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submitted by lsmarshall(415),
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pbSnvyteniroa is eth attger of nasempaoinstt ts(ntuea no)ti;x lsuecm sasmsp are tacsrcicahriet. lOny ohret wanrse uyo gitmh idoscren is lstAnlieahtocreceesy scnei he is a frmaer adn ozrbzduws tfeno yracr us ot eth direospm ..l.nad ubt pmstmyso of a ircigheoncl osmtr aer tneabs.

vshummy  Synaptobrevin is a SNARE protein. Why they couldn’t just give us SNARE I’ll never know. +45  
yotsubato  Cause they're dicks, and they watched sketchy to make sure our buzzwords were removed from the exam +46  
yotsubato  Oh and they read FA and did UW to make sure its not in there either +37  
soph  This toxin binds to the presynaptic membrane of the neuromuscular junction and is internalized and transported retroaxonally to the spinal cord. Enzymatically, tetanus toxin is a zinc metalloprotease that cleaves the protein synaptobrevin, an integral neurovesicle protein involved in membrane fusion. Without membrane fusion, the release of inhibitory neurotransmitters glycine and GABA is blocked. -rx questions! +6  
qfever  So out of curiosity I checked out B) N-Acetylneuraminic acid It's sialic acid typical NBME +2  
alexxxx30  shocked they haven't started calling a "farmworker" a "drudge" <-- word I pulled from thesaurus. +3  
snripper  "You shouldn't memorize buzzwords. You gotta learn how to think." Lemme pick another random ass word that doesn't have anything to do with critical thinking skills and use it instead. +5  
mw126  Just as an FYI, there are multiple "SNARE" Proteins. Syntaxin, SNAP 25, Synaptobrevin (VAMP). From google it looks like Tetanospasmin cleaves Synaptobrevin (VAMP). Botulism toxin has multiple serotypes that target any of the SNARE proteins. +2  
wrongcareer69  Here's one fact I won't forget: Step 1 testwriters are incels +2  
baja_blast  FML +  
j44n  its not an ACH-E inhib because he doesnt have dumbell signs +  
flvent2120  I'm not even mad I got this wrong +  

submitted by drdoom(874),
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tferA eth fcfu is diet, eht sllce adn suiste tiasdl ot teh fcuf lliw ceiunnot nnscimuog TPA (&PATg;P-ADt), btu no fehsr ooldb will be drdileeve to ”rc“lea athw wlil be an gmiuuntaalcc tnauom of PDA dna ohetr leeitso.tbma ADP )o(Asnee=ind is iefslt a yrxpo fo pnnuomstcio dan derisv oloadiavsint fo !rseraiet ovlutin(Eo is sr)ma!t iagsIecnnr dnA/seDnieAPo ni a oalc“l mvtonni”nree si a ilnags to het ybdo ttah a lot fo tnocmopiusn si cringrouc eh;tre ths,u sarreiet dna astlreeori latryanlu tdeila ot nriseace odlob lwof asert dna sew“ep a”ywa iomecbtal rspbcdut.oy

lispectedwumbologist  You're a good man. Thank you. +  
drdoom  So glad it helped! +1  
seagull  very well put, thank you +1  
eosinophil_council  Great! +  
aisel1787  gold. thank you! +  
pediculushumanus  beautiful explanation! +2  
rockodude  this explanation was on par with Dr. Sattar IMO +2  
flvent2120  Just to add on to this: FA2020 pg. 297. CHALK (Calcium, H+, Adenosine, Lactate, K+) is known to vasodilate muscles during exercise as well as regulate sympathetic tone of arteries at rest +  

submitted by rongloz(2),

I think this is much simpler and is testing the understanding of basic path concepts of metaplasia and dysplasia. The question stem says there is bronchiolar metaplasia, and dysplasia is a reversible state of cells caused by longstanding hyperplasia or metaplasia (here in this case the baby presents 1 month later after the initial biopsy)

flvent2120  I got this question wrong myself, but the second I looked at the vignette when reviewing, I noticed metaplasia as a hint toward dysplasia as well +  

submitted by jejunumjedi(30),
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Teh bolod seamr isecdtp effhrunSc uFodn the xceta agemi no the web hitw atnp:onexila


doctorboomboom  Hey thanks for finding the image! Do you know why the answer can’t be Chloroquine resistance? I was b/w that and formation of hypnozoites. +5  
jejunumjedi  I think it's just that Schuffner stippling and hypnozoites are both specific to vivax and ovale species. These species could be chloroquine resistant or sensitive, but if you have Schuffner stippling or hypnozoites, you can definitively say that it's either vivax or ovale. +3  
sherry  Species with hypnozoites is not called chloroquine resistant. Chloroquine-resistant species means trophozoite/schizont cant be killed by chloroquine. We dont have enough info to decide whether the spp in the q is resistant/sensitive. But we do know he moved from Honduras to USA 1 year ago. +3  
soph  UW: in africa most malaria species are resistant to chloroquine. he is from hondruas +4  
randios  Can anyone explain the 1-week history of fever? Ruled out vivax and ovale due to 48 hr cycles. Or did they just throw that in as an unspecific symptom. +1  
dr_ligma  unspecific symptom probably +  
mcm94  how I know that is an infection by vivax/ovale ? if there's nothing that says about tertian fever? +  
medguru2295  While it COULD be Chloroquine resistant, its not likely. This patient is likely infected with Vivax or ovale (not Falciparium) why? 1. Honduras (Falcip would be Africa) 2. Sx 1 year later (Liver form Vivax or OVale) 3. As many mentioned, Schuffer bodies Falciparium tends to be the species resistant to Chloroquine. Typically, Chloroquine is given for Vivax & Ovale (typically with something else- Atovaquone, Dapsone etc) to cover Liver Falciparium (no Liver form) is generally Chloroquine resistant (B) and therefore covered with Atovaquone/Proguanil. You do need 8-14 days of tx after coming for Falcip bc it can remain in the Liver for a few days (just not a dormant hypno form). To cover the "week of fever" question- its re-emergence of her sx. They probably just did not want to say cyclic to make it trickier. +4  
flvent2120  Looks like it's been touched on, but you could answer this solely based on the fact that it's been one year since living in Honduras. While it MAY be chloroquine resistant, it IS dormant. Test taking skills would be to choose the answer you can't argue with +  

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drmohandes  Great explanation, thanks. Does anyone know why this patient is anemic though? Is there some link between hyperparathyroidism and anemia I am missing? +2  
drmohandes  *Patient erythryocytes = 3million/mm3 (normal 3.5 - 5.5) +  
melchior  From googling, it looks like it just happens. One author says that high concentrations of parathyroid hormone downregulate erythropoietin receptors. Regardless, it corrects after parathyroidectomy, showing that parathyroid hormone likely causes it, somehow. +  
flvent2120  So I understand why parathyroid can be the right answer, but why couldn't kidney be correct? This is just my overthinking things, but renal cell carcinoma can present with PTHrp leading to hypercalcemia +  

submitted by bingcentipede(243),

Albuterol, a short-acting beta agonist (SABA) is used for immediate relief in asthmatics by activating the B2 receptor and causing bronchodilation.

flvent2120  Lol, I way overthought that question +  

submitted by cassdawg(1101),

Hormone sensitive lipase (HSL) is the enzyme which degrades triglycerides stored within adipocytes (FA2020 p93). Thus, it makes sense that it is activated in times of fasting and suppressed in the fed state.

Insulin would inhibit HSL, as insulin is a fed state enzyme secreted by the pancreas and would want to trigger storage of triglycerides.

In contrast glucagon is secreted in response to hypoglycemia by the pancreas and will trigger fasted state activation. In terms of the fed/fast state I always think of glucagon and epinephrine kind of like a superhero and their side kick, because they usually work together in the fasting state on similar targets to ensure the body has enough energy (this helps me remember that epinephrine and glucagon are fasting state hormones). Here though is epinephrine's big action away from glucagon, where glucagon has minimal effect and epinephrine has the big action of activating HSL! Glucagon has a minor role and other catecholamines and ACTH can also serve to activate HSL as well.

Another example of the synergistic work of glucagon and epinephrine is in glycogen breakdown (FA2020 p85). Both will trigger cAMP increase and protein kinase A activation which will phosphorylate glycogen phosphporylase and activate it (FAST PHOSPHORYLATE! Hormone sensitive lipase is actually phsophorylated to activate it as well).

FUN FACT: Hormone sensitive lipase actually got its name because it was sensitive to epinephrine!

flapjacks  In Type 1 DM, the glucagon response to hypoglycemia is not functional and these individuals are reliant on the epinephrine-stimulated hepatic glycogenolysis. I recall this by remembering you can administer glucagon to these patients if they're having a hypoglycemic episode. They can respond to it, but they aren't releasing it. +1  
passplease  How did you eliminate thyroxine? As it also plays a role in lipolysis. I was thrown off my the low blood pressure and therefore did not select epinephrine. Why would they still have a low blood pressure? +  
jackie_chan  ^ they have low blood pressure because DKA causes a lot of dehydration (vomiting, diuresis due to osmotically active glucose in urine) so low BP Thyroxine I eliminated because remember that thyroxine is unique in that it functions similar to a steroid hormone and acts in the nucleus to upregulate expression of many genes. I figured hormone-sensitive lipase needs to be activated, not stimulated to upregulate expression, so I thought about EPI and beta-3 stimulation. fuckPeter +  
schep  I figured since he has low BP/dehydrated, his body would try to maintain cardiac output by increasing sympathetic tone (releasing epinephrine). In hypovolemic shock, systemic vascular resistance is up because of this compensation. +  
j44n  also thyroxine works like a steroid hormone meaning it takes a while to cause its effect +  
flvent2120  That'd be cool if it were called "epinephrine sensitive lipase" +  

submitted by seagull(1539),
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tuo of scoiiy,rut ohw yam ploeep ewkn hsit? nodt( be shy ot ysa you did or n?)dtdi

yM epvotyr inoueadtc dn'dti igrnain itsh ni em.

johnthurtjr  I did not +1  
nlkrueger  i did not lol +  
ht3  you're definitely not alone lol +  
yotsubato  no idea +  
yotsubato  And its not in FA, so fuck it IMO +1  
niboonsh  i didnt +  
imnotarobotbut  Nope +  
epr94  did not +  
link981  I guessed it because the names sounded similar :D +14  
d_holles  i did not +  
yb_26  I also guessed because both words start with "glu"))) +27  
impostersyndromel1000  same as person above me. also bc arginine carbamoyl phosphate and nag are all related through urea cycle. +1  
jaxx  Not a clue. This was so random. +  
ls3076  no way +  
hyperfukus  no clue +  
mkreamy  this made me feel a lot better. also, no fucking clue +1  
amirmullick3  My immediate thought after reading this was "why would i know this and how does this make me a better doctor?" +7  
mrglass  Generally speaking Glutamine is often used to aminate things. Think brain nitrogen metabolism. You know that F-6-P isn't an amine, and that Glucosamine is, so Glutamine isn't an unrealistic guess. +4  
djtallahassee  yea, I mature 30k anki cards to see this bs +4  
taediggity  I literally shouted wtf in quiet library at this question. +1  
bend_nbme_over  Lol def didn't know it. Looks like I'm not going to be a competent doctor because I don't know the hexosamine pathway lol +21  
drschmoctor  Is it biochemistry? Then I do not know it. +5  
snoochi95  hell no brother +1  
roro17  I didn’t +  
bodanese  I did not +  
hatethisshit  nope +  
jesusisking  I Ctrl+F'd glucosamine in FA and it's not even there lol +  
batmane  i definitely guessed, for some reason got it down to arginine and glutamine +2  
waterloo  Nope. +  
monique  I did not +  
issamd1221  didnt +  
baja_blast  Narrowed it down to Arginine and Glutamine figuring the Nitrogen would have to come from one of these two but of course I picked the wrong one. Classic. +1  
amy  +1 no idea! +  
mumenrider4ever  Had no idea what glucosamine was +  
feeeeeever  Ahhh yes the classic Glucosamine from fructose 6-phosphate question....Missed this question harder than the Misoprostol missed swing +1  
surfacegomd  no clue +  
schep  no idea. i could only safely eliminate carbamoyl phosphate because that's urea cycle +  
kernicteruscandycorn  NOPE! +  
chediakhigashi  nurp +  
kidokick  just adding in to say, nope. +  
flvent2120  Lol I didn't either. I think this is just critical thinking though. The amine has to come from somewhere. Glutamine/glutamate is known to transfer amines at the least +1  

submitted by bingcentipede(243),

It's a little bit of anatomy, a little bit of knowing what the question wants us to know.

Here's a nice pic of the ureter under the ovary:

Specifically, you want to protect the ureter during surgery. "Bridge over water" kind of applies here, knowing that uterine artery is also being ligated during ovary removal. It's so important for surgeons to be able to differentiate the arteries (which are ok to be sacrificed if you're doing a hysterectomy/oophorectomy) but the ureter must be kept intact.

i_hate_it_here  Isn't the round ligament of the uterus inferior to the ovary? Why would that not want to be preserved as well? +1  
flvent2120  It is inferior, but I think it comes down to what the question is trying to ask. To me I was stuck on that fact as well, but it came down to "what has a significant function and therefore needs to be protected?". The round ligament doesn't have any arteries and whatnot, whereas damaging the ureter has significant consequences. With that, the question seemed to be hinting at "ureter" +