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submitted by sympathetikey(1253),
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onteisH tolaitayenc lwsaol orf rtanlixeoa fo het NDA so atth scirrnipoantt cna ocpedre. llA arstn tnrcoiie aicd cuases eht seoluygcnatr ni MAPL ot uerhtrf eu,artm hwihc esrqieru NAD aorpitnnitrcs / tnrosali.nta

osler_weber_rendu  The questions asks for response to ATRA. Should that not be decreased transcription to treat the cancer? Which makes methyl transferase (aka methylation) the more likely answer +5  
pg32  @osler, no @sympathetikey is correct. ATRA's mechanism in treating APML is to encourage the cells to mature. Maturation would require gene transcription, meaning histone acetylases would be used. +1  
nnp  but ATRA is letting transcription of an abnormal protein ( that is 15:17 translocation) +2  
lowyield  i believe the mechanism of APML is that the compound protein is ineffective at allowing for maturation of the blasts. giving ATRA allows the blasts to circumnavigate this step, relieving the backup +8  

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sit sebt ot ihknt abtuo taitpiryu naemsoad as noe of etrhe bgi n,sptoio cpoiatnrl cgin,eerts CATH gscnei,ert ro HG eisgr.tecn eTh olny ttyuairip mtuor htat escasu rososepotsio nad hertorfee eht mooisrncspe tfureasrc nees ni hte tesuosinq lcuod eb a TACH erngtesic piaityrut aodnmea o:(net darcaoanmmoe utjs nesam atth eth ruomt is g&1tmm0; ni i).sze sarcndeie ATHC aslde to eciasrend osclroti nad feheetrro eseadrecd saotloetibcs yttiaicv en(ob ian)ofomtr = sootsiesoopr

nnp  even prolactin causes reduced bone density +2  
jmangels  I was thinking the same thing about the prolactin, but the weight gain made me lean toward ACTH +2  
jurrutia  Prolactinoma reduces bone density due to suppression of estrogen. However, that wouldn't explain weight gain. +  

submitted by neonem(550),
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heTes ear gtou srcstla.y I osspeup hte tesb ywa ot neieaefdtitrf hits aces rofm ooegsudutp is that hte crysstal rae psarh m&pa; dle-eneheapds dan ont ddo-bar.ihpemhso

sympathetikey  Yep. They tried to throw you off with the picture, but the wording in the stem says its a "photomicrograph" -- not exposed to plane polarized light, where you would see the negative birefringence. +17  
linwanrun1357  Why is NBME so mean to us. Do those mean a lot in clinic? +  
suckitnbme  @linwanrun1357 I highly doubt you would be looking at your own joint fluid aspirates instead of sending it to the lab. +3  
nnp  what those yellow white nodules signify? +  
peqmd  In clinic gout is typically a clinical diagnosis. If you can treat w/ NSAIDs instead of aspirate you would do that. You would aspirate if you are considering septic arthritis so you can get culture. I don't think anyone aspirate for heck of it. +  
lowyield  @nnp, the yellow white nodules are tophus which is a sign of chronic gout, characterized histologically by aggregates of uric acid crystals, can show up as skin nodules most commonly on external ear, olecranon bursa or achilles tendon (pg 467 FA 2020) +  

submitted by beeip(123),
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Yuo anc ese the rodfienoetname ruuecsttr in tsih dm.iagra

lsmarshall  Rectal prolapse through posterior vagina ("rectocele"). +8  
famylife  "When a rectocele becomes large, stool can become trapped within it, making it difficult to have a bowel movement or creating a sensation of incomplete evacuation. Symptoms are usually due to stool trapping, difficulty passing stool, and protrusion of the back of the vagina through the vaginal opening. During bowel movements, women with large, symptomatic rectoceles may describe the need to put their fingers into their vagina and push back toward the rectum to allow the stool to pass (“splinting”). Rectoceles are more common in women who have delivered children vaginally." +15  
usmleuser007  really like the pubic hair.... +3  
nnp  why not spasm of external anal sphincter? +  
vulcania  After looking it up I think that external anal sphincter spasm would be more associated with rectal pain and maybe fecal incontinence. I chose the same answer because I figured if there was a problem with the rectovaginal septum it would have been noted on physical exam... +1  
ajss  I did the same, put sphincter spasm because I thought a rectocele would be found on a physical exam. +  
thisshouldbefree  this is the map ive been looking for +1  
mnunez187  I didn't choose spasm because the stem says there the rectal tone is normal +