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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)

dartosfascia asks:
Why would you give GMCSF to someone with AML?? Isn't the whole goal of treatment to knock out the granulocytes? I feel like giving someone GMCSF after they were JUST treated for AML is asking for a relapse but what the hell do I know. help answer!
sammyj98 asks:
maybe I overthought this one, but doesn't she have free air in the bottom left? Or is that the bottom of the pleural space... help answer!
pg32 asks:
Can anyone explain why the lipase concentration is so high if there is an issue with LPL in hyperchylomicronemia? help answer!
garima  due to pancreatitis
jinzo asks:
A - nucleus ( with nucleolus inside ) B - mitochondria C - RER ( you can see attached ribosomes ) D - ?? may be lysosomes E - glycogen granules help answer!
rainlad asks:
How do we explain the bruit in this case? Also why isn't it left artery aneurysm? That seems like it would better explain the bruit help answer!
gdupgrant  The bruit is basically just turbulent flow, which is most commonly caused by artery narrowing. I was just reading https://emedicine.medscape.com/article/463015-clinical on renal artery aneurysm and it looks like most of the hypertension is actually related to a pre aneurysm stenosis, so i think stenosis is the "better" answer, esp. since the pt has like every risk factor for stenosis. To be honest I had not ever really thought about RAA for this case because bruit over RA has been drilled into my head as renal artery stenosis, but i apprecaite seeing how this is a super reasonable answer - just the stenosis is "more likely"
rainlad asks:
would we be worried about using G-CSF given that he has acute leukemia? would it stimulate growth of his cancer cells? help answer!
suckitnbme  I think we're assuming that we eradicated the leukemia with the chemo. However at the same time a lot of normal stem cells were also killed off so we give GCSF to help recovery especially since they have an infection.
drbravojose asks:
FA 2019 p156 Does anyone know how to differentiate the picture labeled Trypanosoma brucei and cruzi? help answer!
footballa  This question is likely not important for two reason: They're both Trypansomastigotes, so of course they look almost the same. You can differentiate these two species clinically as they have very little clinical similarity in patient presentation. For these reasons there's little to no reason you would be expected to differentiate these two species by histology alone
readit asks:
Why is is not pseudo aneurysm? "Aortic pseudoaneurysms typically occur as a result of trauma +/- intervention, a considered subset of traumatic aortic injury in the majority of cases. They can be acute or chronic." https://radiopaedia.org/articles/aortic-pseudoaneurysm?lang=us help answer!
readit  *same goes for saccular aneurysm, which also is usually 2/2 trauma
samsam3711  In the question stem there is no indication of trauma so it would be hard to just assume that
almondbreeze  see my comment above for marfan syndrome. might help
ilovemypuppies2295 asks:
What makes this coxsackie virus over Adenovirus? Both cause myocarditis which would be seen on autopsy? Is it just more common to get coxsackie? help answer!
drdoom  the general consensus appears to be that Coxsackie is more common than Adenovirus, but i haven’t come across any papers or textbooks that would agree (they only mention “Coxsackie” and “Adenovirus” as associations with myocarditis)
qfever asks:
Does anyone know what are A, C, D? For C not sure if it's pointing to the ribosomes on RER. (I'm assuming E is glycogen granules based on a comment below!) help answer!
lilyo asks:
Anyone have an idea on how to approach this question? help answer!
gdupgrant  So the thing i think they tried to catch people on was that the SMV Joins with the splenic to become the portal vein and the IMV feeds into the splenic vein. And they want you to know that cecum is midgut, so drained by the SMV. so my approach was automatically eliminate any answer that included IMV or Splenic vein and that left me with only Ileocolic → superior mesenteric → portal → right hepatic branch of the portal
poisonivy asks:
can we consider the overdose as a suicidal attempt? if so... wouldn't she be considered as without decision-making capacity? help answer!
em_goldman  People who are suicidal still have decision-making capacity; it's not equivalent to advanced dementia or other situations where decision making is impaired. Laws vary by state; I know in my state that the maximum time for holding someone against their will is 48 hours unless a court has deemed them incompetent and designated another person as their legal decision maker, including people who are actively suicidal. My understanding of the law as a layperson is that her living will was signed along with people bearing witness to the fact that she was the one who signed it, and it was what she wanted. Ethics aside, it would be almost impossible to prove that she legally initiated a DNR in a state of suicidality that was intense enough to interfere with her decision-making capacity in that moment.
mahitha asks:
Can anyone PLZZ explain how lymes disesa has memory problems and depressed mood? help answer!
drdoom  Chronic inflammation, and the persistent elaboration of cytokines that go along with it, can cause all sorts of unusual and nonspecific problems, including cognitive compromise. (Just imagine how you might feel if you had low-grade fever for, say, a decade.) Patients who have suffered significant cardio- or cerebrovascular “events” report depressed mood following the event. My guess is that the memory problems can be from chronic inflammation or as a result of spirochete vasculitis which, over time, results in a kind of vascular dementia (“multi-infarct”). You see spirochete vasculitis (of the thoracic aorta), as well as vascular dementia, in another famous spirochete, Treponema pallidum, the culprit behind Syphilis.
mrglass asks:
Why would this not be acute transplant rejection leading to ARDS? The creatinine is elevated, and I see any reason why it would be elevated beyond rejection help answer!
sammyj98  I selected the same. I think part of the question wanted us to recognize that the pt was not receiving CMV prophylaxis (hinted that they are getting TMP-SMX but no Gancyclovir) so they're at really high risk for CMV specifically. UpToDate: •Universal prophylaxis with valganciclovir or ganciclovir is typically given to patients at risk for cytomegalovirus (CMV) reactivation (eg, seropositive recipients and those with seropositive donors). The duration of therapy often depends on the type of organ transplanted, the risk status of the patient, and individual institutional practice. Some transplant centers prefer to use a pre-emptive approach (eg, routine CMV viral load monitoring within initiation of treatment when reactivation becomes evident) for specific patient populations. (See 'Cytomegalovirus' above.)
brookly_ asks:
I thought bulimia give rise to metabolic alkalosis ...can someone elaborate ? help answer!
divya asks:
okay but where in the question is it asking whether it's intention to treat or per protocol or as treated??? are we to assume its ITT if they don't mention anything or the part of the question that says "primary analysis" the giveway to ITT?? help answer!
kpjk  I had the same doubt. I think if we were to consider "per protocol" then answer would have to be a mash of options A and B. There is no option that would be right for per protocol
mikay92 asks:
Did anyone else find this question painfully poorly written? I spent so long just trying to figure out what the heck they were asking. It's as if they don't want us to do well... help answer!
drdoom  I don’t think the NBME ever “intends” to write an ambiguous or poorly worded stem. What they want to do is write questions whose response choices are not “blatantly obvious” but which do have a single, “most correct” choice. That’s actually surprisingly difficult! If the correct choice were “obvious”, the test would not be doing a good job assessing anyone’s ability to make subtle judgment calls (an important skill, one might argue, in the morass that is the real world); this is also the reason they eschew “buzzwords”, generally. If a stem has two or more choices that are “equally correct”, the same lapse has occurred: they would be failing to assess the capacity to make subtle judgment calls.
drdoom  All that said, please see this perfect metaphorical description of all Step 1 questions: reddit.com/r/step1/comments/4jegfu/took_step_1_wanted_to_share
blueberrymuffinbabey asks:
I got this one wrong, but based on the ITT perspective others mentioned, maybe the "in their primary analysis" part of the question is a tip off. They'd start with including them in the original groups and then do additional analysis to try and tease out the impact? IDK help answer!
diabetes asks:
how is adrenal medulla has ACH nicotinic receptor which are ligand-gated Na/k channeles ? muscarinic ACH receptors are G-protein-coupled receptors. help answer!
gdupgrant  epinephrine acts on alpha or beta adrenergic receptors which are all G protien receptors. muscarinic receptors are also G coupled but Acetyl choline wasnt an answer choice. In the adrenal medulla the chromaffin cells are kinda like modified post ganglionic neurons and have nicotinic receptors.
diabetes asks:
can somebody explain how energy production by glycolysis increased, since aerobic glycolysis produce 32 net ATP,compare to 2 net ATP through anaerobic glycolysis ? help answer!
diabetes  i think the stem should be "energy production by an anaerobic glycolysis "
blueberrymuffinbabey  yeah that's the bit that tripped me up too. i get that there would be increased glycolysis in general to compensate for lack of TCA function but...the fact that it says "energy production by glycolysis" is kind of misleading/confusing.
medninja asks:
This question sounded like botulism, anybody knows why is tetanus? help answer!
hello36654 asks:
so why is "cessation of fast axonal transport" wrong? Don't myelinated axons, by definition, have fast conductance? So demyelinated axons would have "cessation of fast axonal transport", which is the answer A, right? help answer!
diabetes  i think it slows down ,no cessation .
gdupgrant  Because fast axonal transport refers to the transport of vesicles containing neurotransmitters or some kind of cell product up and down microtubules in the axon. It isn't related to actual electrical signal transduction.
hello36654 asks:
I understand why it's lung now, but I picked thyroid gland because often times thyroid tumors press on the parathyroid sitting above, which causes the parathyroids to secrete more Ca...can someone comment if they've read this too? help answer!
paulkarr  I personally have not read that, but I wouldn't be surprised by that fact. I think with these NBME problems though, if you can get the answer within one "step" that should be your choice. Here you can just go Squamous Cell Carcinoma with a direct action on serum calcium levels (via PTHrP). Thyroid requires a few more steps, (assuming your statement is true) so in the eyes of NBME, it ain't gonna be the right choice. Always follow the "KISS" logic!
yobo13 asks:
Can someone explain why it can't be Crohn's since that would also cause a non AGMA? help answer!
drpatinoire  If she has Crohn, she has already lost a lot of K, HCO3-, then the compensatory system wouldn't let her keep losing electrolytes in her urine.

Recent comments (see more)

... epiglotitties made a comment on nbme20/block4/q#10 (A 65-year-old woman who has a 25-year history of...)
 +1  upvote downvote
submitted by epiglotitties(1)

There is an abnormally decreased function of the hydroxylation of proline because the 2nd stage in collagen synthesis (hydroxylation of specific proline and lysine residues) requires vitamin C. Since this patient has Scurvy (vit. C deficiency), this process is unable to occur.

... donttrustmyanswers made a comment on nbme18/block2/q#8 (39 yo man, polycystic kidney disease)
 +0  upvote downvote
submitted by donttrustmyanswers(0)

Uremia = Metabolic acidosis = Bicarb is low. High respiration = Low Co2; for respiratory compensation.

... donttrustmyanswers made a comment on nbme18/block3/q#9 (35 yo woman with infertility)
 +0  upvote downvote
submitted by donttrustmyanswers(0)

The fallopian tubes should leak contrast because there is a gap between fallopian tubes and ovary. I.e. if there is no spillage, that means there is a blockage = infertility!

... donttrustmyanswers made a comment on nbme18/block3/q#46 (45 yo man for annual health maintenance examination)
 +0  upvote downvote
submitted by donttrustmyanswers(0)

According to UpToDate:

At levels below 886 mg/dL (10.0 mmol/L), the risk of pancreatitis appears to be quite small [76-78]; however, it is reasonable to consider drug therapy at levels of 500 mg/dL (5.6 mmol/L) or above in patients with a prior episode of pancreatitis.

Bonus: They say fenofibrate>gemfibrozil always.

... xlulu made a comment on nbme24/block2/q#32 (A 35-year-old woman undergoes a left oophorectomy...)
 +1  upvote downvote
submitted by xlulu(1)

Ureter courses retroperitoneally, close to gonadal vessels-> at risk of injury during ligation of ovarian vessels. FA 2020 pg 625

... adong made a comment on nbme23/block2/q#3 (A prospective study is done to assess the relative...)
 +0  upvote downvote
submitted by adong(8)

By default you should use intention to treat analysis b/c it's the most conservative.

... adong made a comment on nbme23/block2/q#32 (A 2-year-old girl is brought to the physician...)
 +0  upvote downvote
submitted by adong(8)

You can answer by process of elimination. "Competitive interactions" makes you think stimulatory NT. Cross out GABA and glycine. In the cortex so glutamate. Metabotropic would mean there's second messengers involved and the receptor would not transmit calcium. Hence NMDA.

... hvancampen made a comment on nbme24/block2/q#7 (A 75-year-old man with a 10-year history of...)
 +0  upvote downvote
submitted by hvancampen(0)

According to lumen, "the Bowman’s capsule space exerts hydrostatic pressure of its own that pushes against the glomerulus. Increased Bowman’s capsule hydrostatic pressure will decrease GFR, while decreased Bowman’s capsule hydrostatic pressure will increase GFR.

An example of this is a ureter obstruction to the flow of urine that gradually causes a fluid buildup within the nephrons. An obstruction will increase the Bowman’s capsule hydrostatic pressure and will consequently decrease GFR."

https://courses.lumenlearning.com/boundless-ap/chapter/physiology-of-the-kidneys/