Cultural and Environmental Factors Affecting the Production of \u3cem\u3eDendranthema x grandiflorum\u3c/em\u3e

The purpose of this experiment was to reduce the schedule of cut mum production by decreasing the number weeks of long days and supplementing the flowers with the plant hormone gibberellic acid (GA). GA is a plant hormone which enlarges the cells of the stems and could conceivably affect mum vegetative growth during long days. In this experiment, long days were reduced to 0, 3, 10, 13, 17 and 20. During the long day treatments, different rates of products were applied. Both ProGibb 4% and Fascination were used to look at the effects of the different variations of GA; GA3, GA4, and GA7

Use of a Needs Assessment to Develop a Curriculum for an Internal Medicine Boot Camp for Graduating Medical Students

Transitioning between medical school and internship is stressful with newly increased responsibilities. One way to prepare fourth year medical students for residency is through a boot camp course. Boot camps are more frequently cited in the surgical literature as a way to increase the confidence of students entering surgical internship, but may offer similar benefits to students entering an internal medicine internship. With a 5-point Likert -cale survey, we conducted a needs assessment of fourth-year students entering internal medicine internship, interns, and hospitalist attendings. We asked students about their current comfort level in 23 topics encountered in internal medicine. For interns, we asked them to reflect on their comfort level with each topic at entrance into internship. For attendings, we asked them to rate the importance of each topic. Our results showed that over half of current interns indicated feelings of discomfort with a greater number of topics than did students (16 vs. 6). Interestingly, inpatient and outpatient procedures showed very high levels of discomfort by students and interns though were rated as being unimportant by hospitalist faculty. Using data from our needs assessment, we sought to create a curriculum for graduating medical students entering an internal medicine internship that would address their verbalized needs as well as inferred needs defined by faculty responses. Findings that our fourth-year students reported higher comfort level with topics than internal medicine interns reflecting back on their comfort level may be a result of different medical school preparations, response bias, or recall bias

Anterior Visceral Endoderm Directs Ventral Morphogenesis and Placement of Head and Heart via BMP2 Expression

SummaryIn amniotes, ventral folding morphogenesis achieves gut internalization, linear heart tube formation, ventral body wall closure, and encasement of the fetus in extraembryonic membranes. Impairment of ventral morphogenesis results in human birth defects involving body wall, gut, and heart malformations and in mouse misplacement of head and heart. Absence of knowledge about genetic pathways and cell populations directing ventral folding in mammals has precluded systematic study of cellular mechanisms driving this vital morphogenetic process. We report tissue-specific mouse mutant analyses identifying the bone morphogenetic protein (BMP) pathway as a key regulator of ventral morphogenesis. BMP2 expressed in anterior visceral endoderm (AVE) signals to epiblast derivatives during gastrulation to orchestrate initial stages of ventral morphogenesis, including foregut development and positioning of head and heart. These findings identify unanticipated functions for the AVE in organizing the gastrulating embryo and indicate that visceral endoderm-expressed BMP2 coordinates morphogenetic cell behaviors in multiple epiblast lineages.Video Abstrac

Mock Paging Program in Internal Medicine Boot Camp

Purpose: To provide practice in common mock paging scenarios in internal medicine (IM) with formative feedback. Abstract: Transitioning to residency is a stressful time with increased expectations. One expected skill is answering and triaging pages, by utilizing clinical knowledge, behaviors and attitudes to provide the best care possible. To increase experience, comfort level and critical thinking skills, we created 14 unique IM cases for mock paging through the Southern Illinois University mock paging program. The 14 IM cases encompass common scenarios found on the wards. A panel of invited experts reviewed each case for appropriate responses, including assessments, investigations, management, and communication which aided in creating a rubric of what students should and should not do in each case. During the boot camp course, nurse educators called the students and introduced a case, where the student was expected to ask questions and communicate a plan. Immediate feedback offered by the educators after case completion was followed with weekly compiled feedback to the group. At the end of the boot camp course, a retrospective pre-post survey was given. Results: Our retrospective pre-post survey for our inaugural cohort (2019) showed that prior to our boot camp course students felt low comfort level in answering pages and after the mock paging program, they felt increased comfort level in answering pages. We surveyed them again 4 months into their residency; all surveyed reported increased comfort level during the beginning of residency after participation in our mock paging program. Conclusion: We demonstrated increased comfort level with mock paging and acknowledge retrospective pre-post surveys can be influenced by recall bias. We had a limited sample size given our small inaugural class. Overall, our study supports that students perceive benefit from a mock paging program. Our work would be strengthened by tying this perception to on the job skills

POEMS syndrome; a rare multi-systemic disorder that overlaps common conditions leading to confirmation bias

This case highlights the tendency towards confirmation bias in patients with a new diagnosis of a rare disease, our patient’s signs and symptoms that arose from Scleroderma and its treatment obscured her presentation with POEMS syndrome. POEMS syndrome is a rare cause of low-SAAG ascites Consider POEMS in any patient signs and symptoms of polyneuropathy and monoclonal gammopath

A complete sample of radio sources in the North Ecliptic Cap, selected at 38 MHz -- III. further imaging observations and the photometric properties of the sample

Further imaging observations of a sample of radio sources in the North Ecliptic Cap are presented and a number of new identifications are made. Using redshifts from spectroscopic data presented in a companion paper (Lacy et al.\ 1999b), the photometric properties of the galaxies in the sample are discussed. It is shown that: (1) out to at least z~0.6 radio galaxies are good standard candles irrespective of radio luminosity; (2) for 0.6~<z~<1 a large fraction of the sample have magnitudes and colours consistent with a non-evolving giant elliptical, and (3) at higher redshifts, where the R-band samples the rest-frame UV flux, most objects have less UV luminosity than expected if they form their stellar populations at a constant rate from a high redshift to $z\sim 1$ in unobscured star-forming regions (assuming an Einstein -- de Sitter cosmology). The consequences of these observations are briefly discussed.Comment: 10 pages, 6 figures, accepted by MNRA

Cocaine Intoxication and Thyroid Storm: Similarity in Presentation and Implications for Treatment

Introduction: Cocaine, a widely used sympathomimetic drug, causes thermoregulatory and cardiac manifestations that can mimic a life-threatening thyroid storm. Case: A man presented to the emergency department requesting only cocaine detoxification. He reported symptoms over the last few years including weight loss and diarrhea, which he attributed to ongoing cocaine use. On presentation he had an elevated temperature of 39.4°C and a HR up to 130 beats per minute. Examination revealed the presence of an enlarged, non-tender goiter with bilateral continuous bruits. He was found to have thyrotoxicosis by labs and was treated for a thyroid storm and cocaine intoxication concurrently. The patient was ultimately diagnosed with Graves disease and treated with Iodine-131 therapy. Conclusion: Cocaine use should be considered a possible trigger for thyroid storm. Recognition of thyroid storm is critical because of the necessity for targeted therapy and the significant mortality associated with the condition when untreated.\u2

Long-term Glycemic Control and Dementia Risk in Type 1 Diabetes.

ObjectiveIndividuals with type 1 diabetes have experienced an increase in life expectancy, yet it is unknown what level of glycemic control is ideal for maintaining late-life brain health. We investigated the association of long-term glycemic control with dementia in older individuals with type 1 diabetes.Research design and methodsWe followed 3,433 members of a health care system with type 1 diabetes, aged ≥50 years, from 1996 to 2015. Repeated measurements of hemoglobin A1c (HbA1c), dementia diagnoses, and comorbidities were ascertained from health records. Cox proportional hazards models were fit to evaluate the association of time-varying glycemic exposure with dementia, with adjustment for age, sex, race/ethnicity, baseline health conditions, and frequency of HbA1c measurement.ResultsOver a mean follow-up of 6.3 years, 155 individuals (4.5%) were diagnosed with dementia. Patients with ≥50% of HbA1c measurements at 8-8.9% (64-74 mmol/mol) and ≥9% (≥75 mmol/mol) had 65% and 79% higher risk of dementia, respectively, compared with those with &lt;50% of measurements exposed (HbA1c 8-8.9% adjusted hazard ratio [aHR] 1.65 [95% CI 1.06, 2.57] and HbA1c ≥9% aHR 1.79 [95% CI 1.11, 2.90]). By contrast, patients with ≥50% of HbA1c measurements at 6-6.9% (42-52 mmol/mol) and 7-7.9% (53-63 mmol/mol) had a 45% lower risk of dementia (HbA1c 6-6.9% aHR 0.55 [95% CI 0.34, 0.88] and HbA1c 7-7.9% aHR 0.55 [95% CI 0.37, 0.82]).ConclusionsAmong older patients with type 1 diabetes, those with majority exposure to HbA1c 8-8.9% and ≥9% had increased dementia risk, while those with majority exposure to HbA1c 6-6.9% and 7-7.9% had reduced risk. Currently recommended glycemic targets for older patients with type 1 diabetes are consistent with healthy brain aging

Clinical vignette: Zero in 60 in 48 hours

Cirrhosis is a known cause of thrombocytopenia but it is important to consider other etiologies when the degree of thrombocytopenia is severe, especially in light of impending life-threatening bleeding. One must always maintain a low threshold for additional diagnostic entities when patients present acutely and confirmatory testing reveals profound thrombocytopenia. A 34-year-old man with cirrhosis secondary to Hepatitis C and alcohol abuse presented with persistent bleeding from preexisting oral ulcers and hematuria. Patient denied melena, hematemesis or hematochezia. His past medical history was significant for pancytopenia secondary to cirrhosis, active hepatitis C infection and hypersplenism. He denied any recent change in his medications nor taking any herbal medications or supplements. Vital signs were normal on admission. Physical examination was positive for dried blood on the lips and hepatosplenomegaly. Lab work revealed a platelet count of 0 with chronic leukopenia and anemia. His baseline platelet count is approximately 35,000. Urine analysis indicated gross blood. Coagulation workup was not suggestive of Disseminated Intravascular Coagulation (DIC). Peripheral smear was significant for complete lack of platelets without schistocytes. He was started on daily platelet transfusions with minimal change in his platelet count. A diagnosis of secondary Immune Thrombocytopenic Purpura (ITP) was made and therapy was initiated with intravenous immunoglobulin (IVIG) and dexamethasone. His platelet count failed to improve with worsening hematuria. He also received Rituximab, Romiplostim infusions and high dose methylprednisolone. The patient underwent splenic artery embolization three times. In spite of all efforts he continued to have hematuria and bleeding from intravenous lines with only transient rise in counts. He was taken for laparoscopic splenectomy with a platelet count of 35,000; following which the bleeding subsided and his platelet count improved to 100,000. Patient had a complicated hospital course but was eventually discharged home and currently his platelet counts are within normal limits. This patient appeared to have developed secondary ITP from his active Hepatitis C. Though he had chronic thrombocytopenia from cirrhosis and splenomegaly, it would be unusual to see this degree of platelet drop from these causes alone. ITP is a diagnosis of exclusion and bleeding is usually not proportionate to level of thrombocytopenia as in this patient. This case illustrates the fact that a clinician must have a low threshold for expanding the differential diagnosis of thrombocytopenia, especially diagnoses that are likely to harm the patient such as Thrombotic Thrombocytopenic Purpura, Disseminated Intravascular Coagulation and ITP. This case also demonstrates the challenging nature of managing severe refractory ITP. Splenectomy is the preferred therapy for patients with ITP who are refractory to first-line therapy with glucocorticoids or IVIG and is shown to cause sustained remission in two-thirds of patients

Sex, Diabetes Status and Cognition: Findings from the Study of Longevity in Diabetes

INTRODUCTION: Women comprise two-thirds of people with dementia, making female sex a significant dementia risk factor. Both type 1 diabetes (T1D) and type 2 diabetes (T2D) are known dementia risk factors with an increasing global incidence. Understanding whether subtle sex differences persist in cognitive function prior to dementia in the context of diabetes may help elucidate the magnitude of sex effects on dementia risk. RESEARCH DESIGN AND METHODS: We examined cross-sectional data from the Study of Longevity in Diabetes (SOLID), a prospective cohort study of members of Kaiser Permanente Northern California aged 60 years and older with T1D (n=758), T2D (n=232) and without either T1D or T2D (n=247). We used factor analysis to generate summary scores of cognitive domains and used regression analyses to examine the associations between sex and cognition adjusting for sociodemographic and cardiovascular confounders. RESULTS: We included 1237 participants (630 women and 607 men) with mean age 68 years. By design, the distribution of men and women in T1D, T2D and no diabetes was similar. Women had better cognitive performance than men in global cognition (β=0.21, 95% CI 0.16 to 0.26), language (β=0.08, 95% CI 0.004 to 0.15), executive function (β=0.13, 95% CI 0.05 to 0.20), episodic verbal memory (β=0.68, 95% CI 0.59 to 0.77) and attention (β=0.20, 95% CI 0.11 to 0.28) but not in episodic visual memory (β=0.006, 95% CI -0.07 to 0.09) adjusting for age and education independent of diabetes status. We did not find an interaction between sex and diabetes status for any of the cognitive outcomes. CONCLUSIONS: Women in late mid-life have better cognitive performance than men in many cognitive domains independent of the presence of T1D or T2D. Further work is required to understand whether these differences change over time or in older cohorts and to understand their relationship to subsequent dementia