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 +0  (free120#20)

stress increases cortisol..which decreases IL-2 activity,hence decreasing Th1 production and effects macrophages.





Subcomments ...

The question says they don't responds to antacids THEN asks which you to identify which drug is the most effective at suppressing acid production, NOT what the most effective antacid is. The answer is PPI's.

I will say, however, I was looking for something like octeotride.

drdoom  lucid. nice catch. +1  
maddy1994  WHY not blockage of h2 receptors +1  
krewfoo99  @maddy1994. PPI are more effective than H2 blockers in suppression of gastric acid +  


The most important hints to the question are as follows, with #2 being the most specific:

1) patient reports pain with overhead motion and reports recurrent overhead motion during work. Overhead motion can damage the supraspinatus muscle due to impingement by the acromion.

2) Pain is worst with internal rotation of the shoulder - this is consistent with the findings of the empty-can test, which indicates a supraspinatus injury.

mousie  I was thinking along the lines of overhead motion - damage to the subacromial bursa which is between the acromion and the supraspinatus ... also its the most commonly injured rotator cuff m. so could have guessed this one right +  
sympathetikey  Thanks for the explanation. I was scratching my head as to why this is correct, since supraspinatus only does 15 degrees of abduction, but you make a lot of sense. +1  
charcot_bouchard  IDK WTF i picked Trapezius +7  
ls3076  why would injury to supraspinatus cause weakness with internal rotation though? +5  
targetusmle  yeah coz of that i picked subscapularis +1  
maddy1994  ya the whole question pointed to supraspinatus ...but last line internal rotation made me pick subscapularis +2  
darthskywalker306  I went for Trapezius. That shoulder flexion thing was a big distraction. Silly me. +  


submitted by sajaqua1(227),

MHC I function is integral to cancer suppression. MHC I displays endogenously synthesized proteins and presents them to CD8+ T cells. The failure to display MHC I, or MHC I display of non-self (and by extension cancerous) proteins triggers a cellular immune response, leading to destruction of the cell.

The proteasome is used for the degradation of worn out, senescent, or malformed proteins. As cancer develops, more mutations lead to increased wrong proteins. Only by expression of the proteasome, or its over-expression, can these mutant proteins be degraded fast enough to not be displayed by MHC I and lead to the cell being killed. Bortezomib blocks the proteasome, so the mutant proteins are displayed on the surface, allowing the immune system to recognize and kill pathological cells.

catch-22  Another way to approach it is to think about MHC class I processing. Basically, if you inhibit the proteasome, peptides will not be generated and nothing is available to be loaded onto MHC I (remember MHC I has to be loaded before it's transported to the cell surface). Cells that don't express MHC I get killed by the natural killers. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2214736/ +7  
kai  "In conclusion, we have demonstrated that the proteasome inhibitor bortezomib down-regulates class I and enhances the sensitivity of myeloma to NK cell–mediated lysis" from the conclusion of the NIH paper +3  
maddy1994  another mechanism is by blocking proteosome u even decrease degration of proapoptotic proteins...so it enchances apoptosis(from uworld) +1  


submitted by welpdedelp(77),

It was the only peripheral lung cancer, its also more common in women. Metastasis would have shown multiple lesions

sympathetikey  Also, lung adenocarcinoma is the most common lung cancer overall, most common in women, and most common in non-smokers. I know she smoked in the past, but that's what tipped me off to it. +2  
alexb  Yeah I literally picked SCC bc I knew she'd smoked in the past smh +  
maddy1994  20 years of non smoking history ,she wouldnt be at elevated risk for smoking related carcinoma. +  


submitted by sam1(4),

What about the additional flow through the circumflex?

maddy1994  exactly man i got 4.5 and i thought he asked ventricle and left circumflex should be there so i put 5 ...glad someone thought like me.i was just cursing myself for over thinking. +1  


submitted by welpdedelp(77),

Hemochromatosis, aka "bronze diabetes". Cannot be Addison due to the hyperglycemia and normal BP

alexb  I missed this bc didn't notice it was a middle-aged guy w/ just 3 year hx of Type 1 DM. +1  
tinydoc  I got it mixed up with primary adrenal insufficiency and the acth ⇒ hyperpigmentation. +2  
maddy1994  testicular atrophy &hepatomegaly helped me out to eliminate the options..when i was left with ferritin and saw pigmentation it clicked that it is hemochromatosis +  
krewfoo99  Symptoms of Darkening of skin, liver dysfunction, diabetes, with testicular atrophy will always be hemochromatosis +