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Comment of the Week

After the cuff is tied, the cells and tissue distal to the cuff will continue consuming ATP (ATP->ADP), but no fresh blood will be delivered to “clear” what will be an accumulating amount of ADP and other metabolites. ADP (=Adenosine) is itself a proxy of consumption and drives vasodilation of arteries! (Evolution is smart!) Increasing ADP/Adenosine in a “local environment” is a signal to the body that a lot of consumption is occurring there; thus, arteries and arterioles naturally dilate to increase blood flow rates and “sweep away” metabolic byproducts.

          —drdoom, nbme24/Block 3/Question#2

Lol of the Week

Which of the following reasons is why this question is bull?

1) Using the word "cyclic" instead of tricyclic for clarity

2) Knowing all of epidemiology of all drugs

3) having to reason out that anticholinergic effects are probably the worst over alpha1 or H1 effects to no certainty.

4) The crippling depression of studying for days-to-weeks on end to probably do average on the test.

          —seagull, nbme22/Block 2/Question#36

Help your fellow humans! (see more)

elf16 asks:
How is this different from the question on NBME 21 in which a 68-year old man also had psychogenic ED? But the answer was normal libido and nocturnal erections. help answer!
cat5280 asks:
Could someone please explain why you were able to eliminate the spinocerebellar tracts? help answer!
ergogenic22  Spinocerebellar is only responsible for Proprioception (unconscious). This patient also has reduced vibration sensation, which the dorsal column tracts are responsible for.
krewfoo99 asks:
Why would decreased movement through the cerebreal aquaduct be wrong? With all the build of blood in the CSF tract without absorption, wouldnt movement also be decreased through the aqueduct? help answer!
defalty98 asks:
Why are we complicating things? Change in the bases will destroy the palindromic sequence required for any restriction endonuclease to work. Methylation is the only option that makes sense. help answer!
jigyasa asks:
Why have you taken 180 as patient years? Isn't patient years calculated as no of patients multiplied by the number of years they suffer? help answer!
titanesxvi asks:
why not decrease CA activity in the proximal tubule? this also could lead to metabolic acidosis. help answer!
ergogenic22  carbonic anhydrase inhibitors can cause Type 2 RTA but it is not the cause here (cystinosis)
krewfoo99 asks:
Why would perforins be the wrong answer? Wouldnt accumulation of toxic proteins cause the cell to undergo apoptosis ? help answer!
ergogenic22  Bortezomib does not directly activate perforin. It directly inhibits the proteasome which → enables CD8+ T cells to initiate apoptosis → via perforin release (in essence a downstream effect).
krewfoo99 asks:
In what situations will HbH be formed (3 alpha chain deletions)? help answer!
ergogenic22  one parent has 2 deletions on the same gene, the other parent has 1 deletion, and the offspring receives all three. In this question, both parents have alpha 1 deletion
ergogenic22  actually its possible that they both have 2 gene deletions, but regardless, a-thalassemia trait is more likely
ergogenic22  and someone above said Asian people are cis-2 deletion so the offspring will not receive two deletion from one parent
ergogenic22  ↑↑ I made a mistake by confusing trans and cis cis has deletions on the same chromosome and can pass two deletions to off spring, therefore a chance of allowing HbH
krewfoo99 asks:
Can someone explain what the picture is supposed to show? Is it supposed to be segmented neutrophils? help answer!
titanesxvi  yes do to B12 deficiency
krewfoo99 asks:
Wouldnt the HCOM murmur be best heard in the aortic area? help answer!
krewfoo99  Correction: Shouldnt it be heard best in the left upper sternal border?
krewfoo99 asks:
Anyone know why heart sounds would be distant in COPD exacerbation? help answer!
yng  Patient is usually obese (blue bloater) --> diaphragm movement is limited --> can't take deep breaths, and in extreme cases, the chest size increased and causing distant heart sound.
krewfoo99 asks:
Anyone know why heart sounds would be distant in COPD exacerbation? help answer!
marat  Cause lungs are overextended
marat  overexpanded
krewfoo99 asks:
In boards and beyond, It is said that third degree heart block is due to block in the HIS Purkinjee system. So why would ablation of AV node cause this disease? Wouldnt destruction of part of left ventricle be a better answer ? help answer!
amirmullick3 asks:
Is this Guillain barre though? I felt it was Acute inflammatory demyelinating polyradiculopathy, discussed on page 512 FA 2019. There is no relation to C jejuni here nor does the patient have any other relations to infection such as eating something or etc. help answer!
niboonsh asks:
external carotid branch supplies the superior parathyroid glands as well........? help answer!
yng  Yes the superior part supplied by superior thyroid gland which is a branch of external carotid branch.
divya asks:
Can anyone discuss what's responsible for inhibiting the processes given as other options? help answer!
divya asks:
Why is there rhinorrhea in opioid withdrawal? And also, if stimulants like cocaine cause nasal vasoconstriction, shouldn't opioid withdrawal do the same? help answer!
sunshinesweetheart asks:
out of curiosity, why are AST and ALT high? is that saying the NRTI used was diadenosine which led to pancreatitis also? help answer!
krewfoo99  AST and ALT will not be elevated in pancreatitis, they will only be increased during liver damage. NRTI causes hepatoxicity (although FA 2018 states NNRTI causes hepatotoxicity, NRTI could also be an option considering the two classes are similar. The hepatoxicity will cause an increase in ALT and AST
paloma asks:
What about pulmonary vascular resistance? It follows the systemic vascular resistance? help answer!
cooldudeboy1  crackles are heard bilaterally so there is pulm patho which leads to increased pulm vascular resistance, since systemic blood flows into the lungs. any block in the flow ahead (lungs) will increase resistance in flow behind ( systemic )
bronchophony asks:
Why not clinical trial? They could report a rare adverse effect in phase 4 clinical trial right? help answer!
sunshinesweetheart  there's no control group. it's just a case study. x3
sunshinesweetheart  plus clinical trials at that stage would have had tons and tons of participants (and, most importantly to rule out all the answers, control group)
md_caffeiner asks:
what to do with the NONADHERIANT BADDIES??? Intention to treat, "i had the intention to treat so i am gonna leave in this group no matter what" as treated , "he is not treated as it is so im gonna change his group to control" per protocol, "you are fired from all of it, protocols bitch" help answer!
houseppary asks:
but what is wrong with "Spirochete invasion of gastric cells"? It seems like H pylori is sometimes described as curved and sometimes as a spirochete. And "gastric cells" is general enough that I don't see why it can be wrong. There is H pylori in the gastric cells. help answer!
amphotericin asks:
Why would you not check cortisol, if you're worried for MEN1? I assumed high calcium was implied based on the renal stones help answer!
fallot4logy asks:
in the other hand , urine potassium is high enough , so if seizures =>rhabdomyolysis => myoglobinuria => ATN => high potassium excretion , why not? help answer!
krewfoo99  True but hypokalemia would occur in the recovery phase. So weeks after the inciting phase.

Recent tangents

Perfect image which can explain everything in this question!

if one still doesn't understand to add on .. 1000 cm^3 = 1000 ml 1000ml = 1 Litre

There's an episode in scrubs the person is orange i looked up "too much carrot" they look orange NBME language strikes again

Recent comments (see more)

... imgdoc made a comment on nbme23/block4/q#48 (A 2-week-old female newborn of Mexican descent is...)
 +0  upvote downvote
submitted by imgdoc(30)

I just realized that the answer I selected would've been considered passive aggressive: "Have you considered talking to a faith healer to see if there are any other measures you should try?"


... imgdoc made a comment on nbme23/block1/q#16 (Physical analysis of the isolated genomic DNA from a...)
 +0  upvote downvote
submitted by imgdoc(30)

Explanations for this are too complicated. Think of it like this:

You've got a piece of mutated DNA that is able to be digested by a restriction endonuclease, that means the DNA was transcriptionally available to begin with. AKA it was not methylated, because as we know, methylation = heterochromatin which is transcriptionally inactive. that means methylase was mutated

Only other plausible answer was DNase, and if it was mutated it would be inactive, not overactive.

... xkno made a comment on nbme23/block2/q#42 (A 63-year-old woman comes to the physician because...)
 +0  upvote downvote
submitted by xkno(0)

I overthought this one big time. Since the question said the mass was pressing on the outside of the trachea, I figured that during inspiration, b/c the chest expands, so more space, so the mass would have less effect on the trachea as the chest expands (and conversely, it'd have more of an effect during expiration as the chest wall retracts). Apparently, it was just straight up blockage and I thought waaay to hard. Oops.

... diabetes made a comment on nbme24/block3/q#44 (A 62-year-old man comes to the physician for a...)
 +0  upvote downvote
submitted by diabetes(1)

When ZES is suspected, the initial test recommended is a fasting serum gastrin (FSG) determination in the absence of antisecretory therapy (Sensitivity- 98–100% in ZES patients various series. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5757869/

... abhishek021196 made a comment on nbme21/block1/q#19 (A 22-year-old man has had frequent episodes of...)
 +0  upvote downvote
submitted by abhishek021196(0)

Hereditary angioedema (HAE) caused by C1-esterase inhibitor deficiency is an autosomal-dominant disease resulting from a mutation in the C1-inhibitor gene. HAE is characterized by recurrent attacks of intense, massive, localized subcutaneous edema involving the extremities, genitalia, face, or trunk, or submucosal edema of upper airway or bowels. Routine long-term prophylaxis with either attenuated androgens or C1-esterase inhibitor has been shown to reduce the frequency and severity of HAE attacks.

... abhishek021196 made a comment on nbme21/block1/q#13 (A 25-year-old man develops shortness of breath after...)
 +0  upvote downvote
submitted by abhishek021196(0)

Hypoxic pulmonary vasoconstriction (HPV), also known as the Euler-Liljestrand mechanism, is a physiological phenomenon in which small pulmonary arteries constrict in the presence of alveolar hypoxia (low oxygen levels). By redirecting blood flow from poorly-ventilated lung regions to well-ventilated lung regions, HPV is thought to be the primary mechanism underlying ventilation/perfusion matching.[1][2] The process might initially seem counterintuitive, as low oxygen levels might theoretically stimulate increased blood flow to the lungs to increase gas exchange. However, the purpose of HPV is to distribute bloodflow regionally to increase the overall efficiency of gas exchange between air and blood. While the maintenance of ventilation/perfusion ratio during regional obstruction of airflow is beneficial, HPV can be detrimental during global alveolar hypoxia which occurs with exposure to high altitude, where HPV causes a significant increase in total pulmonary vascular resistance, and pulmonary arterial pressure, potentially leading to pulmonary hypertension and pulmonary edema. Several factors inhibit HPV including increased cardiac output, hypocapnia, hypothermia, acidosis/alkalosis, increased pulmonary vascular resistance, inhaled anesthetics, calcium channel blockers, positive end-expiratory pressure (PEEP), high-frequency ventilation (HFV), isoproterenol, nitric oxide, and vasodilators.

... chandlerbas made a comment on nbme20/block2/q#19 (A 66-year-old man is brought to the emergency...)
 +0  upvote downvote
submitted by chandlerbas(11)

either bladder cancer (unilateral in this case) or transitional cell carcinoma (also uni) are precipitated by smoking inhalant toxic injury. BUT what matters more than the cause is that the reader recognize that this is without a doubt

obstructive hydronephrosis with dilated pelvicalyceal system and cortex of kidney showing atrophy and thinning.

Assuming that the pt lost blood from the MVA - this would further enhance the renal ischemia (PCT and ascending LOH are both very sensitive to ischemic conditions 30 minutes of blood loss is enough to exacerbate the already ischemic conditions.

... lilyo made a comment on nbme20/block3/q#10 (A 59-year-old man develops fatigue and decreased...)
 +0  upvote downvote
submitted by lilyo(1)

Prosthetic valves are one of the causes of extravascular hemolysis so suspect this in a patient that has symptoms of anemia such as fatigue, pallor, jaundice. Further supporting evidence in this patient is the increased indirect bilirubin. Also, look for elevated LDH, decreased haptoglobin.