exam answer for 'all the following increase need for Vit D EXCEPT' = religious practices. However logically covering skin reduces UV synthesis. Learn the exam answer."),
  Q(128,"Vitamin A deficiency causes:"),
  opt("A","Scurvy",false),
  opt("B","Night blindness and xerophthalmia",true),
  opt("C","Rickets",false),
  opt("D","Pellagra",false),
  ans("B","Vitamin A deficiency: night blindness, xerophthalmia, impaired immunity. (Oral exam topic 2026)"),
  Q(129,"Fat-soluble vitamins are:"),
  opt("A","A, D, E, K",true),
  opt("B","B complex, C",false),
  opt("C","A, C, D, E",false),
  opt("D","B12, Folic acid",false),
  ans("A – A, D, E, K","Fat-soluble vitamins stored in liver/adipose tissue. Water-soluble: B complex + C."),

  pb(),
  // ══ TOPIC 28 ══
  h1("Topic 28 – Minerals: Physiological Importance, Sources and Needs"),
  Q(130,"Which mineral is bananas rich in?",true),
  opt("A","Calcium",false),
  opt("B","Iron",false),
  opt("C","Potassium",true),
  opt("D","Magnesium",false),
  ans("C – Potassium","Bananas = potassium-rich. (Real exam 2026 — Toseva asks specific food sources)"),
  Q(131,"Which food is rich in magnesium?",true),
  opt("A","Bananas",false),
  opt("B","Almonds",true),
  opt("C","Milk",false),
  opt("D","Oranges",false),
  ans("B – Almonds","Almonds = rich in magnesium. (Real exam 2026)"),
  Q(132,"Iron deficiency affects learning ability in children:"),
  opt("A","No effect on cognition",false),
  opt("B","Yes — iron deficiency impairs cognitive function and learning",true),
  opt("C","Only affects physical development",false),
  opt("D","Only in adults",false),
  ans("B – YES","Iron essential for brain development and neurotransmitter synthesis. (Real exam 2026)",true),
  Q(133,"Iodine deficiency causes:"),
  opt("A","Rickets",false),
  opt("B","Anaemia",false),
  opt("C","Endemic goitre and cretinism",true),
  opt("D","Fluorosis",false),
  ans("C","Iodine deficiency → hypothyroidism → goitre in adults, cretinism in neonates."),

  pb(),
  // ══ TOPIC 29 ══
  h1("Topic 29 – Milk, Dairy Products, Eggs in Human Nutrition"),
  Q(134,"What reagent is used to test if sodium carbonate (baking soda) has been added to milk?",true),
  opt("A","Nessler reagent",false),
  opt("B","Rosolic acid",true),
  opt("C","Barium chloride",false),
  opt("D","Orthotolidine",false),
  ans("B – Rosolic acid","Red reaction if positive for Na₂CO₃ addition. (Real exam 2026)"),
  Q(135,"The milk peroxidase test indicates:"),
  opt("A","Presence of antibiotics in milk",false),
  opt("B","That milk has been effectively pasteurised",true),
  opt("C","Bacterial contamination",false),
  opt("D","Fat content of milk",false),
  ans("B","Peroxidase is inactivated by pasteurisation. Positive peroxidase = NOT pasteurised. (Real exam 2026)",true),
  Q(136,"The device used to measure milk density is called:"),
  opt("A","Lactoscope",false),
  opt("B","Lactometer",true),
  opt("C","Hydrometer only",false),
  opt("D","Densitometer",false),
  ans("B – Lactometer","(From MCQ bank)"),

  pb(),
  // ══ TOPIC 30 ══
  h1("Topic 30 – Meat, Fish and Their Products in Human Nutrition"),
  Q(137,"The meat sample must be condemned if:",true),
  opt("A","The fat content is above average",false),
  opt("B","One form of Trichinella spiralis is found in it",true),
  opt("C","The colour is slightly different from normal",false),
  opt("D","The sample is refrigerated",false),
  ans("B","Zero tolerance for Trichinella spiralis — even one larva = sample destroyed. (Real MCQ bank)"),
  Q(138,"Salmonellosis is one of the most common foodborne infections:",true),
  ...tf(138,"Salmonellosis is one of the most common foodborne infections.","TRUE","Salmonella = most common foodborne infection worldwide. (Real exam 2026)",true),

  pb(),
];

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  fs.writeFileSync('/tmp/workspace/hygiene-mcqs/MCQ_Part_A_Topics1_60.docx', buf);
  console.log('Part A done. Size:', buf.length);
});

// PART B: Topics 31-90
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  new Paragraph({ alignment: AlignmentType.CENTER, spacing: { before: 200, after: 100 },
    children: [new TextRun({ text: "HYGIENE & ECOLOGY — COMPLETE MCQ BANK", bold: true, size: 36, font: "Calibri" })] }),
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    children: [new TextRun({ text: "PART B: Topics 31–90  |  ★REAL EXAM = appeared in June 2026 actual exam", bold: true, size: 22, italics: true, font: "Calibri", color: "C00000" })] }),
  pb(),

  // ══ TOPIC 31 ══
  h1("Topic 31 – Foods of Vegetable Origin: Cereals, Pulses, Nuts"),
  Q(201,"Which of the following is a correct statement about cereals?",true),
  opt("A","Cereals are complete proteins",false),
  opt("B","Cereals are the main source of complex carbohydrates and provide B vitamins",true),
  opt("C","Cereals have no nutritional value",false),
  opt("D","Cereals are rich in Vitamin C",false),
  ans("B","Cereals (wheat, rice, maize) = CHO + B vitamins + fibre + incomplete proteins. (Oral exam 2026)"),
  Q(202,"Pulses (legumes) are nutritionally valuable because:"),
  opt("A","They are the richest source of Vitamin A",false),
  opt("B","They are high in plant protein, fibre, and complex carbohydrates",true),
  opt("C","They are complete sources of all essential amino acids",false),
  opt("D","They are the main source of iron",false),
  ans("B","Pulses = plant protein (incomplete), high fibre, low fat, complex CHO."),
  ...tf(203,"Nuts are a rich source of unsaturated fats, vitamin E, and minerals.","TRUE","Nuts: healthy fats, Vit E, Mg, Cu, Se; recommended as part of healthy diet."),

  pb(),
  // ══ TOPIC 32 ══
  h1("Topic 32 – Foods of Vegetable Origin: Vegetables and Fruit"),
  Q(204,"Vegetables and fruits are primarily important for their content of:"),
  opt("A","Complete proteins and saturated fats",false),
  opt("B","Vitamins, minerals, fibre, and antioxidants",true),
  opt("C","Complex carbohydrates and B12",false),
  opt("D","Saturated fatty acids",false),
  ans("B","V&F = vitamins (especially C, A, folate), minerals, fibre, antioxidant phytochemicals."),
  Q(205,"The recommended daily servings of vegetables and fruit (WHO) is:"),
  opt("A","1–2 portions",false),
  opt("B","At least 5 portions (400g)",true),
  opt("C","3 portions maximum",false),
  opt("D","10 portions",false),
  ans("B – ≥5 portions/day","WHO recommends ≥400g (5 portions) of fruit and vegetables daily."),

  pb(),
  // ══ TOPIC 33 ══
  h1("Topic 33 – Sugar, Fats/Oils, Alcohol, Beverages"),
  Q(206,"Sugar, sugar products and honey in excessive amounts are associated with:"),
  opt("A","Anaemia and osteoporosis",false),
  opt("B","Dental caries, obesity, diabetes, and cardiovascular disease risk",true),
  opt("C","Kidney stones only",false),
  opt("D","No significant health effects",false),
  ans("B","Excessive sugar intake: dental caries, obesity, T2DM, CVD. WHO recommends <10% energy from free sugars."),
  Q(207,"Which of the following statements about alcohol is CORRECT?",true),
  opt("A","Alcohol provides 7 kcal/g",true),
  opt("B","Alcohol provides 4 kcal/g like protein",false),
  opt("C","Alcohol provides 9 kcal/g like fat",false),
  opt("D","Alcohol provides 0 kcal (empty calories only)",false),
  ans("A – 7 kcal/g","Alcohol = 7 kcal/g. No nutritional value but energy dense. (Oral exam topic 2026)"),
  ...tf(208,"Saturated fats should not predominate over unsaturated fats in a healthy diet.","TRUE","WHO recommends replacing saturated with unsaturated fats to reduce CVD risk. (Real exam 2026)",true),

  pb(),
  // ══ TOPIC 34 ══
  h1("Topic 34 – Functional Foods and Genetically Modified Foods"),
  Q(209,"Functional foods are defined as:"),
  opt("A","Foods that are genetically modified",false),
  opt("B","Foods that have a health benefit beyond basic nutrition due to added or naturally occurring bioactive components",true),
  opt("C","Foods with no additives",false),
  opt("D","Organic foods only",false),
  ans("B","Functional foods: probiotics, prebiotics, fortified foods, phytochemical-rich foods."),
  ...tf(210,"Genetically modified (GM) foods undergo safety assessment before approval.","TRUE","GM foods are assessed for allergenicity, toxicity, and nutritional equivalence before market approval."),

  pb(),
  // ══ TOPIC 35 ══
  h1("Topic 35 – Food Processing and Preservation"),
  Q(211,"Which of the following is a method of food preservation?"),
  opt("A","Refrigeration, freezing, canning, salting, smoking, drying",true),
  opt("B","Only boiling and sterilisation",false),
  opt("C","Irradiation is not permitted",false),
  opt("D","Only chemical additives",false),
  ans("A","Food preservation: physical (cold, heat, radiation), chemical (salt, sugar, acid, additives), biological (fermentation)."),
  Q(212,"Pasteurisation of milk achieves:"),
  opt("A","Complete sterilisation",false),
  opt("B","Destruction of pathogenic organisms without significantly affecting nutritional value",true),
  opt("C","Only extension of shelf-life without killing bacteria",false),
  opt("D","Removal of fat",false),
  ans("B","Pasteurisation: 72°C for 15 sec (HTST) or 63°C for 30 min (LTST). Kills pathogens; preserves nutrients."),

  pb(),
  // ══ TOPIC 36 ══
  h1("Topic 36 – Healthy Nutrition. Enteral and Parenteral Nutrition"),
  Q(213,"The Body Mass Index (BMI) uses:"),
  opt("A","Height and muscle mass",false),
  opt("B","Weight and muscle mass",false),
  opt("C","Height and weight",true),
  opt("D","Height, weight, and muscle mass",false),
  ans("C – Height and weight","BMI = weight(kg) / height(m)². (Real MCQ bank)"),
  Q(214,"BMI groups from underweight to obese type 3 are:"),
  opt("A","<16, 16–18.5, 18.5–25, 25–30, 30–35, 35–40, >40",true),
  opt("B","<18.5, 18.5–25, 25–30, >30",false),
  opt("C","<20, 20–25, 25–30, >30",false),
  opt("D","Only three categories",false),
  ans("A","Full BMI classification: severe underweight <16, underweight 16–18.5, normal 18.5–25, overweight 25–30, obese I 30–35, obese II 35–40, obese III >40. (Real exam 2026)",true),
  Q(215,"Parenteral nutrition is:"),
  opt("A","Nutrition delivered via nasogastric tube",false),
  opt("B","Nutrition delivered intravenously, bypassing the GI tract",true),
  opt("C","Oral nutrition supplements",false),
  opt("D","Nutrition via gastrostomy",false),
  ans("B","Parenteral = IV route (TPN). Enteral = GI route (nasogastric, gastrostomy, jejunostomy)."),

  pb(),
  // ══ TOPIC 37 ══
  h1("Topic 37 – Principles of Diet Therapy"),
  Q(216,"The principles of diet therapy (curative nutrition) include:",true),
  opt("A","One standard diet for all diseases",false),
  opt("B","Individualised diet based on diagnosis, metabolic state, and therapeutic goals",true),
  opt("C","Fasting as the primary therapeutic tool",false),
  opt("D","Vitamin supplementation only",false),
  ans("B","Diet therapy: individualised, based on disease mechanism, aims to correct metabolic abnormalities."),
  ...tf(217,"Diet therapy uses the Pevzner diet classification system (diets numbered 1–15).","TRUE","Pevzner system: 15 standard therapeutic diets for different conditions (e.g. diet 1 = peptic ulcer, diet 9 = diabetes)."),

  pb(),
  // ══ TOPIC 38 ══
  h1("Topic 38 – Alternative Nutrition"),
  Q(218,"Which of the following is a characteristic of a VEGAN diet?"),
  opt("A","Excludes all animal products",true),
  opt("B","Includes dairy but excludes meat",false),
  opt("C","Includes eggs but excludes meat",false),
  opt("D","Restricts calories only",false),
  ans("A","Vegan: excludes all animal products. Vegetarian: excludes meat but may include dairy/eggs."),
  Q(219,"The main nutritional risk of strict vegan diets is deficiency of:"),
  opt("A","Vitamin C",false),
  opt("B","Vitamin B12, iron, calcium, omega-3, zinc",true),
  opt("C","Vitamin A only",false),
  opt("D","Carbohydrates",false),
  ans("B","B12 found only in animal products → must supplement. Also: iron (non-haem less absorbed), Ca, Zn, omega-3."),

  pb(),
  // ══ TOPIC 39 ══
  h1("Topic 39 – Nutrition of Pregnant and Lactating Women"),
  Q(220,"During pregnancy, which nutrient is especially important for preventing neural tube defects?"),
  opt("A","Vitamin C",false),
  opt("B","Folic acid (Vitamin B9)",true),
  opt("C","Vitamin D",false),
  opt("D","Calcium",false),
  ans("B – Folic acid","400–800 mcg folic acid pre-conception and first trimester prevents neural tube defects."),
  Q(221,"The additional energy requirement during the 2nd and 3rd trimester of pregnancy is approximately:"),
  opt("A","100 kcal/day",false),
  opt("B","300 kcal/day",true),
  opt("C","500 kcal/day",false),
  opt("D","No additional energy needed",false),
  ans("B – +300 kcal/day","Pregnancy: +300 kcal/day (2nd/3rd trimester). Lactation: +500 kcal/day."),
  ...tf(222,"Alcohol and smoking are absolutely contraindicated during pregnancy.","TRUE","Both are teratogenic; no safe level of alcohol in pregnancy."),

  pb(),
  // ══ TOPIC 40-41 ══
  h1("Topics 40–41 – Nutrition of Children and Schoolchildren"),
  Q(223,"Does iron deficiency affect learning ability in children?",true),
  opt("A","No, iron only affects red blood cells",false),
  opt("B","Yes, iron deficiency impairs cognitive function and learning",true),
  opt("C","Only in children over 10 years",false),
  opt("D","Only when combined with protein deficiency",false),
  ans("B – YES","Iron essential for myelination and neurotransmitter synthesis. (Real exam 2026)"),
  Q(224,"Physical development in the preschool years (3–6 years) is at:"),
  opt("A","A rapid spurting rate",false),
  opt("B","A relatively even/steady rate",true),
  opt("C","A rapid then slow rate",false),
  opt("D","Identical rate to infancy",false),
  ans("B – Relatively even rate","Preschool = steady moderate growth. Rapid growth in infancy and puberty. (Real exam 2026)",true),
  ...tf(225,"The period of middle and late childhood involves slow, consistent growth.","TRUE","School-age children have slow, consistent growth until puberty. (MCQ bank)"),
  ...tf(226,"Children require proportionally more protein and calcium per kg body weight than adults.","TRUE","Higher anabolic needs for growth; protein ~1.5g/kg for children vs ~0.8g/kg adults."),

  pb(),
  // ══ TOPIC 42-43 ══
  h1("Topics 42–43 – Nutrition for Mental Workers and Sportsmen"),
  Q(227,"When does an average medical student expend the most energy?",true),
  opt("A","During intense study",false),
  opt("B","During basal metabolic rate processes",true),
  opt("C","During light exercise",false),
  opt("D","During sleep",false),
  ans("B – Basal Metabolic Rate","BMR accounts for ~60–70% of total energy expenditure even in students. (Real exam 2026)"),
  Q(228,"Athletes and sportsmen have increased requirements for:"),
  opt("A","Vitamins only",false),
  opt("B","Energy, carbohydrates, protein, fluids, and electrolytes",true),
  opt("C","Fat only",false),
  opt("D","Calcium and phosphorus only",false),
  ans("B","Sport nutrition: high CHO for fuel, protein for muscle repair, hydration, electrolytes."),

  pb(),
  // ══ TOPIC 44-45 ══
  h1("Topics 44–45 – Nutrition in Occupational Hazards, Stress, Elderly"),
  Q(229,"Nutrition in occupational exposure to heavy metals should include:"),
  opt("A","Low calorie diet",false),
  opt("B","Increased protein, antioxidants, calcium, and pectin to reduce absorption and enhance excretion",true),
  opt("C","High fat diet",false),
  opt("D","Fasting days",false),
  ans("B","Protective nutrition for chemical hazards: milk, pectin, vitamins C/E (antioxidants), Ca competes with Pb/Cd absorption."),
  Q(230,"Nutrition requirements in elderly include:"),
  opt("A","Same as young adults",false),
  opt("B","Reduced total calories but maintained or increased micronutrient density; increased calcium and Vitamin D",true),
  opt("C","Increased fat intake",false),
  opt("D","Reduced protein intake",false),
  ans("B","Elderly: lower BMR → less energy, but nutrients stay same/higher. Ca+D for osteoporosis prevention."),

  pb(),
  // ══ TOPIC 46 ══
  h1("Topic 46 – Foodborne Diseases: Infections, Intoxications, Mycotoxicoses"),
  Q(231,"The difference between foodborne INFECTION and foodborne POISONING (intoxication) is:",true),
  opt("A","Infections are caused by preformed toxins; poisonings by live bacteria",false),
  opt("B","Infections involve live pathogen ingestion and proliferation; intoxications are caused by preformed toxins in food",true),
  opt("C","There is no practical difference",false),
  opt("D","Only infections cause fever",false),
  ans("B","Infection: live pathogen (Salmonella, Campylobacter). Intoxication: preformed toxin (S. aureus, Cl. botulinum). (Real MCQ bank)"),
  Q(232,"Botulism is caused by:"),
  opt("A","Salmonella typhimurium",false),
  opt("B","Staphylococcus aureus",false),
  opt("C","Clostridium botulinum toxin in food",true),
  opt("D","E. coli O157",false),
  ans("C","Botulism = preformed neurotoxin from Cl. botulinum in anaerobic conditions (canned foods)."),
  Q(233,"Salmonellosis is one of the most common foodborne infections:",true),
  ...tf(233,"Salmonellosis is one of the most common foodborne infections.","TRUE","Salmonella = most common foodborne illness worldwide. (Real exam 2026)",true),

  pb(),
  // ══ TOPIC 47-48 ══
  h1("Topics 47–48 – Chemically Contaminated Foods. Non-Microbial Poisoning"),
  Q(234,"Arsenic is taken in primarily through:"),
  opt("A","Dermal absorption only",false),
  opt("B","Inhalation and ingestion",true),
  opt("C","IV injection only",false),
  opt("D","Ocular absorption",false),
  ans("B – Inhalation and ingestion","Arsenic causes ulceration of mucous membranes. Both routes = causal relationship. (Real exam 2026)",true),
  Q(235,"Non-microbial food poisoning includes poisoning from:"),
  opt("A","Poisonous mushrooms (Amanita phalloides), solanine, cyanogenic glycosides, fish toxins",true),
  opt("B","Only industrial chemicals",false),
  opt("C","Only heavy metals",false),
  opt("D","Salmonella and Campylobacter",false),
  ans("A","Non-microbial: naturally toxic foods (mushrooms, solanine in green potatoes, aflatoxins, fish toxins)."),

  pb(),
  // ══ TOPIC 49 ══
  h1("Topic 49 – Food Allergy, Food Intolerance and Drug-Nutrient Interactions"),
  Q(236,"Food ALLERGY differs from food INTOLERANCE in that:"),
  opt("A","Allergy involves an immune response (IgE-mediated); intolerance does not",true),
  opt("B","They are identical conditions",false),
  opt("C","Intolerance is more severe than allergy",false),
  opt("D","Allergy only affects children",false),
  ans("A","Food allergy = immune (IgE). Intolerance = non-immune (e.g. lactose intolerance = enzyme deficiency)."),
  ...tf(237,"Drug-nutrient interactions can reduce the effectiveness of medications.","TRUE","E.g. grapefruit inhibits CYP3A4; warfarin affected by Vit K; tetracycline chelated by calcium."),

  pb(),
  // ══ TOPIC 50 ══
  h1("Topic 50 – Diseases from Improper Nutrition: Malnutrition and Overnutrition"),
  Q(238,"Kwashiorkor is caused by:",true),
  opt("A","Severe calorie deficiency",false),
  opt("B","Severe protein deficiency with adequate or excessive calorie intake",true),
  opt("C","Vitamin A deficiency",false),
  opt("D","Iron deficiency",false),
  ans("B","Kwashiorkor = protein deficiency → oedema, pot belly, depigmentation. Marasmus = total calorie deficiency → wasting. (Real exam 2026)"),
  Q(239,"Marasmus is characterised by:"),
  opt("A","Oedema and pot belly",false),
  opt("B","Severe wasting of muscle and fat from total calorie deficiency",true),
  opt("C","Protein deficiency with adequate calories",false),
  opt("D","Only occurs in obese patients",false),
  ans("B","Marasmus = severe calorie + protein deficiency → profound wasting, stunting, no oedema."),

  pb(),
  // ══ TOPICS 51-56 ══
  h1("Topics 51–56 – Dietary Prevention of Chronic Diseases"),
  Q(240,"Dietary prevention of obesity primarily involves:"),
  opt("A","High fat, low carbohydrate diet",false),
  opt("B","Energy balance: caloric intake ≤ energy expenditure; reducing sugar and saturated fats",true),
  opt("C","Fasting every other day",false),
  opt("D","Protein-only diet",false),
  ans("B","Obesity prevention: energy balance, less sugar/fat, more fibre, physical activity. (Oral exam 2026)"),
  Q(241,"Dietary prevention of cardiovascular disease includes:",true),
  opt("A","Increase saturated fat; decrease fibre",false),
  opt("B","Mediterranean diet: olive oil, fish, vegetables, fruits, whole grains; reduce salt and saturated fat",true),
  opt("C","High sodium diet for blood pressure",false),
  opt("D","Eliminate all fats from diet",false),
  ans("B","CVD prevention: Mediterranean diet, omega-3, reduce salt/sat fat/trans fat, increase fibre, antioxidants."),
  Q(242,"Dietary prevention of cancer involves:",true),
  opt("A","High red meat consumption",false),
  opt("B","Increasing fruits/vegetables/fibre, reducing processed meat, alcohol, and energy-dense foods",true),
  opt("C","High protein diet",false),
  opt("D","Supplementing with synthetic beta-carotene in smokers",false),
  ans("B","Cancer diet prevention: 5+ portions F&V/day, fibre, limit alcohol, processed/red meat. (Oral exam 2026)"),
  Q(243,"Dietary prevention of Type 2 diabetes includes:"),
  opt("A","High glycaemic index foods to stimulate insulin",false),
  opt("B","Low GI diet, high fibre, reduced sugar and refined CHO, weight management",true),
  opt("C","High protein only",false),
  opt("D","Avoid all carbohydrates",false),
  ans("B","T2DM prevention: low GI, high fibre, weight control, physical activity."),
  Q(244,"Dietary prevention of GOUT involves:"),
  opt("A","Low purine diet; avoid organ meats, anchovies, shellfish, alcohol (especially beer)",true),
  opt("B","High meat diet",false),
  opt("C","High calcium intake",false),
  opt("D","Fasting",false),
  ans("A","Gout = uric acid crystal deposition; reduce purines (meat, offal, beer), increase water."),
  Q(245,"Dietary prevention of osteoporosis includes:"),
  opt("A","Low calcium diet",false),
  opt("B","Adequate calcium, Vitamin D, moderate protein; avoid excess alcohol, caffeine, and smoking",true),
  opt("C","High sodium diet",false),
  opt("D","Avoiding all dairy",false),
  ans("B","Osteoporosis: Ca 1000–1200mg/day, Vit D, weight-bearing exercise, no smoking/excess alcohol."),

  pb(),
  // ══ TOPIC 57 ══
  h1("Topic 57 – Occupational Hygiene: Subject, Aim, Tasks, Work Forms, Hazards"),
  Q(246,"The five groups of occupational hazards are:"),
  opt("A","Physical, Chemical, Biological, Psychological/psychosocial, Ergonomic/musculoskeletal",true),
  opt("B","Heat, Cold, Noise, Dust, Chemicals",false),
  opt("C","Radiation, Sound, Smell, Light, Temperature",false),
  opt("D","Only physical and chemical hazards",false),
  ans("A","Five major occupational hazard groups. (MCQ bank — dentistry question lists all 5)"),
  Q(247,"Work activity forms include:"),
  opt("A","Physical work, mental (intellectual) work, and mixed forms",true),
  opt("B","Only manual labour",false),
  opt("C","Only sedentary work",false),
  opt("D","Shift work only",false),
  ans("A","Work forms: physical (dynamic/static muscle work), mental/intellectual, mixed (physical + mental)."),

  pb(),
  // ══ TOPIC 58-59 ══
  h1("Topics 58–59 – Physiology of Work. Fatigue and Exhaustion"),
  Q(248,"Physiological parameters of work assessed in occupational hygiene include:",true),
  opt("A","Heart rate, oxygen consumption, muscle strength, reaction time",true),
  opt("B","Blood glucose only",false),
  opt("C","Height and weight",false),
  opt("D","Visual acuity only",false),
  ans("A","Physiological work assessment: HR, O₂ consumption, ventilation, energy expenditure, reaction time. (Oral exam 2026)"),
  Q(249,"Work-related fatigue differs from exhaustion in that:"),
  opt("A","Fatigue is reversible with rest; exhaustion is chronic and may lead to burnout",true),
  opt("B","They are identical",false),
  opt("C","Exhaustion is shorter lasting",false),
  opt("D","Only fatigue affects mental work",false),
  ans("A","Fatigue = reversible physiological state. Exhaustion = chronic, pathological, requires medical intervention."),
  Q(250,"The PAL (Physical Activity Level) score is:"),
  opt("A","A body mass measurement",false),
  opt("B","Total energy expenditure divided by basal metabolic rate; describes activity intensity",true),
  opt("C","A psychological test for fatigue",false),
  opt("D","A blood test marker",false),
  ans("B","PAL = TEE/BMR. Stages: sedentary (1.2), lightly active (1.4–1.6), moderately active (1.6–1.8), very active (>1.8). (Oral exam 2026)",true),

  pb(),
  // ══ TOPIC 60 ══
  h1("Topic 60 – Ergonomics. Video Display Work"),
  Q(251,"Common awkward postures in dental practice include:",true),
  opt("A","Knee and ankle flexion",false),
  opt("B","Elbow and wrist flexion and thumb hyperextension",true),
  opt("C","Only shoulder elevation",false),
  opt("D","Hip extension only",false),
  ans("B","Ergonomic hazard in dentistry: elbow, wrist, thumb postures. (Real MCQ bank)"),
  Q(252,"Ergonomics is defined as:"),
  opt("A","The study of work environments only",false),
  opt("B","The science of designing work, tools, and environment to fit the human worker to prevent injury and improve efficiency",true),
  opt("C","The study of factory production methods",false),
  opt("D","The study of nutrition in the workplace",false),
  ans("B","Ergonomics = human factors engineering; adapts work to human capabilities."),
  ...tf(253,"Prolonged VDU (computer screen) use is associated with eye strain, musculoskeletal disorders, and psychosocial stress.","TRUE","VDU ergonomic risks: asthenopia, neck/back problems, carpal tunnel, psychosocial stress."),

  pb(),
  // ══ TOPIC 61 ══
  h1("Topic 61 – Physical Hazards: Industrial Microclimate"),
  Q(254,"Industrial microclimate is assessed by measuring:"),
  opt("A","Air temperature, humidity, air velocity, and radiant temperature",true),
  opt("B","Noise and vibration only",false),
  opt("C","Chemical concentrations only",false),
  opt("D","Lighting levels only",false),
  ans("A","Microclimate = air temp + humidity + air velocity + mean radiant temp. Evaluated by WBGT or effective temperature."),
  Q(255,"An objective physical method for complex microclimate evaluation is:",true),
  opt("A","Anfimov test",false),
  opt("B","WBGT (Wet Bulb Globe Temperature) index",true),
  opt("C","Schellong test",false),
  opt("D","Psychrometry alone",false),
  ans("B – WBGT","Physical objective method. Physiological methods = core temp, sweat rate. Integral = effective temperature. (Real exam 2026)"),

  pb(),
  // ══ TOPIC 62 ══
  h1("Topic 62 – Physical Hazards: Atmospheric Pressure in Workplace"),
  Q(256,"Decompression sickness occurs due to:"),
  opt("A","Oxygen toxicity during diving",false),
  opt("B","Nitrogen bubble formation in tissues following rapid decompression",true),
  opt("C","Carbon dioxide accumulation",false),
  opt("D","Hypoxia at altitude",false),
  ans("B","Rapid ascent → N₂ comes out of solution → bubbles → emboli. Prevention: slow staged decompression."),
  ...tf(257,"Workers in hyperbaric environments (caissons, divers) are at risk of decompression sickness.","TRUE","Occupational decompression sickness = occupational hazard from increased atmospheric pressure work."),

  pb(),
  // ══ TOPIC 63 ══
  h1("Topic 63 – Physical Hazards: Occupational Noise"),
  Q(258,"The frequency of noise is expressed in:",true),
  opt("A","Decibels (dB)",false),
  opt("B","Hertz (Hz)",true),
  opt("C","Watts",false),
  opt("D","Pascals",false),
  ans("B – Hertz (Hz)","Frequency = Hz. Intensity = dB. Occupational noise limit: 85 dB(A) for 8h/day. (Real MCQ bank)"),
  Q(259,"Prolonged occupational noise exposure causes:"),
  opt("A","Acute hearing loss only if >140 dB",false),
  opt("B","Progressive sensorineural hearing loss (noise-induced hearing loss)",true),
  opt("C","Only temporary threshold shift",false),
  opt("D","No permanent effects below 100 dB",false),
  ans("B","Chronic noise → permanent sensorineural hearing loss (NIHL); starts at 4000 Hz (audiogram notch)."),

  pb(),
  // ══ TOPIC 64 ══
  h1("Topic 64 – Physical Hazards: Occupational Vibration"),
  Q(260,"Occupational vibration can be assessed by:",true),
  opt("A","Audiometry",false),
  opt("B","Vibration measurement (accelerometer) and clinical/neurological examination",true),
  opt("C","Blood pressure monitoring",false),
  opt("D","Spirometry",false),
  ans("B","Vibration assessment: accelerometers, neurological exam, cold provocation test (Raynaud's). (Oral + real exam 2026)",true),
  Q(261,"Hand-arm vibration syndrome (HAVS) is characterised by:"),
  opt("A","Hearing loss",false),
  opt("B","Raynaud's phenomenon (white finger), neurological symptoms, musculoskeletal effects",true),
  opt("C","Lung disease",false),
  opt("D","Liver damage",false),
  ans("B","HAVS: vascular (Raynaud's/white finger), neurological (tingling, numbness), musculoskeletal changes."),
  Q(262,"Prevention of occupational vibration includes:",true),
  opt("A","No preventive measures available",false),
  opt("B","Vibration-dampening tools, rotation of workers, health monitoring, PPE gloves",true),
  opt("C","Increased work hours to adapt",false),
  opt("D","Only earplugs",false),
  ans("B","Vibration prevention: engineering controls, administrative (rotation), PPE, monitoring. (Real exam 2026)"),

  pb(),
  // ══ TOPIC 65 ══
  h1("Topic 65 – Physical Hazards: Ultrasound and Infrasound"),
  Q(263,"Infrasound differs from audible sound in that:"),
  opt("A","Its frequency is above 20,000 Hz",false),
  opt("B","Its frequency is below 20 Hz; inaudible but can cause physiological effects",true),
  opt("C","It is louder than audible sound",false),
  opt("D","It has no health effects",false),
  ans("B","Infrasound <20 Hz: inaudible; effects = fatigue, headache, disorientation. Ultrasound >20,000 Hz."),

  pb(),
  // ══ TOPIC 66 ══
  h1("Topic 66 – Non-Ionizing Radiation: UV and Infrared in Workplace"),
  Q(264,"Occupational exposure to UV radiation causes:",true),
  opt("A","No health effects",false),
  opt("B","Photokeratitis (arc eye), skin erythema, cataracts, and skin cancer with chronic exposure",true),
  opt("C","Only temporary erythema",false),
  opt("D","Internal organ damage primarily",false),
  ans("B","Occupational UV hazards: arc eye (welders), skin cancer (outdoor workers). (Oral exam 2026)"),
  Q(265,"UV radiation includes which subtypes?",true),
  opt("A","UVA (315-400nm), UVB (280-315nm), UVC (100-280nm)",true),
  opt("B","Only UVA and UVB",false),
  opt("C","Three types with no wavelength difference",false),
  opt("D","UV1 and UV2 only",false),
  ans("A","UVA = long wave (ageing, melanoma). UVB = medium wave (sunburn, vitamin D). UVC = short wave (bactericidal, blocked by ozone). (Oral exam: Toseva loves UVA/B/C and melanoma)",true),

  pb(),
  // ══ TOPIC 67 ══
  h1("Topic 67 – Non-Ionizing Radiation: Radiofrequency Radiation"),
  Q(266,"Radiofrequency (RF) radiation in the workplace is associated with:",true),
  opt("A","Ionising effects",false),
  opt("B","Thermal effects (tissue heating) and possible non-thermal biological effects",true),
  opt("C","No health effects proven",false),
  opt("D","Only psychological effects",false),
  ans("B","RF = non-ionising; primary effect is tissue heating. Occupational sources: radar, radiofrequency welding, diathermy. (Oral exam 2026)"),

  pb(),
  // ══ TOPICS 68-69 ══
  h1("Topics 68–69 – ELF Radiation, Static Fields, Lasers"),
  Q(267,"Lasers in the workplace pose health risks primarily to:"),
  opt("A","The liver and kidneys",false),
  opt("B","The eyes and skin",true),
  opt("C","The lungs only",false),
  opt("D","The cardiovascular system",false),
  ans("B","Laser radiation: retinal damage (even brief exposure), skin burns. Eye protection mandatory."),

  pb(),
  // ══ TOPIC 70 ══
  h1("Topic 70 – Dust and Particulate: Classification, Health Effects, Prevention"),
  Q(268,"Methods for dust analysis in workplace air are:",true),
  opt("A","Absorption sampling and grab sampling",true),
  opt("B","Only grab sampling",false),
  opt("C","Spectrophotometry only",false),
  opt("D","MPN method",false),
  ans("A – Absorption sampling + grab sampling","(Real MCQ bank)"),
  Q(269,"Pneumoconiosis is caused by:"),
  opt("A","Chemical vapours",false),
  opt("B","Inhalation of dust particles causing permanent lung damage/fibrosis",true),
  opt("C","Bacterial infection",false),
  opt("D","Radiofrequency radiation",false),
  ans("B","Pneumoconioses: silicosis (silica), asbestosis (asbestos), coal workers' pneumoconiosis, anthracosis."),
  Q(270,"Grab sampling for air pollutants is used for:",true),
  opt("A","Low concentrations",false),
  opt("B","High concentrations",true),
  opt("C","Only microbiological analysis",false),
  opt("D","Liquid pollutants only",false),
  ans("B – High concentrations","Grab sampling = instantaneous sample for high concentrations. Absorption = time-weighted average. (Real exam 2026)"),

  pb(),
  // ══ TOPIC 71 ══
  h1("Topic 71 – Chemical Hazards: Classification, Toxicology, Risk Assessment"),
  Q(271,"Hazardous substances are classified by category, including:",true),
  opt("A","Explosive, highly flammable, harmful, corrosive, carcinogenic",true),
  opt("B","Only toxic and non-toxic",false),
  opt("C","Only carcinogenic and non-carcinogenic",false),
  opt("D","Only by route of exposure",false),
  ans("A","Classification: explosive, flammable, harmful, toxic, carcinogenic, mutagenic, reprotoxic, corrosive, irritant. (Real MCQ bank)"),
  Q(272,"Toxicokinetics refers to:"),
  opt("A","The toxic effects of substances on target organs",false),
  opt("B","How the body absorbs, distributes, metabolises, and excretes toxic substances (ADME)",true),
  opt("C","The dose at which toxicity begins",false),
  opt("D","The psychological effects of chemicals",false),
  ans("B","Toxicokinetics = ADME. Toxicodynamics = mechanism of toxic effect on the body."),
  Q(273,"Hazard, risk, and risk assessment in occupational hygiene:"),
  opt("A","Are all the same concept",false),
  opt("B","Hazard = potential for harm; Risk = probability of harm occurring; Risk assessment = systematic evaluation",true),
  opt("C","Only apply to chemical hazards",false),
  opt("D","Are only relevant in nuclear industries",false),
  ans("B","Hazard ≠ risk. Risk = hazard × exposure. Risk assessment = identify hazard, assess exposure, characterise risk. (Oral exam 2026)"),

  pb(),
  // ══ TOPIC 72 ══
  h1("Topic 72 – Chemical Hazards: Heavy Metals"),
  Q(274,"The critical target organ for long-term cadmium exposure is:",true),
  opt("A","The liver",false),
  opt("B","The lung",false),
  opt("C","The kidney",true),
  opt("D","The nervous system",false),
  ans("C – The kidney","Cadmium → tubular proteinuria (Itai-Itai disease). (Real MCQ bank + oral exam 2026)"),
  Q(275,"Mercury exists as liquid at room temperature and its vapour is:",true),
  opt("A","Inhaled but not absorbed",false),
  opt("B","Inhaled via aerosols and absorbed through the respiratory tract; affects the CNS",true),
  opt("C","Only absorbed through skin",false),
  opt("D","Non-toxic in vapour form",false),
  ans("B","Mercury vapour = inhaled → CNS damage. PPE: respirator + ventilation. (Oral exam 2026)",true),
  Q(276,"Minamata disease is caused by:"),
  opt("A","Lead poisoning",false),
  opt("B","Methylmercury poisoning from contaminated fish",true),
  opt("C","Cadmium poisoning",false),
  opt("D","Arsenic poisoning",false),
  ans("B","Minamata, Japan: industrial mercury discharge → fish contamination → neurological disease. (Oral exam 2026)",true),
  Q(277,"Lead aerosol in workplace air is sampled by:",true),
  opt("A","Grab sampling",false),
  opt("B","Absorption sampling",true),
  opt("C","MPN counting",false),
  opt("D","Spectrophotometry directly",false),
  ans("B – Absorption sampling","Lead aerosol = absorption (filter) sampling. (Real exam 2026)"),
  Q(278,"Occupations at risk of CADMIUM exposure include:"),
  opt("A","Dental amalgam work, instrument making",false),
  opt("B","Ni-Cd battery production, metal plating, dye manufacturing, fertilizer industry",true),
  opt("C","Glass industry, pesticide production",false),
  opt("D","Painting, ceramics, smelting",false),
  ans("B","Cadmium: Ni-Cd batteries, electroplating, dyes, phosphate fertilizers, welding cadmium-coated metals."),
  Q(279,"Occupations at risk of MERCURY exposure include:"),
  opt("A","Battery production, ceramics",false),
  opt("B","Glass industry, metallurgy",false),
  opt("C","Dental work, laboratory instruments, mining, explosive detonators, chlor-alkali industry",true),
  opt("D","Fertilizer industry, welding",false),
  ans("C","Mercury: dental (amalgam), lab thermometers/barometers, mercury fulminate (detonators), chlor-alkali plants."),
  Q(280,"Occupations at risk of LEAD exposure include:"),
  opt("A","Dental work, explosive detonators",false),
  opt("B","Battery production (lead-acid), paint industry, ceramics, smelting",true),
  opt("C","Glass industry, pesticide production",false),
  opt("D","Ni-Cd battery production, dye manufacturing",false),
  ans("B","Lead: lead-acid batteries, paint, ceramics/pottery glazes, smelting, printing (old typesetting)."),
  Q(281,"Occupations at risk of ARSENIC exposure include:"),
  opt("A","Dental amalgam work, instruments",false),
  opt("B","Ni-Cd batteries, dye industry",false),
  opt("C","Glass industry, metallurgy, pesticide production, mining, semiconductor manufacturing",true),
  opt("D","Lead-acid battery production, smelting",false),
  ans("C","Arsenic: glass industry (bubble removal), metallurgy, pesticides/herbicides, mining, semiconductor (GaAs). Causes ulceration and cancer. (Real exam 2026)"),
  ...tf(282,"Arsenic is taken in through both inhalation and ingestion, and causes ulceration — both statements are correct with a causal relationship.","TRUE","(Real exam 2026 — 4-mark question)",true),

  pb(),
  // ══ TOPIC 73 ══
  h1("Topic 73 – Chemical Hazards: Toxic Gases"),
  Q(283,"Carbon monoxide poisoning causes tissue hypoxia because:"),
  opt("A","It destroys red blood cells",false),
  opt("B","It binds haemoglobin 250x more strongly than oxygen, forming carboxyhaemoglobin",true),
  opt("C","It reduces lung function",false),
  opt("D","It blocks the electron transport chain directly",false),
  ans("B","CO binds Hb → COHb → reduced O₂ delivery to tissues → hypoxia."),

  pb(),
  // ══ TOPIC 74 ══
  h1("Topic 74 – Chemical Hazards: Organic Solvents"),
  Q(284,"Organic solvents in the workplace are particularly hazardous because:",true),
  opt("A","They are solid at room temperature",false),
  opt("B","They evaporate easily and can be inhaled; lipid soluble — affect CNS and liver",true),
  opt("C","They are non-volatile",false),
  opt("D","They only affect the skin",false),
  ans("B","Organic solvents: volatile → inhaled; lipophilic → CNS depressants, hepatotoxic. (Real exam 2026)",true),

  pb(),
  // ══ TOPIC 75 ══
  h1("Topic 75 – Chemical Hazards: Pesticides"),
  Q(285,"Pesticide approval in Bulgaria requires:",true),
  opt("A","One-time approval with no renewal",false),
  opt("B","Annual re-approval for use",true),
  opt("C","Approval only by local authorities",false),
  opt("D","No formal approval process",false),
  ans("B – Annual re-approval","(Real exam 2026 oral question)",true),
  Q(286,"Organophosphate pesticides cause toxicity by:",
  false),
  opt("A","Heavy metal accumulation",false),
  opt("B","Inhibiting acetylcholinesterase → accumulation of acetylcholine → cholinergic crisis",true),
  opt("C","Direct liver toxicity only",false),
  opt("D","Blocking sodium channels",false),
  ans("B","OP pesticides: irreversible AChE inhibition → SLUDGE: Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis. Antidote: atropine + pralidoxime."),
  Q(287,"Classification of pesticides includes:",true),
  opt("A","Insecticides, herbicides, fungicides, rodenticides, nematocides",true),
  opt("B","Only insecticides and herbicides",false),
  opt("C","Class I to IV by toxicity only",false),
  opt("D","No formal classification",false),
  ans("A","Pesticide classification by target organism AND by toxicity (WHO classes I-IV). (Oral exam 2026)"),

  pb(),
  // ══ TOPICS 76-81 ══
  h1("Topics 76–81 – Occupational Medicine in Specific Industries"),
  Q(288,"In healthcare workers (occupational medicine), the major biological hazards are:",true),
  opt("A","Heavy metals only",false),
  opt("B","Hepatitis B, Hepatitis C, HIV, and tuberculosis",true),
  opt("C","Pesticide exposure",false),
  opt("D","Noise-induced hearing loss only",false),
  ans("B","Healthcare workers: HBV, HCV, HIV (needlestick), TB (aerosol). (MCQ bank — dentistry hazards)"),
  Q(289,"In metallurgy, the major occupational hazard is:",true),
  opt("A","Pesticide poisoning",false),
  opt("B","Heat stress, heavy metals (lead, cadmium, mercury, arsenic), dust, noise, vibration",true),
  opt("C","UV radiation only",false),
  opt("D","Only chemical vapours",false),
  ans("B","Metallurgy: heat, heavy metals (Pb, Cd, Hg, As), silica dust, noise, vibration. (Oral exam 2026)"),
  Q(290,"In agriculture, the major occupational hazards include:"),
  opt("A","Pesticides, biological hazards (zoonoses), dust, UV exposure, musculoskeletal strain",true),
  opt("B","Only chemical hazards",false),
  opt("C","Heavy metals and nuclear radiation",false),
  opt("D","Only noise",false),
  ans("A","Agriculture: pesticides, zoonoses (brucellosis, leptospirosis), organic dust, UV, awkward postures."),

  pb(),
  // ══ TOPIC 82 ══
  h1("Topic 82 – Childhood and Adolescent Hygiene: Growth and Morbidity"),
  Q(291,"Growth and developmental age periods in children include:",true),
  opt("A","Newborn, infancy, preschool, school-age, adolescence",true),
  opt("B","Only infancy and adolescence",false),
  opt("C","Three periods only",false),
  opt("D","Age periods are not defined in hygiene",false),
  ans("A","Age periods: newborn (0-28d), infancy (0-1yr), early childhood (1-3yr), preschool (3-6yr), school-age (6-14yr), adolescence (14-18yr). (Oral exam 2026)"),
  Q(292,"Characteristics of morbidity among children and adolescents include:"),
  opt("A","Same pattern as adults",false),
  opt("B","Higher rates of infectious diseases, respiratory conditions, and dental caries; lower CVD and cancer",true),
  opt("C","Predominantly cardiovascular disease",false),
  opt("D","No significant disease patterns",false),
  ans("B","Children: infections, respiratory, dental, injuries. Adolescents: mental health, substance use, sexual health."),

  pb(),
  // ══ TOPIC 83 ══
  h1("Topic 83 – Age, Morphological and Physiological Peculiarities in Children"),
  Q(293,"Age, morphological and physiological peculiarities of children and adolescents that are most asked about in oral exam include:",true),
  opt("A","Height, weight, head circumference, cognitive/motor/social development milestones",true),
  opt("B","Only weight",false),
  opt("C","Only height",false),
  opt("D","Only neurological assessment",false),
  ans("A","Oral exam 2026: child morphology (anthropometry) + physiology (organ function, metabolic rate, immune competence)."),
  ...tf(294,"Children have higher basal metabolic rate per kg body weight than adults.","TRUE","Higher BMR in children due to growth, proportionally larger body surface area."),

  pb(),
  // ══ TOPIC 84 ══
  h1("Topic 84 – Calendar Age, Biological Age and Acceleration"),
  Q(295,"The difference between calendar (chronological) age and biological age is:"),
  opt("A","They are always identical",false),
  opt("B","Calendar age = actual years lived; biological age = level of biological maturity which may differ",true),
  opt("C","Biological age is always higher",false),
  opt("D","Calendar age is irrelevant in hygiene",false),
  ans("B","Biological age based on bone age, sexual maturity, physiological parameters. Secular acceleration (trend) = earlier biological maturity."),
  Q(296,"Acceleration (secular trend) refers to:"),
  opt("A","Faster running speeds in children",false),
  opt("B","The trend for children to grow taller and reach puberty earlier than previous generations",true),
  opt("C","Increased school performance",false),
  opt("D","Faster cognitive development only",false),
  ans("B","Secular acceleration: each generation slightly taller, heavier, earlier puberty onset than previous."),

  pb(),
  // ══ TOPIC 85 ══
  h1("Topic 85 – Physiological Bases of School Education"),
  Q(297,"The physiological basis for school education considers:"),
  opt("A","Only academic curriculum",false),
  opt("B","Brain maturation, attention span, fatigue curves, and cognitive load capacity at different ages",true),
  opt("C","Physical fitness standards only",false),
  opt("D","Family income",false),
  ans("B","School physiological requirements: age-appropriate lesson duration, rest breaks, subject alternation, fatigue prevention."),

  pb(),
  // ══ TOPIC 86 ══
  h1("Topic 86 – Daily Regimen for Children. Prevention of School Fatigue"),
  Q(298,"Prevention of school fatigue and exhaustion in children includes:",true),
  opt("A","Longer school hours for better learning",false),
  opt("B","Alternating subjects, adequate sleep, outdoor breaks, regular meals, and appropriate homework load",true),
  opt("C","Eliminating physical education",false),
  opt("D","No special measures needed",false),
  ans("B","Daily regimen for children: sleep (9-10h), meals (4-5x/day), outdoor activity, alternating school tasks. (Oral exam 2026)"),

  pb(),
  // ══ TOPIC 87 ══
  h1("Topic 87 – Physiological Bases of Physical Education. Medical Control"),
  Q(299,"Medical control on physical education at school classifies children into:",true),
  opt("A","Fit and unfit only",false),
  opt("B","Group I (normal), Group II (extended norm), Group III (outside norm)",true),
  opt("C","Four groups by weight",false),
  opt("D","No formal grouping",false),
  ans("B","Group I = x±1SD (normal). Group II = x±1SD to x±2SD (extended norm). Group III = outside x±2SD (non-standard). (Oral exam 2026)"),
  note("Group I: full PE. Group II: modified PE. Group III: medical PE/physiotherapy."),

  pb(),
  // ══ TOPIC 88-90 ══
  h1("Topics 88–90 – Vocational Training, Crèches, Kindergartens, Schools"),
  Q(300,"Hygienic requirements for kindergartens include:",true),
  opt("A","No special requirements",false),
  opt("B","Age-appropriate furniture, safe outdoor play areas, adequate lighting, hygienic food service, qualified staff",true),
  opt("C","Only food safety standards",false),
  opt("D","Only building requirements",false),
  ans("B","Crèche/kindergarten: furniture sized to children, safe outdoor areas, natural light, ventilation, food hygiene."),
  Q(301,"The minimum floor area per child in a kindergarten classroom is a key hygiene requirement because:"),
  opt("A","It affects furniture cost",false),
  opt("B","Adequate space per child reduces overcrowding, prevents disease transmission, and allows activity",true),
  opt("C","It is only an aesthetic requirement",false),
  opt("D","It is not regulated",false),
  ans("B","Floor area per child regulated to prevent overcrowding and ensure hygiene standards in educational settings."),
];

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