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As emergency medicine (EM) residents prepare for the transition into unsupervised practice, their focus shifts from demonstrating competencies within familiar training environments to anticipating their new roles and responsibilities as attending physicians, often in unfamiliar settings. Using the self-regulated learning framework, we explored how senior EM residents proactively identify goals and enact learning strategies leading up to the transition from residency into unsupervised practice. In this study we used a constructivist grounded theory approach, interviewing EM residents in their final year of training at two residency programs. Using the self-regulated learning framework as a sensitizing concept for analysis, we conducted inductive, line-by-line coding of interview transcripts and grouped codes into categories. Theoretical sufficiency was reached after 12 interviews, with four subsequent interviews producing no divergent or disconfirming examples. We interviewed16 senior residents about their self-regulated learning approaches to preparing for unsupervised practice. Participants identified two types of gaps that they sought to address prior to entering practice: knowledge/skill gaps, and autonomy gaps. We employed specific workplace learning strategies to address each type of gap, which we have termed cherry-picking, case-based hypotheticals, parachuting, and making the call, and reflection on both internal and external sources of feedback to assess the effectiveness of these learning strategies. This study presents participants' identification of gaps in their residency training, their learning strategies, and reflections as cyclical processes of self-regulated learning. In their final months of training EM residents strategically leverage learning strategies to bridge gaps between their self-assessed capabilities and those they anticipate needing to succeed in unsupervised practice. These findings show that trainees have agency in how they use goal setting, strategic actions, and ongoing reflection to prepare themselves for unsupervised practice. Our findings also suggest tailored approaches whereby programs can support learning experiences that foster senior residents' agency when preparing for the challenges of future practice.

Introduction: There is a limited list of emergent spinal cord pathology that must be considered in patients with focal neurological deficits in the emergency department. Identification of these conditions requires a detailed history and neurological exam and may also require advanced testing and imaging. Case Report: Here we present the case of a patient with a rare arteriovenous malformation of the spinal cord vessels causing congestive myelopathy (Foix-Alajouanine syndrome) that presented as a clinical mimic of spinal cord compression. Conclusion: Emergency physicians should be aware of Foix-Alajouanine syndrome, as its workup and management differ from more common pathologies that may present similarly.

Cohesin is a protein complex known for its essential role in chromosome segregation. However, cohesin and associated factors have additional functions in transcription, DNA damage repair, and chromosome condensation. The human cohesinopathy diseases are thought to stem not from defects in chromosome segregation but from gene expression. The role of cohesin in gene expression is not well understood. We used budding yeast strains bearing mutations analogous to the human cohesinopathy disease alleles under control of their native promoter to study gene expression. These mutations do not significantly affect chromosome segregation. Transcriptional profiling reveals that many targets of the transcriptional activator Gcn4 are induced in the eco1-W216G mutant background. The upregulation of Gcn4 was observed in many cohesin mutants, and this observation suggested protein translation was reduced. We demonstrate that the cohesinopathy mutations eco1-W216G and smc1-Q843Δ are associated with defects in ribosome biogenesis and a reduction in the actively translating fraction of ribosomes, eiF2α-phosphorylation, and (35)S-methionine incorporation, all of which indicate a deficit in protein translation. Metabolic labeling shows that the eco1-W216G and smc1-Q843Δ mutants produce less ribosomal RNA, which is expected to constrain ribosome biogenesis. Further analysis shows that the production of rRNA from an individual repeat is reduced while copy number remains unchanged. Similar defects in rRNA production and protein translation are observed in a human Roberts syndrome cell line. In addition, cohesion is defective specifically at the rDNA locus in the eco1-W216G mutant, as has been previously reported for Roberts syndrome. Collectively, our data suggest that cohesin proteins normally facilitate production of ribosomal RNA and protein translation, and this is one way they can influence gene expression. Reduced translational capacity could contribute to the human cohesinopathies.

Background Oxidative stress (OS) is an important factor in brain aging and neurodegenerative diseases. Certain neurons in different brain regions exhibit selective vulnerability to OS. Currently little is known about the underlying mechanisms of this selective neuronal vulnerability. The purpose of this study was to identify endogenous factors that predispose vulnerable neurons to OS by employing genomic and biochemical approaches. Results In this report, using in vitro neuronal cultures, ex vivo organotypic brain slice cultures and acute brain slice preparations, we established that cerebellar granule (CbG) and hippocampal CA1 neurons were significantly more sensitive to OS (induced by paraquat) than cerebral cortical and hippocampal CA3 neurons. To probe for intrinsic differences between in vivo vulnerable (CA1 and CbG) and resistant (CA3 and cerebral cortex) neurons under basal conditions, these neurons were collected by laser capture microdissection from freshly excised brain sections (no OS treatment), and then subjected to oligonucleotide microarray analysis. GeneChip-based transcriptomic analyses revealed that vulnerable neurons had higher expression of genes related to stress and immune response, and lower expression of energy generation and signal transduction genes in comparison with resistant neurons. Subsequent targeted biochemical analyses confirmed the lower energy levels (in the form of ATP) in primary CbG neurons compared with cortical neurons. Conclusion Low energy reserves and high intrinsic stress levels are two underlying factors for neuronal selective vulnerability to OS. These mechanisms can be targeted in the future for the protection of vulnerable neurons.

African house snakes (Lamprophis fuliginosus) were used to compare the metabolic increments associated with reproduction, digestion, and activity both individually and when combined simultaneously. Rates of oxygen consumption (V̇ O2) and carbon dioxide production (V̇ CO2) were measured in adult female (nonreproductive and reproductive) and adult male snakes during rest, digestion, activity while fasting, and postprandial activity. We also compared the endurance time (i.e., time to exhaustion) during activity while fasting and postprandial activity in males and females. For nonreproductive females and males, our results indicate that the metabolic increments of digestion (∼3–6-fold) and activity while fasting (∼6–10-fold) did not interact in an additive fashion; instead, the aerobic scope associated with postprandial activity was 40%–50% lower, and animals reached exhaustion up to 11 min sooner. During reproduction, there was no change in digestive V̇ O2, but aerobic scope for activity while fasting was 30% lower than nonreproductive values. The prioritization pattern of oxygen delivery exhibited by L. fuliginosus during postprandial activity (in both males and females) and for activity while fasting (in reproductive females) was more constrained than predicted (i.e., instead of unchanged V̇ O2, peak values were 30%–40% lower). Overall, our results indicate that L. fuliginosus’s cardiopulmonary system’s capacity for oxygen delivery was not sufficient to maintain the metabolic increments associated with reproduction, digestion, and activity simultaneously without limiting aerobic scope and/or activity performance.

A 52-year-old man without known medical history presented with painful, progressive, bilateral lower extremity edema over a two-week period. An abdominal exam noted a firm left upper quadrant mass. Emergency department (ED) point-of-care ultrasound (POCUS) revealed a hyperechoic, heterogeneous structure in the inferior vena cava that was determined to represent a tumor thrombus extending from a primary renal cell carcinoma. This case demonstrates how POCUS was valuable in rapidly diagnosing this rare cause of lower extremity edema and its usefulness in directing the initial ED management of this patient.

Purpose This paper aims to explore the use of a design process of inquiry that incorporates both deep customer insight (DCI) and traditional market research (TMR) in an ill-defined, complex current market opportunity to generate new business opportunities for firm-based innovation. Design/methodology/approach The paper reports on an empirical research case study conducted within a multi-national insurance agency looking at the shift in mobility in Australia. Data were collected across seven distinct research phases, all of which used TMR and DCI techniques for joint comparison. Findings The findings revealed that TMR and DCI methodologies developed both contradictory and complementary research outcomes. These outcomes saw rise to newly generated novel business model concepts for market entry opportunity from the case study firm. Research limitations/implications The theoretical outcome of this study is the design thinking DCI framework providing guidance on appropriate implementation of research methods to respond to complex market opportunity. Practical implications DCI methods used in conjunction with TMR can provide early stage market opportunity assessment for firms seeking to innovate from a customer perspective. Originality/value This is the first paper to apply a design approach, combining TMR and DCI methods to a complex market opportunity rather than a tangible problem. In addition, it also contributes to the emerging field of DCI methodologies by providing a practical examination of their use in the field.

Introduction: As emergency medicine (EM) residents prepare for the transition into unsupervised practice, their focus shifts from demonstrating competencies within familiar training environments to anticipating their new roles and responsibilities as attending physicians, often in unfamiliar settings. Using the self-regulated learning framework, we explored how senior EM residents proactively identify goals and enact learning strategies leading up to the transition from residency into unsupervised practice. Methods: In this study we used a constructivist grounded theory approach, interviewing EM residents in their final year of training at two residency programs. Using the self-regulated learning framework as a sensitizing concept for analysis, we conducted inductive, line-by-line coding of interview transcripts and grouped codes into categories. Theoretical sufficiency was reached after 12 interviews, with four subsequent interviews producing no divergent or disconfirming examples. Results: We interviewed16 senior residents about their self-regulated learning approaches to preparing for unsupervised practice. Participants identified two types of gaps that they sought to address prior to entering practice: knowledge/skill gaps, and autonomy gaps. We employed specific workplace learning strategies to address each type of gap, which we have termed cherry-picking, case-based hypotheticals, parachuting, and making the call, and reflection on both internal and external sources of feedback to assess the effectiveness of these learning strategies. This study presents participants’ identification of gaps in their residency training, their learning strategies, and reflections as cyclical processes of self-regulated learning. Conclusion: In their final months of training EM residents strategically leverage learning strategies to bridge gaps between their self-assessed capabilities and those they anticipate needing to succeed in unsupervised practice. These findings show that trainees have agency in how they use goal setting, strategic actions, and ongoing reflection to prepare themselves for unsupervised practice. Our findings also suggest tailored approaches whereby programs can support learning experiences that foster senior residents’ agency when preparing for the challenges of future practice.

The topology and geometry of infinite-type surfaces has seen an increase in study over the past decade, which includes an interest in the Teichmüller theory of such surfaces. While the Teichmüller space of a finite-type surface has a natural topology, we can associate several Teichmüller spaces to an infinite-type surface, no two of which are homeomorphic. This is due to the fact that metrics on an infinite-type surface can be very different. We wish to explore how different two metrics can be. In particular, we relate this question to a purely combinatorial one: by considering a certain type of pants decomposition on the surface and a sequence of finite-type subsurfaces that extend from a fixed finite-type subsurface, we give bounds on the growth of the Euler characteristic of the sequence of subsurfaces. We give a linear lower bound and an exponential upper bound on the rate of growth. Moreover, we give a class of surfaces for which these growth rates are tight. Hence in the realm of infinite-type surfaces, a single surface can have wildly different subsurface growth rates.

VISUALLY guided reaching requires complex neural transformations to link visual and proprioceptive inputs with appropriate motor outputs 1,2 . Despite the complexity of these transformations, hand–eye coordination in humans is remarkably flexible, as demonstrated by the ease with which reaching can be adapted to distortions in visual feedback. If subjects attempt to reach to visual targets while wearing displacing prisms, they initially misreach in the direction of visual displacement. Given feedback about their reaching errors, however, they quickly adapt to the visual distortion. This is shown by the gradual resumption of accurate reaching while the prisms remain in place, and by the immediate onset of reaching errors in the opposite direction after the prisms have been removed 3 . Despite an abundance of psy-chophysical data on adaptation to prisms, the functional localization of this form of sensorimotor adaptation is uncertain. Here we use positron emission tomography (PET) to localize changes in regional cerebral blood flow (rCBF) in subjects who performed a prism-adaptation task as well as a task that controlled for the sensory, motor and cognitive conditions of the adaptation experiment. Difference images that reflected the net effects of the adaptation process showed selective activation of posterior parietal cortex contralateral to the reaching limb.