We would recommend quality over quantity for UW review. Certain weeks will be busier for you depending on when you have exams and other commitments. Aim for a number of questions per day (or per week) that allows you to review each one thoroughly without feeling rushed for time. Also understand that there will be certain days when you won't make qbank progress. You may want to work in a few “OFF” days to account for this. Consistency is also important. You want to feel like you can make steady progress throughout the year without having a wide open schedule, because you will never have a wide open schedule. You may also want to track the questions you complete. The qbank software tracks for you, but you can use a notebook and write down every night you complete a set, including the topic and number of questions. This can help keep you on track and create a system of structure and accountability. I can't comment for sure on what percentage of the material you've learned during 1st year, although 5% seems low. It is important to complete questions in areas you have covered. For example, it is not helpful to do heme questions if you haven't learned heme yet.

Study schedule, First Aid

We would recommend quality over quantity for UW review. Certain weeks will be busier for you depending on when you have exams and other commitments. Aim for a number of questions per day (or per week) that allows you to review each one thoroughly without feeling rushed for time. Also understand that there will be certain days when you won't make qbank progress. You may want to work in a few “OFF” days to account for this. Consistency is also important. You want to feel like you can make steady progress throughout the year without having a wide open schedule, because you will never have a wide open schedule. You may also want to track the questions you complete. The qbank software tracks for you, but you can use a notebook and write down every night you complete a set, including the topic and number of questions. This can help keep you on track and create a system of structure and accountability. I can't comment for sure on what percentage of the material you've learned during 1st year, although 5% seems low. It is important to complete questions in areas you have covered. For example, it is not helpful to do heme questions if you haven't learned heme yet.

Study schedule, First Aid

This newborn patient also has an SBO due to fibrotic strictures suggesting a severe congenital anatomical anomaly. They are vomiting with a distended bowel due to the sbo just like in question 1. Given we suspect a congenital anomaly where the bowel is tied down (and therefore can’t rotate), malrotation would fit both as the cause of the sbo, the age of the patient, and a result of the fibrous banding. So in sum, sbos are significant with vomiting and distension. Meckel's is very benign and usually presents incidentally (as in this question) or with mild melena that would prompt a tech-99 scan in a newborn, but does not BY ITSELF cause an SBO.

Malrotation, Extrinsic compression, Embryologic processes

This newborn patient also has an SBO due to fibrotic strictures suggesting a severe congenital anatomical anomaly. They are vomiting with a distended bowel due to the sbo just like in question 1. Given we suspect a congenital anomaly where the bowel is tied down (and therefore can’t rotate), malrotation would fit both as the cause of the sbo, the age of the patient, and a result of the fibrous banding. So in sum, sbos are significant with vomiting and distension. Meckel's is very benign and usually presents incidentally (as in this question) or with mild melena that would prompt a tech-99 scan in a newborn, but does not BY ITSELF cause an SBO.

Malrotation, Extrinsic compression, Embryologic processes

This patient has an SBO due to foreign body and then has meckles discovered incidentally on surgical exploration. As discussed, a Meckel's is a rather benign entity that causes little more than mild bleeding and an occasional intussusception if it serves as a lead point.  So again, they just happen to see this meckles when digging around in the bowel. The patients vomiting is related to their SBO, which is due to the foreign body, not the incidental Meckel's. The description of the incidental finding is also classic for what a Meckel's is: a band of tissue connecting the small bowel to the umbilicus. The age of the patient is also classic.

Meckel, Laparotomy, Embryological defect

In short yes, absolutely hold off. You’ve taken 2 so you know your baseline. Ideally you have at least 3 exams to take after you’ve fully studied for the exam (gone through UW at least once, preferably twice). The average of those 3 exams in the final 1.5-2 weeks will determine where you really are post studying heading into the exam. Frankly any other scores before you’ve done a meaningful amount of studying and prep are not useful indicators of where you’ll be after appropriate study time.  

Studyperiod, Practicetests, NBME

In short yes, absolutely hold off. You’ve taken 2 so you know your baseline. Ideally you have at least 3 exams to take after you’ve fully studied for the exam (gone through UW at least once, preferably twice). The average of those 3 exams in the final 1.5-2 weeks will determine where you really are post studying heading into the exam. Frankly any other scores before you’ve done a meaningful amount of studying and prep are not useful indicators of where you’ll be after appropriate study time.  

Studyperiod, Practicetests, NBME

At a high level key differences you should look for include: -Malro causes more classic and severe SBO (persistent distention, fullness, pain) whereas meckles does not unless a concomitant intususception has occurred in which case you’ll see colicky pain with less distension given the relapsing remitting course. -Malro will be diagnosed with a barium study and small bowel follow through whereas meckles will show focal uptake on a technicium 99 scan -Meckles can present with isolated blood whereas malro you’d only see blood in a well entrenched SBO, so there’s a disease severity and time course component here that could be in the prompt.

Uworld, Meckel, Malrotation, Diverticulum

Great questions! Moving your test date is something you should do carefully.  In determining where your test date should be you need to assess your current performance, your score goal, and the score 'you can live with'.  The 'you can live with score' is sort of the point below which you would tell yourself that you absolutely would go through all of the difficulty of Step 1 studying again in order to improve. Right now I would probably choose the 7 weeks of studying unless you are within 20 points of your score goal as of say June 1st. This is definitely an estimate. One of the reasons I might choose the later date is that you can, in fact, move up your test date if you are really meeting and exceeding your score goal. It does happen and can be good if you are well ahead of pace.  Burnout is a real thing so waiting too long to take your test after you are ready can be detrimental. I think choosing the later test date also sets you up to get either no benefit (not moving up your score and not going to the US) or a big benefit (feeling good about yourself and moving up your date), rather than the opposite situation where you expect to go to the US but then have to cancel (a total bummer).

Testdate, Studyperiod

The striatum is a nodal structure of the basal ganglia circuits and is one of the brain areas with the highest concentration of markers of cholinergic transmission. Giant aspiny cholinergic interneurons constitute only 1%–3% of the neurons of the striatum but exert a powerful influence on its output, which is mediated by the medium spiny neurons (MSNs). ACh, acting via different receptor subtypes, affects the activity of the MSNs both directly and via modulation of glutamate release from corticostriate terminals and of dopamine release from nigrostriatal terminals. Acetylcholine, via its reciprocal interactions with dopamine (DA), has an important role in the differential modulation of striatal output via the so-called direct and indirect pathways of the basal ganglia circuits. The excitatory M1 and the inhibitory M4 receptors are the main cholinergic receptors in MSNs; both the inhibitory M2/M4 and the excitatory nACRs are expressed in presynaptic glutamatergic and dopaminergic terminals.

Striatum, ACh

Phosphoinositides (PIs) make up only a small fraction of cellular phospholipids, yet they control almost all aspects of a cell's life and death. A wide range of biological processes are regulated by PIs, turning these lipids into one of the most universal signaling entities in eukaryotic cells. PIs control organelle biology by regulating vesicular trafficking, but they also modulate lipid distribution and metabolism via their close relationship with lipid transfer proteins. PIs regulate ion channels, pumps, and transporters and control both endocytic and exocytic processes. As expected from such pleiotropic regulators, derangements of phosphoinositide metabolism are responsible for a number of human diseases ranging from rare genetic disorders to the most common ones such as cancer, obesity, and diabetes. Moreover, it is increasingly evident that a number of infectious agents hijack the PI regulatory systems of host cells for their intracellular movements, replication, and assembly. As a result, PI converting enzymes began to be noticed by pharmaceutical companies as potential therapeutic targets. For Step 1, PI's are primarily relevant in the signaling pathway downstream of Gq receptor, where PIP2 -> IP3 and DAG, leading to smooth muscle contractions.

Phosphoinositides

To summarize, you have max 1000 questions that you'd like to see again and you have about 30 days left. In my opinion, I would try to get through a large chunk of the questions you got wrong and finish up your first pass of UWorld. Try to increase your daily question volume to 90 or 100 per day. I would intersperse the two question types so as to complete this first pass and then leave yourself without 3 weeks to start working through the Q Bank again. Keep in mind that reviewing wrong answers,  and the 2nd pass of the Q Bank, should be faster than the first pass. However don't just super speed through as many questions as possible on the second pass just to say you did them all twice. Quality review is still important, esp on questions where greater than 50% of respondents got the question right. As you approach test day it may be worth decreasing the time on Pathoma and putting more effort into questions and Flashcards.

Tips, Studying, Study schedule, Last month

Yes oxytocin release is the body's natural way of "clamping down" the uterus after birth. You will see pitocin (formulated oxytocin) given almost immediately after given to help speed this along. Baby is also put on the breast to stimulate oxytocin release.  The most common cause of uterine atony is retained products of conception (POCs), and it should be confirmed that all of the placenta has been delivered. Oxytocin is a common drug (and endogenous pituitary hormone) used to both induce uterine contractions during labor and to induce the contraction of the uterus post-partum in cases of uterine atony. Prolactin is a hormone that causes breast milk production endogenously.

NBME 15

The primary cause of lead's toxicity is its interference with a variety of enzymes because it binds to sulfhydryl groups found on many enzymes. Part of lead's toxicity results from its ability to mimic other metals that take part in biological processes, which act as cofactors in many enzymatic reactions, displacing them at the enzymes on which they act. Inhibition of d-ALA dehydrates and ferrochelatase lead to accumulation of d-ALA and protoporphyrin. This inhibits heme synthesis and results in anemia. These precursors may also be directly toxic to neurons. However, lead also acts through other processes to result in neurotoxicity: Lead is able to pass through the endothelial cells at the blood brain barrier because it can substitute for calcium ions and be uptaken by calcium-ATPase pumps. Furthermore, lead also inhibits NMDA receptors.

Protopophryin, Neurotoxicity, Lead poisoning, D-ALA

Nelson and colleagues' early study of children with salmonellosis showed that those who were treated with ampicillin or amoxicillin were more likely to have both prolonged excretion and clinical relapse than were those who were given placebo. Animal studies support the hypothesis that antibiotics do this by suppressing the “protective” effects of endogenous intestinal bacterial flora, which results in recrudescence of the hardy Salmonella species. Many clinicians are not aware that the median duration of fecal shedding of nontyphoidal salmonellae after intestinal infection is ∼1 month in adults and 7 weeks in children <5 years of age.

Salmonellosis, Nontyphoidal, Antibiotics

The most common cause of all granuloma formation worldwide is tuberculosis. The formation of granulomas in tuberculosis is thought to be a physiological reaction to prevent the systemic spread of the causative pathogen, the mycobacterium. is immune response typically results in a caseating granuloma with signs of necrosis. Many other infectious agents can trigger granuloma formation as well as foreign body material such as beryllium, and inherited defects in neutrophil function (chronic granulomatous disease). In chronic inflammatory diseases and primary immunodeficiencies with chronic inflammation, the granulomas have not been associated with specific external agents. With the exception of granulomatosis with polyangiitis, these granulomas are non-caseating and typically observed in patients with sarcoidosis, Crohn's disease and common variable immunodeficiency. Sarcoidosis remains a diagnosis of exclusion.

Tuberculosis, Sarcoidosis, Non-caseating, Granulomas, Auto inflammatory

1. We like starting with topic-based questions for the first pass and then moving to mixed blocks for the second pass.
2. 60% is fine. Focus more on learning from the explanations than percent correct. If you perform poorly on a set of questions, you may want to take longer reviewing the blocks and studying up on topics that caused you difficulty.
3. You should still aim to complete Uworld twice--first by topic and then mixed. Working through a qbank from early in med school is generally a smart move. But we wouldn't necessarily say that counts as a first pass because the work is so spread out. Working through a high volume of topic-focused questions in a relatively short amount of time helps you see the patterns/nuances in that topic and keep it all in your head. Then mixed is helpful because it adds another layer of complexity and difficulty in that it that forces you to switch from topic to topic and identify what is being asked. That mimics the test day experience.

Uworld, Tips, Study schedule, Practice questions

It's natural to feel anxiety when answering these tricky questions with all the high stakes. Here are a few tips to consider:

1. Take practice Uworld sets TIMED and in non-private locations. This extra stress is helpful because it mimics what you might face on the real exam. Even having some ambient nose can be helpful because it makes the process more challenging and that's what you want.
2. To become more confident when you're answering questions, follow a structured question breakdown approach like the 1-2-3-4 step Elite approach that we showed you in one of the lectures. The repetition and consistency build confidence and decrease the chance you'll make doubt yourself and/or make a careless error. An important element of the standardized approach is Step 3 ("summarize the prompt"). Forcing yourself to summarize each prompt is a great exercise for boards and wards. You'll find yourself more confident that you know what you're doing --> you are less likely to change your answer.
3. Generally you want to trust your instincts and avoid changing answers at the last second. While you certainly want to be able to explicitly talk out why you're picking each answer, one of the benefits of doing thousands of practice questions is that your brain starts to recognize the history and laboratory patterns that make up any vignette and almost subconsciously come up with the right answer. Trust your brain! Even if your instincts are occasionally off, remember you don't need to be perfect: as long as you answer enough questions correctly, you can pass the test and even do well.

Tips, Testanxiety