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Welcome to cheesetouch’s page.
Contributor score: 26


Comments ...

 +0  (nbme18#15)

Lose GI defense mechanism -> loss of parietal cells. ECL cells may hypertrophy to encourage acid secretion because the parietal cells are not responding to their usual signals. Zollinger-Ellison/gastrinoma causes hypertrophy of the gastric mucosa so that is also wrong.


 +0  (nbme18#9)

Dx is porphyria cutanea tarda. The deficient or defective enzyme is uroporphyrinogen decarboxylase. At the start of heme synthesis, succinyl CoA and glycine combine to form ALA (via ALA synthase), the very start of heme synthesis.


 +1  (nbme18#1)

Teratogens are most susceptible to give damage in 3-8th weeks (embryonic period - organogenesis) of pregnancy. FA p 596 (2018); teratogens section


 +1  (nbme18#47)

Flexor digitorum PROFUNDUS tendon inserts on the DISTAL phalanges; flexor digitorum superficialis inserts on the middle phalanges. the profound go far - profundus to distal/furthest phalynx


 +0  (nbme18#47)

2 months old w/ holosystolic LLSB murmur -- ONLY holosystolic murmurs are mitral regurg, Tricuspid regurg, VSD PDA - continuous machine like murmur


 +1  (nbme18#10)

Even though following people ahead for 3 years may seem like a prospective cohort, that is minor and the study design with randomly assigned experimental and control groups is still a randomized clinical trial


 +1  (nbme15#31)

pregnancy causes hypervolemia, and higher blood volume/flow through the heart will increase murmurs (aortic regurg.)


 +0  (nbme15#23)

Pheochromocytomas are tumors of the adrenal medulla, derived from chromaffin cells of the neural crest. In regards to the image, A is possibly the capsule allowing E to be the adrenal medulla? Here are some web images, sorry I can't solve this mystery, zoinks. https://lh3.googleusercontent.com/proxy/TtqGfP9U5W_

drdoom  ^ broken links +

 +0  (nbme15#1)

Methylprednisone, a glucocorticoid, works by intracellular steroid hormone receptor signalling pathways.


 +0  (nbme15#1)

Frothy YELLOW GREEN DISCHARGE, motile organism with flagella -> dx of trichomonas vaginalis, treatment is metronidazole for patient and partner. FA2018 P158.

Trichomonas vaginalis is an STI with foul smelling green discharge, trophozoites on wet mount.

cheesetouch  intravaginal miconazole is the treatment of candida vaginitis (white cottage cheese discharge) +

 +0  (nbme15#49)

Our patient in DKA has high glucose outside her cells that will be taken up when insulin is administered. Glucokinase is the first step in glycolysis and will increase as the glucose is used. The other enzymes represent pathways that will be inactivated when insulin is given/in high glucose state (gluconeogenesis etc.) Insulin fa2018 p322


 +0  (nbme15#36)

Left dominant circulation - posterior descending artery (PDA) which supplies AV node etc is coming from the *left circumflex. Prompt says it is blocked. To get to there, the correct anatomical pathway is Left coronary artery, circumflex artery, posterior interventricular (PDA).

This can be reasoned by process of elimination too. 1- Given the Left dominant circulation, we can eliminate pathways beginning at the right coronary. 2- To get blockage at posterior of heart, we will NOT use anterior interventricular artery, so you can eliminate the 2 options listing those. 3 - The circumflex artery gives rise to the PDA, but is not the final artery in our path to the blockage (so can eliminate another two). This should give you the correct answer.

cheesetouch  FA2018 P277 heart anatomy drawing +

 +0  (nbme15#29)

Glycine is the only inhibitory neurotransmitter present. He likely has glycine encephalopathy is a rare autosomal recessive neurological disorder. Tetanus toxin - blocks release of inhibitory NT's gaba and glycine. Botulism - 'floppy baby ate honey' - inhibition of ACh release at the neuromuscular junction.


 +0  (nbme15#25)

Germline (AKA gonadal) mosaicism: mutation only in egg or sperm cell. Suspect if parent and relatives do not have the disease (or as seen here, if present in an irregular ratio/manner). FA2018 p 57


 +1  (nbme15#17)

Ampicillin (and amoxicillin and aminopenicillins) are penicillinase-sensitive penicilins. Resistance occurs when bacteria produce penicillinase (a type of beta lactamase) which cleaves the B-lactam ring. Resistance to cephalosporins occurs when bacteria produce cephalosporins (a type of beta lactamase) OR through structural changes in penicillin-binding proteins (transpeptidases). FA2018 188-189

beto  produce cephalosporinases* +1

 +1  (nbme15#42)

Acute lymphoblastic leukemia/lymphoma (ALL) is associated with Down Syndrome and most often occurs in children [FA2018 p420]. AML and ALL are increased in those with Down syndrome [p63] but median age of onset of AML is 65 years old (p420). megaloblastosis refers to megaloblastic anemia.


 +0  (nbme15#27)

A decrease in cell number means APOPTOSIS has occurred, thus the surviving tumor cells have a mutation which inhibits apoptosis

baja_blast  TGF-Beta helps regulate cellular differentiation, proliferation, and apoptosis +

 +1  (nbme15#9) 1 tumor w/ met to liver is colon cancer Fa2018 p226
cheesetouch  sorry for a lazy answer folks! +

 +1  (nbme17#6)

Hypokalemia is often from diuretics (EXCEPT the K sparing diuretics on the collecting tubule, SEAT [Spironolactone, eplerenone, Amiloride, Triamterene]) Hydrochlorathiazide, a diuretics acting on the DCT causes hypokalemia.

Other options: Clonidine (alpha blocker), Lisinopril (ACE-inhibitor), Metoprolol (beta blocker), Triamterene (K sparing diuretic).


 +1  (nbme17#36)

Glucocorticoids inhibit Nfkb, suppress both B and t cell function by decreasing transcription of many cytokines. Induce T cell apoptosis FA 2018 P120


 +0  (nbme17#32)

FA 2018 p 290 - treat 3rd degr heart block with pacemaker


 +0  (nbme17#50)

odds ratio for the exposure variable (aniline dye) = (yes cancer and yes dye / yes dye) / (no cancer and yes dye / yes dye) = (250/250) / (50/150) = 3

cheesetouch  FA 2018 P 254 +1
cheesetouch  oops messed up the denominator a bit. 50/150 = (no cancer yes dye / no cancer no dye) +

 +0  (nbme17#1)

Sensitivity of 99% means that almost all TA will have high ESR. (Sn = tp/(tp+fn) -> low False negative). HOWEVER, a specificity of just 60% means high ESR can indicate MANY OTHER disease processes. In a test with low specificity, more tests should be done to confirm diagnosis.


 -2  (nbme17#14)

Azoles (including itraconazole) and omeprazole are both P450 inhibitors. (p450 interactions FA2018 P247, azoles FA2018 p199.


 +0  (nbme17#27)

The unaffected person will have the alleles from their parents not present in the diseased people. This is alleles 2 and 3.





Subcomments ...

submitted by pelparente(7),

I believe this is rotavirus which is a common cause of fatal diarrhea in children. I think "wheel-like shape" is technically a buzz word for rotavirus, but I didn't know that. Yes, there is a vaccine, but it requires 2-3 shots giving within a month starting after 6 weeks of age so maybe this child isn't completely immune yet. Once you get to rotavirus you just need to know the rest and I linked the video below on how I remember all the viruses.

https://www.youtube.com/watch?v=Df_qAFF58Ec

cheesetouch  Rotavirus is the only dsRNA virus and is important/unique from that. +  
overa  the vaccine is orally administrated +  


submitted by match95(34),
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enQtoius was ctyrik -- eend ot kool eta FAELOT lesve.l Both 2B1 eiefincdyc nad etloaf cedicfniye illw sacue an iensraec in eocsnmhiy.eto Oynl B21 eeidcficyn llwi eusac an snaeeric ni THBO lmiclhomyaetn ciad ADN me.hecynitoos

cheesetouch  B12 deficiency 'BOTH be high' (and neuro sx) +  


This lady had preterm premature rupture of membranes. She had a genital tract infection, which is a risk factor for PPROM.

From Uptodate: Many of the microorganisms that colonize the lower genital tract have the capacity to produce phospholipases, which can stimulate the production of prostaglandins and thereby lead to the onset of uterine contractions. In addition, the host's immune response to bacterial invasion of the endocervix and/or fetal membranes leads to the production of multiple inflammatory mediators that can cause localized weakening of the fetal membranes and result in PPROM.

alimd  did you pay fucking $30? +  
cheesetouch  some institutions give students UpToDate access +1  


unscramble the site ⋅ become a member ($42/month)

dMli dunaejic hwti srecaiden adgnotujunce in na oedrl lofewl is ceeaddser eacoPru-geDnlrfutsnsaUlry iyiavt.tc airclulartyP ni octtxen fo sstrse (epodnatpe)mcy

pg32  Went with hepatitis because of his recent surgery. Seen problems like this before where recent surgery means they were given inhaled anesthetic that can cause hepatotoxicity/hepatitis. That, along with the elevated AST/ALT and unconjugated bilirubinemia (signifying liver losing its ability to conjugate bilirubin due to inflammation) made me pick hepatitis. Why is that wrong? +  
suckitnbme  @pg32 AST/ALT are only slightly elevated. The patient also is not particularly symptomatic. He's really not that sick. Hepatoxicity is also most associated with halothane which is no longer used in the US. It would be a different story if the patient had surgery done in a different country (as is common in Uworld questions on this) +3  
mumenrider4ever  I don't know why NBME uses ALT/AST reference ranges from 8-20 u/L when the reference ranges for uworld are 8-40 u/L. So maybe his liver enzymes aren't really elevated since they're below 40 +2  
cheesetouch  Can someone refute 'surgical trauma'? +  
cancelstep  Appendix is pretty far anatomically from the bile ducts. Also damage to bile ducts should cause direct hyperbilirubinemia since there's no problem with conjugation versus Gilbert syndrome which causes impairment of UGT +  


submitted by cassdawg(586),

In hypothesis testing, the alpha value is the probability of making a Type I error. This is the type of error mentioned in the question.

  • Type I error - you find a difference when a difference doens't really exist.
    • One way of remembering this is that this is what scientists "want" to make: they want to find a significant difference in their data, thus it is the "first mistake" they'd make.
    • Alpha is the probability you are willing to accept that you could have made a type I error (i.e. an alpha value of 0.05 means there is a 5% probability you could make a type I error and reject the null hypothesis when you should not)

  • Type II error - you do not find a difference when you should have because a true difference really exists
    • Beta is the probability that you make a type II error
    • Power is equal to (1 - beta)
    • Power can be increased by increasing sample size, and thus with a larger sample you have a lower probability of making a Type II error
    • Power can also be increased by increasing expected effect size or increasing precision. It is interesting to note accuracy has no effect on power.

FA2020 p263

cheesetouch  FA2018 p258 +  


submitted by cassdawg(586),

I don't like this question for many reasons, but basically he has sarcoidosis (noncaseating granulomas with no pathogen found on biopsy) which according to First Aid is more common in African-American females. Since he is African-American that is his risk factor (FA2020 p676).

cheesetouch  FA2018 p658 +  


submitted by baja_blast(37),

Cocaine use in pregnancy is associated with low birth weight, premature membrane rupture and abruptio placentae. Click here for more.

FA 2019 p. 600 gives a list of drug effects during pregnancy.

cheesetouch  teratogens FA2018 p596 +  


submitted by cassdawg(586),

This girl has an ectopic thyroid that has remained attached to the tongue by thyroglossal duct. The mass can be identified as an ectopic thyroid rather than a thyroglossal duct cyst due to the uptake to Tc99 pertectnetate. Thus, a biopsy would show thyroid follicles. (FA2020 p326)

cheesetouch  FA2018 P320 +  
cheesetouch  CONTRAST - branchial cleft cyst in lateral neck from persistent cervical sinus would not move w/ swallowing or tongue protrusion +  


submitted by cassdawg(586),

This girl has an ectopic thyroid that has remained attached to the tongue by thyroglossal duct. The mass can be identified as an ectopic thyroid rather than a thyroglossal duct cyst due to the uptake to Tc99 pertectnetate. Thus, a biopsy would show thyroid follicles. (FA2020 p326)

cheesetouch  FA2018 P320 +  
cheesetouch  CONTRAST - branchial cleft cyst in lateral neck from persistent cervical sinus would not move w/ swallowing or tongue protrusion +  


submitted by cassdawg(586),

The ductus arteriosus is kept patent by prostaglandins (which is why the baby is started on a prostaglandin drip id we need to keep the ductus patent in some hypoxic congenital heart diseases).

Thus, to close the PDA, prostaglandins are decreased. cyclooxygenase inhibition (COX) is one way of decreasing prostaglandins and is the physiologic way of closing the ductus as well as how we close it if necessary (to close a PDA you give a baby NSAIDs, FA2020 p486).

cheesetouch  NSAIDs p471 FA2018 +1  


submitted by cheesetouch(26),

Frothy YELLOW GREEN DISCHARGE, motile organism with flagella -> dx of trichomonas vaginalis, treatment is metronidazole for patient and partner. FA2018 P158.

Trichomonas vaginalis is an STI with foul smelling green discharge, trophozoites on wet mount.

cheesetouch  intravaginal miconazole is the treatment of candida vaginitis (white cottage cheese discharge) +  


submitted by hungrybox(800),

These are really the only two that should be on your differential for a diaphragmatic hernia:

A: Abnormal relation of the cardia to the lower end of the diaphragm | Sliding hiatal hernia

B: Protrusion of the fundus into the chest above the level of T10 | Correct! This describes a paraesophageal hernia.

different hernias

parts of stomach

cheesetouch  FA2018 P364 +  


submitted by cassdawg(586),

My take on this question is that he is about to be diagnosed with advanced stage pancreatic cancer, which has a high mortality rate. On its own, pancreatic adenocarcinoma is not associated with any of the psychological disorders. However, a diagnosis of a terminal condition or advanced cancer of any kind that would require aggressive treatment with poor prognosis would be associated with major depression. Thus, he is at most risk of major depressive disorder.

cheesetouch  Study break journal article about depressive symptoms before pancreatic cancer diagnosis - https://journals.lww.com/pancreasjournal/FullText/2018/04000/Early_Detection_of_Pancreatic_Cancer__The_Role_of.1.aspx +  


submitted by cassdawg(586),

This patient likely has Gilbert syndrome (FA2020 p394).

This is because his hyperbilirubinemia occurs during periods of stress and is relatively benign. Gilbert's syndrome has elevated unconjugated bilirubin because there is a mild deficiency in UDP-glucuronyltransferase conjugation. Thus, the cause is decreased conjugation of bilirubin.

cheesetouch  FA2018 P387-388 +  


submitted by cassdawg(586),

Based on the history (consumption of large amounts of alcohol and elevated serum amylase/lipase with hypocalcemia), this man likely has acute pancreatitis (FA2020 p397). One of the major complications is autodigestion of tissues, such as what is seen in the image.

cheesetouch  FA2018 P391 +  


submitted by cassdawg(586),

The description points to pancreatic insufficiency due to steatorrhea (fat in the stool, likely due to insufficiency of pancreatic lipase) and muscle fiber in the stool (which points to incomplete protein digestion, likely due to insufficiency of pancreatic proteases).

Further, he has no deficiency in carbohydrate absorption as evidenced by the D-xylose test (which indicates an intact mucosa for absorption and does not require digestive enzymes, FA2020 p373); and he has no abnormalities on biopsy of the intestine.

Thus, the primary issue is pancreatic insufficiency and supplementation of pancreatic enzymes is most helpful.

cheesetouch  FA2018 P375 +  


submitted by cassdawg(586),

TL;DR: Even with Type I or II renal tubular acidosis the ammoniagenesis from glutamine is not impaired and thus is the main source of ammonia.

Here is my take: Based on her history and measured plasma values, this girl likely has one of the "low potassium" renal tubular acidoses, either Type I or Type II (see this chart for reasoning based on measured values or this image for fun colorful renal tubular acidosis and FA2020 p593)

Then, we are told that she has a defect in "ammoniagenesis". In the renal tubules, ammonia is generated in two primary ways: via direct conversion of glutamine to ammonia in the proximal tubule which is then secreted into the tubule, or by NH3 combining with with H+ in the collecting tubules (which I guess they are considering a separate ammoniagenesis pathway even though its all kinda related?). See this diagram or this diagram

Assuming our girl has Type I renal tubular acidosis, there will be decreased availability of hydrogen ions in the renal tubules to combine with NH3. Thus, the primary source of ammonia production in this patient will be glutamine (which is the major source of ammoniagenesis in a normal person anyways).

Further reasoning - Type I is impaired secretion of hydrogen ions into the lumen, so there will be less hydrogen ions available. She likely has type I because this is primarily treated with potassium citrate (both to buffer and to prevent renal stones which are a common complication). Even if she had Type II the increased excretion of bicarb would also buffer more H+ leaving less for ammoniagenesis in the NH3/H+ combination fashion.

Contrarily, Type 4 renal tubular acidosis (hyperkalemic) results in decreased synthesis of ammonia in the proximal tubules, which we know she does not have because of her low potassium.

cheesetouch  Cassie you're a god. Simple/stupid approach to make a good guess - if she cannot make ammonia in the kidney, main ammonia source probably from an exogenous form like amino acids -> Glutamine! +  


submitted by ergogenic22(246),
unscramble the site ⋅ become a member ($42/month)

LTC daesederc ssgtsuge tirivtrseec sei.sdea turceiRal rattepn essugstg pmyaoulnr sfriibso

cheesetouch  fa2018 p657 +  


submitted by cassdawg(586),

This woman has pulmonary hypertension, likely pulmonary arterial hypertension characterized by increased pulmonary artery pressure with a normal pulmonary capillary wedge pressure (remember pulmonary capillary wedge pressure is associated with left atrial pressure). PAH endothelial dysfunction causes an imbalance in vasoconstrictors (such as endothelin) and vasodilators (NO and prostacyclin). [FA2020 p679]

BosENtan, used to treat PAH, is an ENdothelin antagonist (FA2020 p686)

cheesetouch  FA0281 p667 +  


submitted by cassdawg(586),

He has alpha-1 antitrypsin deficiency which is causing panacinar emphysema and liver damage. This is the major disease to think of when you have a young-ish patient who presents with liver and lung issues. (FA2020 p392)

From the stem: hyperinflation combined with decreased diffusion capacity and decreased FEV1 points toward emphysematous change; lower lobe predominance is seen in panacinar emphysema; hepatomegaly pointing to liver involvement

NOTE: diffuse idiopathic interstitial fibrosis would cause a decreased diffusion capacity, but this is a restrictive lung disease which would not have hyperinflation but instead decreased lung volume

cheesetouch  FA2018 p386 +1  


submitted by fruitkebabs(10),

This is Pierre Robin sequence, which presents with micrognathia, glossoptosis, cleft palate, and airway obstruction.

It is one of the First Arch syndromes, and the major tip off in the stem would be the mandibular cleft since the mandible is derived from 1st pharyngeal arch.

cheesetouch  fa2018 p602 +  
cheesetouch  Glossoptosis is a medical condition and abnormality which involves the downward displacement or retraction of the tongue. +  


submitted by fruitkebabs(10),

This is Pierre Robin sequence, which presents with micrognathia, glossoptosis, cleft palate, and airway obstruction.

It is one of the First Arch syndromes, and the major tip off in the stem would be the mandibular cleft since the mandible is derived from 1st pharyngeal arch.

cheesetouch  fa2018 p602 +  
cheesetouch  Glossoptosis is a medical condition and abnormality which involves the downward displacement or retraction of the tongue. +  


submitted by cheesetouch(26),

Left dominant circulation - posterior descending artery (PDA) which supplies AV node etc is coming from the *left circumflex. Prompt says it is blocked. To get to there, the correct anatomical pathway is Left coronary artery, circumflex artery, posterior interventricular (PDA).

This can be reasoned by process of elimination too. 1- Given the Left dominant circulation, we can eliminate pathways beginning at the right coronary. 2- To get blockage at posterior of heart, we will NOT use anterior interventricular artery, so you can eliminate the 2 options listing those. 3 - The circumflex artery gives rise to the PDA, but is not the final artery in our path to the blockage (so can eliminate another two). This should give you the correct answer.

cheesetouch  FA2018 P277 heart anatomy drawing +  


submitted by cassdawg(586),

Lentigo maligna is a type of melanoma (FA2020 p484), hence why it is important the lesion is brown/black with irregular borders and enlarging (all hallmarks of melanoma). The biopsy description also fits lentigo maligna, but even if you are not a pathologist the description that fits cancer and and "atypical melanocytes" should point you to lentigo maligna.

  • Acanthosis nigricans is thickening (acanthosis means epidermal hyperplasia) and darkening of skin in folds and creases associated with insulin resistance
  • Actinic keratosis is a premalignant lesion that is a small, rough, erethematous or brownish papule/plaque
  • Compound nevus is a type of mole that is slightly elevated, brown or light brown, and has regular borders. It is not fast-growing.
  • Sebhorreic keratosis are "stuck-on" flat, greasy, pigmented squamous epithelial proliferation of immature keratinocytes with keratin-filled cysts. Rapid onset of multiple indicates possible GI malignancy.

FA2020 p482, 477 and 484

cheesetouch  fa2018 p 469 melanoma +  


submitted by ergogenic22(246),
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He hsa a wodn nda out ulipp, cusdae by NC III ayl.sp Hsi agze is edu ot spodeonpu ionatc of eth laraelt rsetuc nad rpuseior lq;oeibu spisot eud ot ieneatronvd fo elavrot eaebaprlp spe.uioissr

hTe olny runjiy stdlie atht cuodl eucsa a NC III lyaps si rmnseayu of hte APC ermigospcsn eht aoootrmlcur .nuulsce

cheesetouch  Compression of superior cervical ganglion -> Horner's syndrome -> ptosis, miosis, anhidrosis, would NOT have dilated pupil. +  


submitted by ergogenic22(246),
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sCilacs rtecpui rfo hnuecneD uaurcsml sh.pdyryto chwhi si ude ot deedlet ptrshdnyio entpr.io

ormF F:A npthyoDris" hples rncoha ucslme ri,fesb irylpairm in etlasekl nad idracac .mseulc tI socecnnt teh trleunlcriaal etoolcnytsek ntc()ia to eth rannstemamebr pirsoten α- dan -dt,grβnclasoyy chhiw are nndceetoc to het arlatexclreul mtxira (MC)"E

cheesetouch  fa2018 p61 +  


submitted by cassdawg(586),

Here is a summary of derivatives of neural crest cells. Also FA2020 p613 for embryologic derivatives [MOTEL PASSES - Melanocytes, Odontoblasts, Tracheal cartilage, Enterochromaffin cells, Leptomeninges (arachnoid, pia), PNS ganglia (cranial, dorsal root, autonomic), Adrenal medulla, Schwann cells, Spiral membrane (aorticopulmonary septum), Endocardial cushions (also derived partially from mesoderm), Skull bones]

cheesetouch  FA2018 P595 +  


submitted by cassdawg(586),

For gonadal drainage: (FA2020 p624)

  • Testes/ovaries drain to paraaortic lymph nodes
  • Body of uterus/cervix/superior bladder to external iliac
  • Prostate/corpus cavernosum, proximal vagina/cervix, and anus above pectinate to internal iliac
  • Distal vagina/vulva, scrotum, and anus below pectinate to superficial inguinal
  • Glans penis to deep inguinal

Basically, the superficial inguinal drains the skin below the umbilicus (except the popliteal area) and the other answers except the correct one are not associated with gonadal drainage

Lymph drainage FA2020 p97

cheesetouch  FA 2018 p606 - gonadal drainage +  


submitted by cassdawg(586),

This indicidual has CATCH22 DiGeorge Syndrome, caused by failure in the development of the 3rd and 4th pharyngeal pouches (FA2020 p116). This is evidenced by the hypocalcemia (agenesis of parathyroids), facial deformities, and conotruncal abnormality (right sided aortic arch).

Big thing is being able to ensure you know it is pharyngeal POUCH not cleft or arch. Pharyngeal arch derivatives are on FA2020 p620. Pharyngeal pouch derivatives are p621. And pharyngeal cleft derivatives are p619. (Aortic arch derivatives are p619 as well, if you want to complete the circle)

Treacher-Collins is error in 1st and 2nd pharyngeal arch derivatives which can present with craniofacial abnormalities, zygomatic and mandibular hypoplasia, and hearing loss. Pierre Robin is similar and presents with micrognathia, glossoptosis, cleft palate, and airway obstruction. Neither of these would present with hypocalcemia.

cheesetouch  FA2018 P602-603 arches/pouches +  
cheesetouch  Arch vs pouch (my thoughts): Arches help build a structure and direct development of cartilage, muscles, nerves. Pouches are cavities or minor organs (middle ear cavity, eustachian tube, thymus, parathyroids). +  


submitted by cassdawg(586),

This indicidual has CATCH22 DiGeorge Syndrome, caused by failure in the development of the 3rd and 4th pharyngeal pouches (FA2020 p116). This is evidenced by the hypocalcemia (agenesis of parathyroids), facial deformities, and conotruncal abnormality (right sided aortic arch).

Big thing is being able to ensure you know it is pharyngeal POUCH not cleft or arch. Pharyngeal arch derivatives are on FA2020 p620. Pharyngeal pouch derivatives are p621. And pharyngeal cleft derivatives are p619. (Aortic arch derivatives are p619 as well, if you want to complete the circle)

Treacher-Collins is error in 1st and 2nd pharyngeal arch derivatives which can present with craniofacial abnormalities, zygomatic and mandibular hypoplasia, and hearing loss. Pierre Robin is similar and presents with micrognathia, glossoptosis, cleft palate, and airway obstruction. Neither of these would present with hypocalcemia.

cheesetouch  FA2018 P602-603 arches/pouches +  
cheesetouch  Arch vs pouch (my thoughts): Arches help build a structure and direct development of cartilage, muscles, nerves. Pouches are cavities or minor organs (middle ear cavity, eustachian tube, thymus, parathyroids). +  


submitted by cassdawg(586),

Based on the question stem and the autoanitbodies given (butterfly rash combined with anti-dsDNA/anti-Sm/antiphospholipid), this woman has classic lupus. SLE is associated with cytopenias, so thrombocytopenia is the best choice of the available answers. Thrombocytopenia is common in lupus (FA2020 p470)

  • HUS is associated with E.coli or Shigella infection and not Lupus. Lupus kidney disease is diffuse proliferative glomerulonephritis.
  • Macrocytic anemia is typically caused by B12 or folate deficiency and not associated with lupus. Lupus anemia is typically anemia of chronic disease, which is normocytic, or due to inadequate RBC production or iron deficiency, which is microcytic.
  • Multiple nucleated erythrocytes are found in leukemias when the RBCs are being "pushed" out of the bone marrow, or in diseases where the bone marrow is highly stressed. Lupus does not typically cause this.
  • I am not 100% sure why rouleax formation is wrong, because as far as I understand any condition that increases monoclonal Abs can cause rouleaux formation, but I am assuming it is just not as common/likely, hence thrombocytopenia which is very common is the better answer
cheesetouch  FA2018 P458 +  


submitted by andro(120),

Myeloproliferative Disorders :

They are all associated with the JAK STAT mutation with the exception of CML which is associated with the fusion gene BCR:ABL ( from t(9;22 )-i.e philadelphia chromosome )

CML Tx : imatinib - BCR-ABL Tyrosine kinase inhibitor

TX of the myeloproliferative disorders - Ruxolitinib - Janus kinase inhibitor

cheesetouch  FA2018 P420-421 +  


So does someone know what is phase 0 for? It was an option... somathing like "let me see if i can study this thing?"

cheesetouch  via google - A Phase 0 study gives no data on safety or efficacy, being by definition a dose too low to cause any therapeutic effect. Drug development companies carry out Phase 0 studies to rank drug candidates in order to decide which has the best pharmacokinetic parameters in humans to take forward into further development. +  
boostcap23  Phase 0 is an extremely small dose (1% of normal) given to easily rule out any harmful effects. Basically used as a quick way to eliminate further trails/research on drugs that don't work. +1  


submitted by cassdawg(586),

Bethanechol is a muscarinic cholinergic antagonist with no action on nicotinic ACh receptors. Bethanechol is commonly used to treat urinary retention by activating bladder smooth muscle via M3 Gq receptors that function by increasing phospholipase C conversion of PIP2 (phosphoinositide) to IP3 and DAG (FA2020 p240, p237, p238).

Wrong answers:

  • Atropine is a muscarinic antagonist which would non increase phosphoinositide turnover but decrease it (FA2020 p241)
  • Neostigmine is an indirect cholinergic agonist that works by inhibiting acetylcholinesterase that does work at the muscarinic synapse as well and is used for myasthenia gravis as well as postoperative ileus and urinary retention
  • Succinylcholine is a depolarizing muscarinic agonistnthat causes sustained depolarization and prevents contraction, used as a paralytic in anesthesia (FA2020 p551)
  • Trimethaphan is a drug that counteracts cholinergic transmission at the nicotinic receptors of the autonomic ganglia and therefore blocks both the sympathetic nervous system and the parasympathetic nervous system. It is used to treat hypertension
cheesetouch  FA2018 P236 +1  


submitted by andro(120),

A note to self : Creatine phosphate is a short term energy source in muscle . Acts by donating phosphate groups to regenerate ATP .

*Creatine is derived from Arginine and metabolised to Creatinine ( which is excreted by the kidneys )

cheesetouch  ATP on FA2018 p74 to annotate book +  


submitted by cassdawg(586),

Chloroquine does not adequately kill the dormant liver form of malaria (hypnozoite), and thus for infections that have a hypnozoite stage treatment requires addition of primaquine (which does adequately kill hypnozoites) to prevent relapse from release of the infection back into the blood. [FA2020 p157]

Hypnozoites are the dormant form of malaria in the liver (think hypno as in sleeping from hypnosis). Plasmodium vivax and ovale have the hypnozoite stage and thus require the addition of primaquine.

cheesetouch  FA2018 p157 too :) +  


submitted by cassdawg(586),

Important aspects of volatile (gas) anesthetics: (FA2020 p549):

  • MAC (minimum alveolar concentration): essentially the ED50 for inhaled anesthetics, this is the minimum concentration of anesthetic that causes a response in 50% of patients
  • LOW MAC means HIGH potency - more potent drugs would have a lower minimum amount needed to be present in the alveoli in order to exert their effect.
  • LOW MAC is related to HIGH lipid solubility (higher oil/gas partition coefficient) - more lipid soluble agents tend to be more potent because of their increased ability to cross the BBB
  • MACs are additive (i.e. one gas at 1.5 MAC = two gases at 0.75 their respective MACs)
  • Blood/gas partition coefficient: an expression of solubility; anesthetics with a low blood gas partition coefficient have a rapid onset/offset
  • i.e. LESS plasma solubule anesthetic = FASTER onset/offset
  • This is because less plasma soluble agents will "fill up" their maximum amount in the blood reservoir quicker and thus are pushed down their concentration gradient into the brain quicker; i.e. they quickly saturate the blood and will move on to affecting the brain quicker
  • MAC and blood/gas partition coefficient also tend to be inversely related -- higher MAC = lower blood/gas partition coefficient and vice versa; thus many of the more potent anesthetics have a longer time for onset/offset
cheesetouch  FA2018 P532 +  


submitted by andro(120),

Note: IL-12 receptor deficiency, or a defect in the Interferon Gamma receptor
Think Disseminated Mycobacterial and Fungal Infections . Also salmonella *

cassdawg  Disseminated mycobacterial infections occur more often with interferon gamma receptor or IL-12 receptor deficiencies due to impaired ability to form granulomas (IL-12 and IFNgamma are the main cytokines involved in granuloma formation). +1  
cheesetouch  FA2018 P 116 under il-12 receptor deficiency +  


submitted by cassdawg(586),

Here, we want to know loading dose which is equal to the volume of distribution x target concentration in plasma.

So our loading dose = 1.81L/kg x 10mg = 18.1mg/kg

She is a 55kg person so 18.1mg/kg x 55kg = 995.5 mg which approximates to 1000mg total loading dose.

Important Pharm Equations to Remember

cassdawg  10mg/L * sorry +  
cheesetouch  fa2018 p229 +  


submitted by cassdawg(586),

A cleft lip/palate with no associated anomalies has multifactorial etiology (FA2020 p621). There is no evidence of associated syndrome or inheritance, so it is multifactorial.

cheesetouch  FA2018 p603 +  


submitted by fruitkebabs(10),

Oseltamivir and zanamivir are influenza neuraminidase inhibitors. Typically, neuraminidase allows influenza particles to bud off host cells. Without the functioning enzyme, the virion buds cannot detach from the host cell membrane.

cheesetouch  FA2018 P201 +  


submitted by cassdawg(586),

The proteasome degrades ubiquitin-tagged proteins into amino acids and releases ubiquitin for recycling.

See here for picture illustration of the process.

cheesetouch  FA2018 p48 +  


submitted by cassdawg(586),

Lipopolysaccharide, or LPS, is the primary endotoxin mediator of gram(-) sepsis leading to septic shock. This woman likely has sepsis from E. coli, a gram negative bacterium which produces LPS, based on her history indicating a UTI. E.coli are the most common cause of UTI. (FA2020 p133)

cheesetouch  FA2018 p145 +1  


submitted by cheesetouch(26),
1 tumor w/ met to liver is colon cancer Fa2018 p226
cheesetouch  sorry for a lazy answer folks! +  


submitted by cassdawg(586),

This is a Congenital Diaphragmatic Hernia (FA2020p370).

Conginital diaphragmatic hernias are caused by a congenital defect of the pleuroperitoneal membrane which allows contents of the abdominal cavity to herniate upward, and displace the contents of the thorax (hence why our baby has displacement of the mediastinal contents to the right). This also leads to lung malformation and respiratory distress (hence the low apgar scores). Because the stomach is likely herniates upward, a nasogastric tube placed would appear in the left mediastinum (because that is where the stomach is). Further, there is an absence of bowel gas in the abdomen likely because the bowels are herniated into the thorax.

cheesetouch  FA2018 P364 CDH +  


submitted by cassdawg(586),

The image shown is one of asbestosis (asbestos bodies resemble dumbbell, as seen here and found FA2020 p677). Aside from the image, he also has the major risk factor of asbestosis of working in a shipyard. Asbestosis typically affects the lower lobes of the lungs (hence the bibasilar crepitant crackles) and carries the ability to cause reticulonodular pulmonary infiltrates / fibrosis.

Similar to the pathology behind silicosis fibrosis, alveolar macrophages respond to aesbestos and release fibrogenic factors.

Alveolar macrophages phagocytize foreign materials, release cytokines and alveolar proteases.

Type I pneumocytes make up the alveolar lining, and Type II pneumocytes generate surfactant and can proliferate into Type I pneumocytes in response to alveolar damage. Kulchitsky cells are cells of origin of small cell lung cancer. Clara cells (now called club cells) are nonciliated bronchiolar exocrine cells that secrete a component of surfactant, degrade toxins, and act as reserve cells.

flapjacks  A barbell, really. +1  
cheesetouch  FA2018 P659 +1  
jer040512  eh... more like a shake weight. +  


submitted by cassdawg(586),

Thiazide diuretics can cause hypokalemia (FA2020 p609).

cheesetouch  FA2018 P 591 +1  


submitted by bingcentipede(120),

The classic triad of a renal cell carcinoma is: 1) hematuria; 2) flank pain; and 3) a palpable flank mass. The classic RCC comes from a VHL mutation. No VHL means you can't inhibit HIF (hypoxia inducible factor). This leads to uncontrolled activation of VEGF, leading to the hypervascular mass.

cheesetouch  FA2018 P583 +1  


submitted by cassdawg(586),

Epstein-Barr virus is associated with lymphomas (endemic Burkitt Lymphoma, Hodgkin lymphoma, CNS B-cell lymphoma), nasopharyngeal carcinoma, and lymphoproliferative disease in transplant patients. (FA2020 p164)

Here is a chart of virus-associated cancers and their viruses. Also found FA2020 p226.

  • CMV is not associated with cancer but is associated with AIDS retinitis and esophagitis.
  • Hepatitis B is associated with hepatocellular carcinoma.
  • HHV-8 is associated with Kaposi sarcoma in AIDS patients (an endothelial neoplasm, FA2020 p478)
  • HTLV-1 (human T-CELL...) is associated with adult T-cell leukemia
cheesetouch  FA2018 P165 +1  
cheesetouch  Additionally, HTLV is a ss+RNA Retrovirus and prompt mentions DNA probe. All other viruses are DNA genomes. +  


submitted by cassdawg(586),

Epstein-Barr virus is associated with lymphomas (endemic Burkitt Lymphoma, Hodgkin lymphoma, CNS B-cell lymphoma), nasopharyngeal carcinoma, and lymphoproliferative disease in transplant patients. (FA2020 p164)

Here is a chart of virus-associated cancers and their viruses. Also found FA2020 p226.

  • CMV is not associated with cancer but is associated with AIDS retinitis and esophagitis.
  • Hepatitis B is associated with hepatocellular carcinoma.
  • HHV-8 is associated with Kaposi sarcoma in AIDS patients (an endothelial neoplasm, FA2020 p478)
  • HTLV-1 (human T-CELL...) is associated with adult T-cell leukemia
cheesetouch  FA2018 P165 +1  
cheesetouch  Additionally, HTLV is a ss+RNA Retrovirus and prompt mentions DNA probe. All other viruses are DNA genomes. +  


submitted by cassdawg(586),

Loratadine is a second generation antihistamine and thus would be preferred in this patient as it does not cause sedation. [FA2020 p686]

Since he works operating heavy machinery, it would be preferred to put him on a second generation antihistamine. Bropheniramine, hydroxyzine, and diphenhydramine are first generation antihistamines which cause sedation.

Ranitidine is a histamine H2 blocker used to decrease secretion by parietal cells in peptic ulcer disease, gastritis, and gastric reflux [FA2020 p399]

cheesetouch  FA2018 P667 +  


submitted by lfcdave182(24),

Pg 391, FA 2020

  • Alcoholic hepatitis: Swollen and necrotic hepatocytes with neutrophilic infiltration; Mallory Bodies (Intracytoplasmic eosinophilic inclusions of damaged keratin filaments)
cheesetouch  FA2018 P385 +  


submitted by cassdawg(586),

DISTRIBUTIVE SHOCK (I.E. SEPTIC OR ANAPHYLAXIS) ARE THE ONLY SHOCKS WITH INCREASED CARDIAC OUTPUT!

FA2020 p310

This man presents with hypothermia (septic shock can present with hyper or hypothermia), tachycardia, and low blood pressure with increased cardiac output, characteristic of septic shock. Further distributive shock is associated with severe decrease in systemic vascular resistance while other forms of shock have increased systemic vascular resistance.

psychofromthemidwest  Thank you so much for this!!! +  
cheesetouch  FA2018 P305 Shock +  


submitted by cassdawg(586),

Spironolactone has a special use in hepatic ascites (FA2020 p609).

Spironolactone is the drug of choice for initial treatment of ascites due to cirrhosis

cheesetouch  FA2018 P591 +  
mittelschmerz  In portal HTN, the splanchnic vasodilation results in a drop in systemic BP and renal hypoperfusion. That leads to RAAS activation that increases SBP enough to maintain renal perfusion, but the aldosterone-mediated Na/H2O retention leads to edematous states (ascites here). Treating with spironolactone allows you to treat the the fluid component without disrupting the vasoconstrictive effects of AngII that is the only thing maintaining renal perfusion, which is why spironolactone is correct here, but also why prescribing an ACEi or ARB in a hepatic patient like this is v v bad. +1  


submitted by cassdawg(586),

This is one of the main consequences of liver failure. [FA2020 p389]

The proposed mechanism is an imbalance in free testosterone and estrogen caused by defect in sex hormone binding globulin (more free estrogen = gynecomastia).

cheesetouch  FA2018 P383 see image in 'cirrhosis and portal hypertension' +  


The prednisone will induce T cell apoptosis (FA2020 pg 120)

cheesetouch  FA2018 p120 +  


submitted by cassdawg(586),

This is normal menopause (FA2020 p636). Average age of onset is 51 years (our woman is 52). Hot flashes are a common symptom.

In menopause, the ovaries stop secreting estrogen (17beta-estradiol is an estrogen) due to a decline in the number of ovarian follicles with age. FSH is increased because the feedback inhibition is removed. The source of estrogen after menopause becomes peripheral conversion of androgens.

peteandplop  FA2019 p622 +1  
cheesetouch  FA2018 P617 +  


submitted by cassdawg(586),

Ligation of the internal iliac artery is used to stop postpartum uterine bleeding while preserving fertility as the ovarian arteries provide collateral circulation (FA2020 p640).

Here is an image showing the uterine artery coming off the internal iliac with the ovarian artery collateral.

Other answers:

  • The external iliac gives rise to the femoral artery, inferior epigastric artery, and the deep circumflex iliac artery
  • The internal pudendal artery supplies the external genetalia and perineum via arteries such as the inferior rectal artery (anal canal BELOW the pectinate line), perineal artery, and ldorsal/deep arteries of the clitoris or dorsal/deep arteries of the penis
  • The median sacral artery is small and supplies the coccyx/sacrum/lumbar vertebrae
  • The obturator artery is a branch of the internal iliac which gives off the pubic branch (supplies pelvic muscles) and acetabular branch (supplies head of the femur)
cheesetouch  fa2018 p624 +1  


submitted by cassdawg(586),

This is feedback inhibition of the RAAS (renin-angiotensin-aldosterone system) axis. Increased aldosterone will feedback and inhibit renin secretion of the kidney. (FA2020 p588)

flapjacks  Increased serum sodium concentration is not specific enough to support the diagnosis +4  
cheesetouch  Fa2018 p332: Hyperaldosteronism - primary hyperaldosteronism seen with adrenal adenoma (Conn syndrome). High aldosterone, low renin. Causes resistant hypertension. +1  
mark0polo  Serum sodium concentration wouldn't actually change because of the aldosterone escape mechanism in primary hyperaldosteronism +2  


submitted by cassdawg(586),

This woman likely has endometriosis, characterized by cyclic pelvic pain, bleeding, and associated with infertility (FA2020 p648). It is associated with "chocolate cysts" on the ovaries. Proliferative endometrial tissue would be found on biopsy

Endometriosis scar tissue/adhesions can cause the uterus to stick in a backwards position (retroverted) according to https://www.healthline.com/health/womens-health/tilted-uterus

Polycystic ovarian syndrome is associated with obesity would also likely have symptoms of hisutism and acne as well as infertility. It also presents with amenorrhea or oligomenorrhea. [FA2020 p645]

waitingonprometric  Also, rule out cancers because no weight loss, symptoms are not constant throughout month, and symptoms are not getting progressively worse over the 2-yr history of pain +4  
cheesetouch  FA2018 P630 +1  


submitted by cassdawg(586),

She has a craniopharyngioma, the most common childhood supratentorial tumor which is derived from remnants of Rathke's pouch (FA2020 p528). Craniopharyngiomas commonly have calcification and can cause hypopituitary issues (like low HGH). Suprasellar is also the location of the pituitary, and pituitary tumors in general cause bitemporal hemianopsia due to compression of the optic chiasm.

Rathke's pouch (where craniopharyngiomas and anterior pituitary are derived from) is derived from the surface ectoderm of the oral cavity.

Note that the neurohypophysis (posterior pituitary) is derived from neural ectoderm while the adenohypophysis (anterior pituitary) is derived from surface ectoderm of the oral cavity.

waitingonprometric  If you can recognize that this is a craniopharyngioma based on "calcified cystic mass in the suprasellar region," then you can think "cranio-" mass in the brain, "-pharyngioma" from structures connected to the mouth. Always works for me! +3  
cheesetouch  FA 2018 P512 +1  


submitted by cassdawg(586),

This is a choriocarcinoma, or a rare malignant trophoblastic tumor developed during/after pregnancy [FA2020 p642]. It is characterized by increased serum beta hCG and "cannonball" metastases to the lung. Biopsy would show trophoblastic tissue with no chorionic villi present.

cheesetouch  Fa 2018 p 622 +1  


From FA2020, pg. 381:

Tubular adenoma--> neoplastic; tubular histology has less malignant potential than villous; tubulovillous has intermediate malignant potential; usually asymptomatic, may present with rectal bleeding. Hence our patient who has been undergoing evaluation for fecal occult blood.

Other answers:

Hyperplastic polyp--> most common, generally smaller and in rectosigmoid region. I'm guessing the picture attached to this question is trying to clue us into this not being a small lesion.

Inflammatory pseudopolyps--> due to mucosal erosion in inflammatory bowel disease. There is no appreciable erosions in this picture, also the mass appears pedunculated, so we know it's not a spot of normal mucosa that just looks raised compared to surrounding erosion.

Juvenile polyp and Peutz-Jeghers syndrome--> these are both genetic disorders with numerous hamartomatous polyps seen in the colon. Peutz-Jeghers also associated with increased risk of breast and other GI cancers. It is unlikely that our patient had either of these b/c he is 70 y/o; therefore, if he had one of these, he would likely have more than one colon lesion and may also present with a history of other cancers at his age.

cheesetouch  great refutation of others, thanks! +1  
lpp06  To add - tubular adenomas are pedunculate masses, as seen in the image +1  


submitted by lfcdave182(24),

Pg 366 FA 2020.

  • Below pectinate line: External hemorrhoids: Painful if thrombosed: Inferior Rectal Vein.
neovanilla  Note: pg 365 FA 2020 states: anorectal varices: portal <--> systemic: superior rectal <--> middle and inferior rectal. Not sure if that's correct, but definitely the info cited in pg 366 is correct +  
cheesetouch  FA 2018 p360 +  


submitted by cassdawg(586),

Atrial myxomas are the most common cardiac tumor in adults, and they may cause embolus complications hence our lady's painless loss of vision, likely due to central retinal artery occlusion [FA2020 p316]

The histology is characteristic of a myxoma with gelatinous material and cells immersed in glycosaminoglycans.

According to Daddy Goljan, basically for primary heart tumors if its an adult its a myxoma, if its a kid its a rhabdomyoma.

cheesetouch  FA20118 P309 +  
bingcentipede  It's also in the LEFT ATRIUM! +1  


submitted by cassdawg(586),

Alendronate is a bisphosphonate which acts as a pyrophosphate analog and binds hydroxyapatite in bones and inhibits osteoclast activity. (FA2020 p486)

As a general rule, most drugs of osteoporosis inhibit osteoclast activity and bone resorption somehow (the bisphosphonates, calcitonin mimetics [directly bind a receptor on osteoclasts], estrogens/SERMs [inhibit PTH mediated bone resorption and cytokine secretion], Denosumab [mAb which inhibits RANKL which typically activates osteoclasts]). The ONLY FDA approved medication which has the ability to stimulate bone formation is teriparatide.

(FA2020 p462 osteoporosis)

cheesetouch  Fa2018 p 471 bisphosphonates (alendronate, ibandronate, risedronate, zoledronate) +  


I think that this is osteogenesis imperfecta based on the hx of several fractures that occurred during birth.

From FA2019, pg. 51: Manifestations can include--multiple fractures with bone deformities and minimal trauma; may occur during the birth process

OI is caused by gene defects in COL1A1 and COL1A2; most common form is autosomal dominant with decreased production of normal type 1 collagen.

cheesetouch  OI does have macrocephaly https://rarediseases.org/rare-diseases/osteogenesis-imperfecta/ +1  
cheesetouch  FA2018 P 51 +  
peteandplop  If you've ever seen Unbreakable, the main villain (Mr. Glass) has OI and is born with many broken bones--memorable scene to remember this disease (https://youtu.be/5E69-oJ7TDc?t=100); Other memory device, OI = bONEs for Collagen Type ONE +3  


I think that this is osteogenesis imperfecta based on the hx of several fractures that occurred during birth.

From FA2019, pg. 51: Manifestations can include--multiple fractures with bone deformities and minimal trauma; may occur during the birth process

OI is caused by gene defects in COL1A1 and COL1A2; most common form is autosomal dominant with decreased production of normal type 1 collagen.

cheesetouch  OI does have macrocephaly https://rarediseases.org/rare-diseases/osteogenesis-imperfecta/ +1  
cheesetouch  FA2018 P 51 +  
peteandplop  If you've ever seen Unbreakable, the main villain (Mr. Glass) has OI and is born with many broken bones--memorable scene to remember this disease (https://youtu.be/5E69-oJ7TDc?t=100); Other memory device, OI = bONEs for Collagen Type ONE +3  


submitted by cheesetouch(26),

odds ratio for the exposure variable (aniline dye) = (yes cancer and yes dye / yes dye) / (no cancer and yes dye / yes dye) = (250/250) / (50/150) = 3

cheesetouch  FA 2018 P 254 +1  
cheesetouch  oops messed up the denominator a bit. 50/150 = (no cancer yes dye / no cancer no dye) +  


submitted by cheesetouch(26),

odds ratio for the exposure variable (aniline dye) = (yes cancer and yes dye / yes dye) / (no cancer and yes dye / yes dye) = (250/250) / (50/150) = 3

cheesetouch  FA 2018 P 254 +1  
cheesetouch  oops messed up the denominator a bit. 50/150 = (no cancer yes dye / no cancer no dye) +  


submitted by cassdawg(586),

FA2020 p258

Odds ratio = (250/250) / (50/150) = 3

cheesetouch  FA 2018 P254 +1  
bingcentipede  For OR = ad/bc (from a/c divided by b/d) +  


submitted by cassdawg(586),

Monoclonal antibodies used for inflammatory bowel disease include infliximab and adalimumab, both of which are directed against TNFalpha (FA2020 p382, 122, 487)

Another way of thinking about this is to think about common therapeutic antibodies used as well as the function of the other things listed to eliminate them. TNFalpha is commonly blocked by biologics for therapy in autoimmune and inflammatory disease, and generally it makes sense it would be beneficial to block as it is one of the primary pro-inflammatory cytokines

Bradykinin is involved in inflammation but has no major therapeutic Abs targeting it. C5a is an anaphylotoxin, and though monoclonal antibodies targeting C5 do exist they are used to treat paroxysmal noturnal hemoglobinuria. C5a does not play a major role in the pathogenesis of IBD. Blocking class I MHC antigens does not make sense, as antigens are what elicit the immune response and are presented to T-cells and there are millions of possible antigens that could be presented that are eliciting the inflammatory response. If you block class I MHC ittself it would also be extremely detrimental as then CD8 T-cells would not be able to respond to any infection/etc. Fibrin is involved in the clotting pathway and would not be beneficial to block in IBD. PGE2 is associated with pain, but it is not targeted by any therapeutic antibodies.

cheesetouch  FA P472 adalimumab/infliximab Anti-TNF-a monoclonal Ab +  


submitted by cassdawg(586),

The Congo Red staining showing characteristic birefringence (usually described as apple green) is indicative of amyloid (FA2020 p212). Her findings are characteristic of secondary amyloidosis with serum amyloid A which can cause restrictive cardiomyopathy and nephrotic syndrome and is associated with rheumatoid arthritis.

Amyloid protein composition is misfolded aggregates of beta-pleated sheets.

cheesetouch  FA 2018 p218 +1  


submitted by cassdawg(586),

I don't like how they are asking this, but I think what they are getting at is that after the stent placement ("subsequent to the stent placement") there will be reperfusion injury to the myocardial tissue which occurs through free radical injury and therefore membrane lipid peroxidation is the best answer (FA2020 p210 mentions membrane lipid peroxidation as a mechansism of free radical damage and lists reperfusion injury after thrombolytic therapy as a type). Elevations in the cardiac enzymes I assume are because of the injury to the cells.

zalzale96  Created an account just to up vote this answer +1  
cheesetouch  1998 journal via google " Myocardial injury after cardiac surgery with cardiopulmonary bypass may be related to free oxygen radical-induced lipid peroxidation" +  
peteandplop  "Evidence suggests that reactive oxygen species (ROS) may play important roles in the pathogenesis in myocardial infarction [2]. Following ischemia, ROS are produced during reperfusion phase [3, 4]. ROS are capable of reacting with unsaturated lipids and of initiating the self-perpetuating chain reactions of lipid peroxidation in the membranes" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2274989/) +1  
mittelschmerz  Honestly the wording got me on this one. Great answer +  
acerj  Also, you can rule out a few of the options to help justify this. Post MI you expect necrosis, not apoptosis. Remember, apoptosis is suicide, and necrosis is MURDER! Cell swelling is a sign of cellular injury, not cell shrinkage. The heart will undergo coagulative necrosis, not liquefactive necrosis. Also, protease inactivation by cytoplasmic free calcium is kind of nonsensical to me. Free calcium is more likely to cause cell injury via caspases (a form of proteases amongst other things), which is why calcium is usually bound up inside healthy cells. +