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188 Cards in this Set

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Finding elevated urinary alpha-ketoisocaproate and alpha-ketoisovalerate is an indication of what essential nutrient deficiency?


Vitamin B1


Coenzyme Q10


Vitamin B6


Vitamin D

Vit B1

When serum lipid peroxides are elevated even though all serum antioxidant vitamins are in their upper normal ranges, what other abnormality is likely to be present?


High polyunsaturated fatty acids in plasma


Low polyunsaturated fatty acids in plasma


High vitamin D


Low biotin

High PUFAs in plasma

Which compound is measured as a laboratory test for vitamin K deficiency?


7-Dehydrocholesterol


Undercarboxylated osteocalcin


Dehydroascorbic acid


Sepiapterin

Undercarboxylated osteocalcin

Assessment of vitamin D deficiency is done by measuring serum levels of what compound?

25-Hydroxyvitamin D

A patient can have normal serum vitamin B12, but still show elevated urinary methylmalonate because

Methylmalonate metabolism requires intra-cellular activity of vitamin B12.

Which of the following is NOT a folate deficiency sign?


Urinary xanthurenic acid elevation


Urinary formiminoglutamate elevation


Neutrophyl hypersegmentation


Plasma homocysteine elevation

Urinary xanthurenic acid elevation

Which vitamin insufficiencies are indicated by elevated branched chain keto acids in urine?


Antioxidants


B-complex


Ascorbates


Cholecalciferols

B complex

Why is it incorrect to speak of a “folic acid” deficiency?

Folic acid is not an essential nutrient

Vitamin B6 deficiency causes elevated homocysteine by what mechanism?


Reducing the active form of vitamin B12


Accelerating the conversion of methionine to homocysteine


Impairing the conversion of homocysteine to cysteine


Blocking the transfer of methyl groups to THF

Impairing the conversion of homocysteine to cysteine

What does the abbreviation BH4 represent?

Tetrahydrobiopterin

Which of the following is NOT useful for assessing iron status?

Hair iron concentration

A patient with chronic negative calcium balance is expected to have elevated calcium in which specimen type?


Erythrocytes


Unchallenged 24 hr urine


Head hair


Whole blood

Head hair

What organ failure most directly causes multiple low essential trace elements to be found in blood or urine?

stomach

A DMSA provocation test would usually be done to assess what problem?

toxic element exposure

When very low erythrocyte magnesium is found, the patient is likely to have what other type of insufficiency?


Iron


Glutathione


Vitamin C


Selenium

glutathione

Which of the following is not considered to be a highly toxic element?

boron

Which of the following is a good test for copper excess?


RBC Cu


Urinary copper


Low serum copper to ceruloplasmin ratio


Urinary HVA/VMA ratio

urinary copper

The action of what hormone is reduced in chromium deficiency?


Testosterone


Glucagon


Thyroxine


Insulin

insulin

Why does direct testing of calcium in body fluids fail to reveal nutritional status of calcium?

Strong mechanisms assure constant ionic calcium levels even in calcium deficiency.

What element has been shown to protect from the toxic effects of mercury?


Copper


Selenium


Magnesium


Zinc

selenium

A pattern of elevated essential amino acids is an early sign of deficiency of what vitamin?


B12


A


B6


C

B6

Which medical condition is often found in patients with elevated plasma asymmetric dimethylarginine?


Maldigestion


Hypertension


Food allergies


Chronic fatigue

hypertension

What metabolic process creates the largest demand for amino acids?

protein synthesis

What effect does delayed specimen transport have on relative levels of glutamate and glutamine?

Glutamine is slowly hydrolyzed to glutamate

Which amino acid, when administered as a challenge for testing status of a vitamin, helps to alleviate one of the effects of deficiency of the vitamin?


Tryptophan


Histidine


Phenylalanine


Isoleucine

histidine

Which amino acid is converted into a neurotransmitter by two sequential hydroxylation reactions requiring tetrahydrobiopterin as a cofactor?


Phenylalanine


Tryptophan


Valine


Glutamic Acid

phenylalanine

Which amino acid is a substrate for competing reactions that lead to either a compound that supplies a methyl group or to a compound that supplies protection from oxidative stress?


Homocysteine


Taurine


Proline


Asparagine

homocysteine

What is the principal metabolic outcome of the glycine cleavage system?


Initiation of the pathway that leads to heme formation


Generation of 5-10-methylene THF


Conversion of glycine to an important neurotransmitter


Regeneration of tetrahydrobiopterin

Generation of 5-10-methylene THF

If a plasma amino acid profile shows low levels of four essential amino acids and normal levels of the others what intervention is generally indicated?

A customized mixture of all essential amino acids

The principal advantage of free form amino acid supplements over purified protein products is

More rapid delivery of amino acids into peripheral blood

Which abnormality pattern, when found on a plasma fatty acid report, indicates that a patient is in general essential fatty acid deficiency?


Low ALA, EPA, DHA and high stearic acid


Low omega 3 and omega 6 with elevated Mead acid


Low Mead and palmitic acids


Elevated stearic/oleic ratio

Low omega 3 and omega 6 with elevated Mead acid

Which abnormality pattern, when found on a plasma fatty acid report, indicates that a patient is in omega-3 fatty acid deficiency?


Low ALA and EPA


High palmitic/palmitoleic ratio


Low LA, DGLA and AA


Low stearic/oleic ratio

Low ALA and EPA

Which abnormality pattern, when found on a plasma fatty acid report, suggests that a patient may be hypertriglyceridemic?


An elevated triene/tetraene ratio


Low levels for all omega-3 and omega-6 fatty acids


All saturated and monounsaturated fatty acids found in their 4th or 5th quintiles


A low triene/tetraene ratio

All saturated and monounsaturated fatty acids found in their 4th or 5th quintiles

Which abnormality pattern, when found on a plasma fatty acid report, indicates that a patient is exhibiting the metabolic syndrome?

A “greater than” sign in quintile positions of the saturated fatty acids when they are arranged according to chain length

Which abnormality pattern, when found on a plasma fatty acid report, indicates a patient has adrenoleukodystrophy?

Greatly elevated lignoceric and hexacosanoic acids with normal levels of other saturated fatty acids

Finding multiple odd-chain fatty acids in erythrocytes means that there is some process causing elevated levels of which compound?


Stearate


Erucate


Propionate


Fumarate

propionate

Which fatty acid source is appropriate for treatment of a patient with ALA and EPA in their upper quintiles and with LA and GLA in their first deciles?

primrose oil

What is the common name for the fatty acid written as 20:4n6?

arachidonic acid

What cellular organelles other than mitochondria are required for VLCFA degradation?

peroxisomes

Which vitamin is necessary for stimulation of PPAR?


Folic acid


Vitamin A


Riboflavin


Niacin

Vit A

Which of the following is a urinary organic acid that becomes elevated as a direct result of carnitine deficiency?

adipate

Which of the following is a urinary organic acid that becomes elevated as a result of Coenzyme Q10 deficiency?

succinate

Which of the following is a urinary organic acid that becomes elevated as a direct result of thiamin deficiency?

Alpha-ketoisocaproate

Which of the following is a urinary organic acid that becomes elevated as a direct result of vitamin B6 deficiency?

Xanthurenate

Which of the following is a urinary organic acid that becomes elevated as a direct result of biotin deficiency?

Beta-hydroxyisovalerate

Which of the following is a urinary organic acid that becomes elevated as a direct result of folic acid deficiency?

Formiminoglutamate

Elevation of which of the following urinary organic acids indicates that a patient has increased turnover of epinephrine?

Vanilmandelate

Elevation of which of the following urinary organic acids indicates that a patient has increased turnover of serotonin?

5-Hydroxyindoleacetate

Elevation of which of the following urinary organic acids is produced in a patient with thiamin deficiency that slows the action of the branched-chain keto acid dehydrogenase complex?

Alpha-keto-beta-methylvalerate

Which of the following is a urinary organic acid that becomes elevated in a patient due to massive intestinal overgrowth of Lactobacillus acidophillus?

D-Lactate

Which of the following is true of a laboratory result that lies in the 5th quintile?

Eighty percent or more of the reference population has values less that this result

For optimal wellness assurance, which of the following is the preferred stage of nutrient deficiency detection?

biochemical alterations

Which abnormality is an indication of potential BH4 deficiency?

Elevated plasma Phe/Tyr ratio

A patient with a low urinary N-methylnicotinamide is a candidate for which nutrient addition?

Vit B3

A patient with an elevated level of beta-hydroxyisovalerate in urine is a candidate for which nutrient addition?

biotin

Serum concentrations of which of the following generally is considered to be the best compound for assessing vitamin D status?

25-Hydroxyvitamin D

For a patient with elevated homocysteine, intervention may be focused on which specific nutrient when elevated formiminoglutamate also is found?

5-Methyltetrahydrofolate

Which of the following is a function NOT served by the single carbon pool?

Delivery of reducing equivalents to form BH4

Which factor most commonly leads to multiple elevations of essential amino acids in fasting plasma?

Vit B6 deficiency

Early dietary deficiency states of what essential element has been proposed to be revealed by elevated levels in hair?

calcium

You would correctly recommend iron supplementation based on finding which abnormality in a patients record?

low serum ferritin

Finding very high levels of which element in erythrocytes would be of greatest concern regarding the recent appearance of toxic manifestations in a patient with a history of low urinary selenosugars?

mercury

Metabolic impacts of some toxic elements are sensitively revealed by measuring intermediates in what pathway?

Porphyrin synthesis

What test result might be used to justify intravenous chelation therapy?

elevated whole blood lead

Which of the following describes the ultimate event that results in greater intestinal calcium absorption due to the action of vitamin D?

Enterocyte ribosomal synthesis of calbindin is increased

The principal reason that magnesium is said to be involved in more metabolic reactions that any other element is

The requirement of Mg in reactions utilizing ATP

Which phrase describes the first step in the assimilation of ingested dietary zinc?

Release of bound zinc from food complexes that are denatured by gastric acid

Which abnormality is generally produced by having a fasting plasma specimen sit for 2 days in an outside pickup box during August?

Elevated Gln/Glu ratio

A patient who has been on SSRI medications for 2-3 years is most likely to have a deficiency of which amino acid?

tryptophan

In the absence of any other laboratory evidence, finding a pattern of strongly elevated serene with low glycine on a plasma amino acid profile would suggest deficiency of which essential nutrient?

5-Methyltetrahydrofolate

S-Adenoxylmethionine therapy is most likely to be helpful in cases where elevation of which amino acid is found?

Phosphoethanolamine

Elevated levels of which compound in plasma is predictive of clinical effects due to insufficient nitric oxide?

ADMA

Elevated levels of which compound is associated with difficulty in conversion of ammonia to urea?

*All others shown


Ornithine Citrulline Arginine

Which of the following is NOT a process that is dependent on the availability of arginine?

Porphyrin synthesis

Choline is a derivative of which amino acid?

glycine

The BCKDC is an enzyme that requires how many vitamin-derived cofactors?

5

A patient who shows a pattern of low levels for threonine, glycine and serine is a candidate for what type of specific amino acid supplementation.

Glutathione precursor

A patient with elevated levels of urinary alpha-aminoadipic acid due to an inherited metabolic disorder should avoid supplementation with which amino acid?

Lysine

Tyrosine is the precursor amino acid in the biosynthesis of which compound?

dopamine

Hepatic activity of which pathway is responsible for the disposition of excess dietary tryptophan?

Kynurenin

In order to rapidly offset acute increases in oxidative stress, homocysteine trans-methylation is inhibited while which pathway is stimulated?

Homocysteine trans-sulfuration

Following administration of the radioactive isomer of a certain amino acid, large fractions of the radioactivity was found rapidly and simultaneously to appear in the subjects DNA, RNA, porphyrins, collagen and glutathione. Which amino acid was used?

glycine

Which specific compound, appearing at elevated levels in plasma or urine, would best identify a patient who habitually consumes chicken or turkey almost every day?

anserine

Elevated levels of which of the following fatty acids indicates general PUFA deficiency?

mead

Which of the following is the most abundant PUFA in the average American diet?

linoleic

A patient with biotin deficiency is likely to show elevated levels of which fatty acid?

nonadecanoic

A laboratory report that shows low levels of which fatty acid is of greatest concern regarding neurological development in a 2 year old child?

DHA

What is the principal form of circulating fatty acids in the fasting state?

LDL

Counting the terminal methyl group, how many carbon atoms are present following the double bond most distant from the carboxylic acid in an omega-3 fatty acid?

2

Which class of fatty acids can enter the beta-oxidation cycle without the involvement of the carnitine shuttle?

medium chain

Why does the level of arachidonic acid tend to fall in patients who take large doses of flax oil daily for many weeks?

Competitive inhibition of omega-6 fatty acid binding to delta-6 desaturase enzymes

Why is DHA extremely slow to rise when infants are fed formulas supplemented with flax oil?

The peroxisomal degradation step required to yield DHA is very slow and inefficient

Increased PUFA intake signals the human fat-sensing system to stimulate which process?

Peroxisome proliferation

Essential fatty acid deficiency results in rising levels of which fatty acid?

Palmitoleic

Which fatty acid ratio elevation is frequently found in patients who display inordinately strong responses to inflammatory stimuli?

AA/EPA

Specific concern about a patient's calcium and vitamin D status would be especially confirmed by which test result?

Elevated plasma hydroxylysine and hydroxyproline

A patient who shows steadily falling levels of erythrocyte arachidonic acid after initial normal levels were found would be suspected of excessive intake of which dietary oil?

fish

Other than dietary magnesium intake, erythrocyte magnesium levels are directly related to what metabolic factor?

glutathione status

What cell type failure most directly and specifically contributes to multiple low essential trace elements being found in blood or urine?

parietal cells

Among reports in the medical literature, which is the most commonly used specimen for arsenic exposure screening?

urine

Ammonia detoxification is not described by Phase I and Phase II reactions because

It does not require oxidation and conjugation for clearance.

Which type of organotoxin is famous for originating from soft plastic products?

phthalates

How does dietary fiber help control total estrogen exposure in premenopausal women?

Reduction of enterohepatic estrogen circulation

Why is oral challenging with DMSA used prior to toxic element testing of urine?

To demonstrate metallothionein loading status

What are urinary products of glutathione conjugation called?

mercaptans

What urinary porphyrin becomes uniquely elevated in urine due to mercury toxicity?

Precoproporphyrin

Which of the following is the most common reason for finding elevated benzoic acid in urine?

Hepatic glycine conjugation capacity has been exceeded.

How does the stimulation of hepatic cytochrome P450 activity by compounds in cigarette smoke illustrate the hormesis model of toxicant effects?

Very low doses of a toxic compound can have favorable effects

Which of the following toxicants is considered to be iatrogenic?

acetaminophen

Why would a high protein diet be ill-advised for the patient whose laboratory report indicates a pathological detoxifier pattern?

It would exacerbate the effects of low Phase II detoxification capacity

Which of the following agents acts to protect enzymes inside of the mitochondria from oxidative damage?

Manganese superoxide dismutase

What amino acid is unusually high inside erythrocytes to afford oxidative stress protection?

taurine

Which vitamin sits near the center of the cellular redox potential spectrum?

Vit C

Accumulation of which compound tends to produce reductive stress?

NADH

Which compound is sometimes used as a biomarker of total body protein oxidative damage?

Nitrotyrosine

Match the laboratory markers with their category of oxidative stress damage:


Isoprostanes


Methionine sulfoxide


8-Hydroxy-2’-deoxyguanosine

Isoprostanes - lipid damage


Methionine sulfoxide - protein damage


8-Hydroxy-2’-deoxyguanosine - DNA damage





In a patient with multiple signs of oxidative stress, physiological forms of which two micronutrients are needed because they act in tandem directly upon glutathione to achieve the recycling of the oxidized to the reduced form?

lipoate and nicotinamide

What factor released during sleep adds strong protection against oxidative stress?

melatonin

What antioxidant is specifically indicated to be under stress, leading to reduced antioxidant stress response capacity when a patient is found to have elevated pyroglutamate and alpha-hydroxybutyrate?

glutathione

Which response shows the three trace elements that are required for the action of superoxide dismutase enzymes?

Cu, Zn, Mn

Production of which of the following cell regulators is directly affected by deficiency of iodine?

thyroxin

Production of which of the following cell regulators is directly affected by deficiency of tryptophan?

serotonin

Production of which of the following cell regulators is directly affected by deficiency of arginine?

nitric oxide

Production of which of the following cell regulators is directly affected by excessive consumption of broccoli?

thyroxin

Which of the following is a hormone that is NOT derived from cholesterol?

norepinephrine

Which of the following test results is a marker for chronic stress response?

Low sIgA

What hormonal abnormality would be suspected in a patient with elevated serum triglycerides, elevated serum LDL cholesterol, obesity and non-alcoholic live disease?

Hyperinsulinemia

Which of the following is used to assess risk of cancer from poor regulation of estrogen metabolism?

2/16 Hydroxyestrogen ratio

Cytokine signaling pathways frequently use which type of chemical reaction to transmit and amplify signals?

phosphorylation

The AKT signaling pathway is involved in the initiation of which cellular process?

apoptosis

What information is conveyed by this figure on a laboratory SNP profile report?


Image is of green "-" sign on left & a red "+" sign on right

One allele of the relevant gene was negative and the other one was positive for the relevant SNP.

What kind of clinically relevant information is found at the web site named OMMBID?

Metabolic defects are described for inherited diseases.

What advantage may be derived from the use of a patient’s genomic data when choosing drug therapies?

Dosages may be adjusted according to SNPs that effect their metabolism.

The designation (A856G) conveys what information?

At base position 856 in the related gene there is a single nucleotide polymorphism due to replacement of adenosine by guanosine.

Which of the following steps in gene expression can be altered by environmental factors?

All are correct:


DNA transcription


RNA translation


Post-translational protein alterations

If a patient is found to be homozygous for SNP that causes lowered activity of the enzyme required for conversion of dopamine to epinephrine, what laboratory report abnormality would show metabolic confirmation of the effect?

Low urinary vanilmandelic acid

Which response describes the level at which microRNAs act to affect processes like the uptake of micronutrients such as iron?

Alteration of gene expression rates

How is an enzyme’s activity altered by the presence of a homozygous SNP in the genes that express that enzyme?

Any one of the 3 responses may apply to a given SNP:


The rate of the catalyzed reaction is decreased. There is no change in the rate of the catalyzed reaction.


The rate of the catalyzed reaction is increased.

Based on finding that a patient with greatly elevated homocysteine has normal levels of urinary FIGLU and methylmalonate, which specific vitamin supplementation is likely to result in lower risk for cardiovascular disease?

pyridoxine

Which specific nutrient supplementation is most directly indicated for a patient with greatly elevated urinary quinolinate and very low plasma tryptophan?

niacin

Which laboratory result would provide biochemical confirmation of functional impact from a genetric polymorphism that impairs metabolism of catecholamines?

low urinary VMA and HVA

A laboratory report that shows a pattern of low range levels for multiple trace elements suggests what underlying physiological failure?

insufficient gastric acid output

When a patient's laboratory report shows very low zinc, what other abnormality takes on greatly added significance regarding need for clinical management?

elevated blood cadmium

If you had been monitoring a patient's urinary mercury levels monthly and notice a sudden increase, what kind of treatment procedure would be suspected as a major contributing factor?

dental amalgam removal

For a patient who is in a state of strong negative calcium balance, which profile is most likely to show greatly elevated calcium concentration?

hair

If you were requested to prepare a one day DMSA dosing schedule for a patient, what laboratory profile would you expect to be ordered on that patient?

urine toxic elements

Which potential intervention for a patient would be reinforced by the following laboratory abnormalities? - low plasma homocysteine, low erythrocyte magnesium, high urinary 8-hydroxy-2’-deoxyguanosine, and low urinary sulfate.

N-Acetylcysteine

Considering the precursor amino acid for thyroid hormone production, which laboratory abnormality would suggest a potential line of specific nutritional therapy for a patient with negative autoimmune thyroid antibodies and chronically low thyroid function that is unresponsive to aggressive supplementation of iodine?

Very high plasma Phe/Tyr ratio

Which laboratory profile would you recommend to confirm suspicion of biotin deficiency?

urinary organic acids

If you find mildly elevated urinary methylmalonic acid for a 10-year-old girl with idiopathic polyneuropathy, which laboratory profile would you recommend for confirmation of specific vitamin deficiency?

serum Vit B12

Among the metabolic roles of zinc, which one involves structures called zinc fingers?

gene expression

Measuring levels of which serum protein can provide direct information about a patient’s copper status?

ceruloplasmin

Use of which specimen for measuring potassium concentration has the strongest scientific support for assessing potassium deficiency?

erythrocyte

Which urinary organic acid profile elevated result would be suspected to have been produced by finding that the patient had consumed a large serving of bananas and black walnuts with her evening meal before the overnight urine specimen collection for the test?

5-Hydroxyindoleacetate

Therapy with which type of drug frequently causes elevation of urinary 5-hydroxyindoleacetate?

serotonin reuptake inhibitors

Which laboratory finding tells you that a patient has an increased risk of kidney stone recurrence?

low urinary citrate

Which of the following compounds is NOT a tricarboxylic acid?

succinate

Dietary deficiency of which vitamin causes the situation known as the “Folate Trap?”

Vit B12

A defect in which regulatory system is indicated by finding the pattern of very high glutamic acid and very low glutamine in a plasma amino acid profile for a 4 year old boy with severe hyperactivity?

SN1-SN2 transporter

Which antioxidant is found in erythrocytes at levels nearly 10 times those found in blood plasma?

taurine

What vitamin-derived enzyme cofactor contains pantothenic acid?

Coenzyme A

Which component of biological membranes is most highly susceptible to hydroxyl radical attack?

PUFAs

If glycine is to be administered to support Phase II detoxification, what vitamin also is specifically indicated?

pantothenic acid

Which compound has the unique function of being simultaneously required for the activated methyl-supply system and the glutathione-formation system?

homocysteine

Which laboratory abnormality would be the most ominous as a risk factor for a chronic pain patient who has a tendency to overdose her acetaminophen?

low plasma methionine

What region of the normal human intestinal tract has the greatest rate of increase in bacteria populations per inch of transit?

ileum

Which food-specific serum antibody class is tested primarily to determine the presence of intestinal hyperpermeability?

IgG

Why do microbiological culture techniques performed in routine clinical laboratory services fail to detect the large majority of bacteria that occur in stool specimens?

the bacteria are strict anaerobes

Measuring breath hydrogen after an oral bolus of glucose is a test used to detect which condition?

transitional gut bacterial overgrowth

What condition is revealed by finding a large number of 2+ to 4+ results for food-specific IgG4 concentrations in serum?

Intestinal hyperpermeability

A patient whose diet contains very low levels of polyphenols may have false negative results for which test?

urinary microbial markers

What compound is a precursor in human cells for tetrahydrobiopterin production?

GTP

Your patient reveals that s/he has been supplementing with high doses of fish oil for years and always cooks with safflower oil and corn oil. Based on this information, what analyte(s) would you suspect might be elevated?

lipid peroxides

Concurrent elevations of urinary L-lactate and pyruvate have been shown to respond favorably to which vitamin supplementation?

lipoic acid

Aggressive biotin supplementation would be indicated for a patient with which abnormality?

High urinary beta-hydroxyisovalerate

A patient with a low serum transferrin level is a candidate for supplementation of which nutrient?

Iron

When glutathione becomes oxidized in a reaction that removes an oxygen radical, which compound is the co-substrate for the conversion back to redued glutathione?

NADPH

Increased intake of which nutrient is most specifically indicated for a patient with hyperinsulinemia?

chromium

Which specific nutrient supplementation is most directly indicated for a patient with greatly elevated serum levels of citrulline and ornithine?

magnesium

Which specific nutrient supplementation is most directly indicated for a patient with a greatly elevated plasma phenylalanine to tyrosine ratio?

iron

Folic acid supplementation is indicated when a LOW result is found for which laboratory test?

plasma histidine

When a patient is found to have high levels of LA and GLA, but a low level of DGLA on a plasma fatty acid profile, what specific nutrient intervention is suggested?

zinc

Insufficiency of which hormone is associated with impaired conversion of beta carotene to vitamin A?

thyroid

A patient who had a lab result showing high urinary tricarballylate would be a candidate for which nutrient supplementation?

magnesium

A patient with signs consistent with magnesium deficiency that is confirmed by low erythrocyte magnesium is likely to have low status of what other compound with direct effects on magnesium status?

glutathione

Why would dietary protein intake not be expected to produce elevated levels of amino acids in plasma when the test is done according to usual specimen colection instructions?

After more than six hours, amino acids from dietary protein do not affect peripheral blood amino acid concentrations.

Elevation of which compound indicates that inflammatory responses are occurring in the brain?

Quinolinic acid

A patient with simultaneous strong elevations of urinary citrate, cis-aconitate, isocitrate and orotate is also likely to be exhibiting which other laboratory abnormality?

Ammonemia