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 +0  visit this page (nbme21#49)
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Can anyone help explain what the other options would entail?

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 +0  visit this page (nbme21#1)
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RIPE: Rifampin, Isoniazid (INH), Pyrazinamide, Ethanbutol.

RIPE treats TB.

Side Effects:

  • Rifampin: Red-orange metabolites. Skin/fluids can become red-orange. 'R'ifampin makes you 'R'ed
  • INH: Drug-induced lupus (DLE), iron accumulation in mitochondria (can lead to sideroblastic anemia), neuritis, and hepatitis. Give B6 for neuritis and SB anemia. INH has 3 letters like DLE
  • Pyrazinamide: Hyperuricemia (gout). pURICinamide
  • Ethanbutol: Effects eyes. Decreased visual acuity, red-green colorblindness. EYEthanbutol
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submitted by kms123(2), visit this page
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How would we rule out antithrombin deficiency?

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sd22  PT, PRT, and TT normal in antithrombin deficiency. FA โ€˜20 pg. 428 +
sd22  PTT* lol autocorrect clearly hasnโ€™t been studying +


submitted by kms123(2), visit this page
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How would we rule out antithrombin deficiency?

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sd22  PT, PRT, and TT normal in antithrombin deficiency. FA โ€˜20 pg. 428 +
sd22  PTT* lol autocorrect clearly hasnโ€™t been studying +


submitted by sakbarh(5), visit this page
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She has many cardiovascular risk factors and likely suffered a stroke of the basilar artery causing locked in syndrome. According to FA this can cause a lesion at the pons, medullar, or lower midbrain -- however anatomically the basilar artery runs right on top of the pons so proximity most likely makes it the right answer.

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mousie  The Boards and Beyond video of SC strokes was really helpful at explaining this if you are a video kind of person! +3
yotsubato  What pushed me away from pons was "dysarthric speech" which implied she still could speak to some degree.... which made me pick medulla. +3
mimi21  I think FA may be misleading. Primarily it will effect the Pons because that is where the majority of the Basilar Artery is located. and I guess it could effect the other locations? but everywhere I have looked Locked-in syndrome is an issue with the Pons. But someone please continue to clarify, cause I was a bit tripped up at first with this question +
cbrodo  Although FA says it can be pons, medulla, or lower midbrain, "locked-in" syndrome generally arises from BL pons lesions. Another way you can rule out medulla and midbrain in this question is the ocular movement findings. Since the patient has impaired horizontal gaze BL, you can conclude that the Abducens nuclei are involved on both sides. The abducens nuclei are located in the pons. +48
gh889  USMLE secrets also states that it is most commonly in the pons Bates states that locked-in syndrome preserves consciousness but these patients have limited speaking ability +1
skonys  I approach all of these by the rule of 4 method with the 4 midline CN nuclei being multiples of 12. CN 3,4,6,12. Midbrain= PCA (3 & 4) Pons = AICA (5,7,8) & Basilar (6) Medulla = PICA (9,10,11) & ASA (12) Dysphagia, hoarseness, and absent gag reflex? Must be CN X therefore PICA stroke therefore Lateral Medulla (Wallenberg) Whole Face Paralysis? Must be CN VII therefore AICA thus Lateral Pontine. +2
fatboyslim  @cbrodo Yes. Also, vertical eye movement is preserved because the vertical gaze center is in the midbrain, while the horizontal gaze center is in the pons. +1
sd22  Locked in syndrome also happens 2/2 to central pontine myelinolysis. Another reminder that, although she has a separate etiology, the location of the lesion is still in the pons. +


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The question stem mentions 3 subsets of patients: a) Some patients were inconsistent with taking medication or "not adherent" to medication regimen b) Some patients discontinued the drug they were randomized to completely c) A subset of these patients in point 'b', who stopped the medication were then prescribe the medication from the comparison group.

The ultimate question however is regarding whether patients under point 'a'(as above) should be included or excluded.

Ideally this depends upon your study protocol. In essence you may have an 'Intention to treat protocol' or an 'Adherent protocol'. As part of an adherent protocol you only include patients or study subjects (as referred to in basic science research) you only include those patients that strictly followed the protocol and exclude everyone else. This is mostly how basic science protocols are designed.

With clinical research however being completely per protocol is difficult and that's where the intention-to-treat protocol apples. This is to accommodate the subjective nature of human subjects in clinical research. Following up with human subjects is but obvious harder than manually handling mice or pigs in the lab. So in such cases as long as the study team has followed protocol in contacting the patient and playing their role all patient data can be included even if there are some minor protocol deviations due to logistical issues. All these deviations need to be reported to the IRB ofcourse and specified in the manuscript in the most appropriate manner.

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handsome  what is IRB? hehe idk lol +
adong  A helpful fact I learned that helped it make sense for me is that the reason you do intention to treat is because it can "approximate/represent" how people will react to following through with treatment in real life. If a treatment that is being tested is a hassle and patients drop out, maybe that would actually occur in the real world and thus it is a very practical tool for these scenarios. +
sd22  I was tripped up by the word "efficacy." Efficacy refers to testing under ideal conditions, which I likened to per-protocol, while effectiveness refers to testing under real-life conditions, which thought was closer to intention-to-treat. Since it said efficacy I thought they were looking for per-protocol, but I guess you just assume they're looking of ITT. +


submitted by water(47), visit this page
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surprisingly, I actually learned this from the Magic School Bus when I was a kid. That's the only reason I got this right. Thanks Ms. Frizzle! :D

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paulkarr  She taught me more than my med school professors did... +6
painintheash5  ahahah i remember that episode! +1
meryen13  I think that cartoon is one of the reasons I'm a medical student! lol +1
sd22  That episode flashed in my head when reading this Q and I thought no way... +


submitted by avicenna(12), visit this page
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This is a good explanation video https://www.youtube.com/watch?v=ScoSEeZJE08

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meja2  Great video! +
sd22  @avicenna great username +


submitted by sugaplum(487), visit this page
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This is ridiculous but I could never keep these straight so meet my family:
Achey grandpa Meynert
Dope cousin VT with a side Ho* (who's names are just initials) SNc
Uncle and aunt Raphe and sara Cousin Gabby always screaming Na-Na-Na
norepi reminds me of the color blue, so locus ceruleus

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paulkarr  LOL. Achey Granpa Meynert. I'm gonna steal this from you. +
abhishek021196  Achey grandpa Meynert = ACh / Basal Nucleus of Meynert Dope Cousin VT = Dopamine / Ventral tegmentum, SNc Uncle and aunt Raphe and Sara = Serotonin / Raphe nuclei(medulla, pons) Cousin Gabby always screaming NA-NA-NA = GABA / Nucleus Accumbens Norepi = Locus ceruleus. +2
llamastep1  Amazing +
mnemonicsfordayz  ACHey GRANDPA MEYNERT TREMBLES in the BASEment; DOPE cousin VT SNaCks DOWNstairs by the kitchen TAP; NANA GABBY ROCKS and ANXIOUSLY cooes...; "NENENENE... NENENENE...NENENE...NENE" to CRYING BLUE-eyed baby ELSIE; aunt SERO and uncle RAPHE DULLY PARK in the DOWNpour. CAPS = relevant info, lowercase = irrelevant. Includes diseases: DOWN, ANXIOUSLY, CRYING, DOWN = anxiety/depression; TREMBLES, TAP, ROCKS, PARK = movement disorder; GRANDPA = Alzheimer's. Note: ELSIE = LC = Locus ceruleus +
mnemonicsfordayz  The extended "NENE" series is just for humor - shorten if you like ;) Also, ANXIOUSLY applies to both NTs in that sentence: GABA and NE. +
castlblack  I use AChoo meynose +1
faus305  I almost didn't even look at this review but then I thought "maybe someone has a cool mnemonic." and would you look at this. +1
chaosawaits  My Cousin Vitty! +1
madamestep  Sister Nora in a blue sweater Also if you've seen the devil wears Prada there's a whole fun scene where Meryl Streep destroys Anne Hathaway for not caring about fashion in her cerulean sweater. So that scene reminds me of how stressed (NE) Anne must be in her cerulean sweater. +
sd22  honestly after this exam i will never be able to take my docs seriously. All i see now are the dumbass mnemonics running through their heads. +


submitted by usmleuser007(464), visit this page
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  1. Cancers of the pelvis, including the prostate, spread to the lumbosacral spine via the vertebral venous plexus (VVP).

    • The VVP communicates with a number of venous networks, including the prostatic venous plexus, which receives the venous supply from the prostate, penis, and bladder.

    • VVP runs up the entire spinal column and connects with the venous supply of the brain via a valveless system (Batsonโ€™s Plexus) which allows for bidirectional flow and regulation of intracranial pressure.This venous connection to the cerebral circulation may help explain the propensity of tumors to metastasize to the brain.

  2. The VVP also communicates with the azygos vein in the chest, which explains in part why breast and lung cancers frequently metastasize to the thoracic spine.

    • Similarly, due to pulmonary venous drainage into the left side of the heart, lung tumors often spread systemically via the arterial system.
  3. Although lymph nodes are the most common sites of metastasis in general, lymphatic spread to the skeletal system is very rare.

  4. The pampiniform plexus receives venous drainage from the testis, epididymis, and ductus deferens and drains into the testicular veins.

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chaosawaits  Okay, maybe I'm an idiot but I thought the main cancers that spread hematogenously were sarcomas, hepatocellular carcinoma, choreocarcinoma, renal cell carcinoma, and follicular carcinoma of the thyroid. +1
kcyanide101  I failed this Q because of this reason. I was rationalizing that it was a carcinoma, hence should be LN.... +
sd22  "God gave [men] all a penis and a brain, but only enough blood to run one at a time." -Robin Williams +
thatmd  uw question #11747 +


submitted by neolidone(2), visit this page
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As an IMG comes from a non-english country, I hate this kind of question :(

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sd22  As a non-IMG coming from an English speaking country, I hate this kind of question. +1


submitted by volcanobuns(1), visit this page
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@frimmy_11 Why would protein break down after only 20 hours? Shouldnโ€™t fat be the major contributor now? Also if protein is being used, then why isnโ€™t valine the choice? Itโ€™s also glucogenic.

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sd22  It's not asking for the major contributor, just which one of the choices contributes anything at all. +


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just as a general question, would there be low levels of 1 25-(OH)2 ?

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sd22  Yes, kidney has 1-alpha hydroxylase which converts 25-HCC to 1,25-HCC. CKD -> low 1-a-OHase activity -> low 1,25-HCC +


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