Firecracker

[JackShephard MD]

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med.firecracker.me

New medical education website rooted in an adaptive learning platform. Looks impressive, check it out.

Cheers.

 

[Renaissance Man]

Has the spacing algorithm been working for you all the last 2-3 days? I swear I have rated a few questions 4 or 5 and seen them now back to back to back.

 

[sanj238]

Right, that's essentially how all the steroid hormones work (except T3/T4 and VitA derivatives).. which is what I thought. I guess I'll just memorize it wrong for class then relearn it correctly later when it matters.

Thanks.

No- vitamin A also works this way. My understanding is that only vitamin A and vitamin D use zinc fingers

 

[mcloaf]

Has the spacing algorithm been working for you all the last 2-3 days? I swear I have rated a few questions 4 or 5 and seen them now back to back to back.

No problems here.

 

[Bancrofti]

Has the spacing algorithm been working for you all the last 2-3 days? I swear I have rated a few questions 4 or 5 and seen them now back to back to back.

I've noticed the same. Was thinking that maybe I was just mistaken and I rated it less than a 4 or 5, but now that someone else notices it, maybe I'm not going crazy? It hasn't been a lot, maybe a max of 5 qs/day over the last few days.

 

[001100010010011]

I've seen a few 4/5 rated cards multiple times. I am going to stop flagging new topics and let my question count dwindle down. It's overwhelming right now.

 

[addy]

I've seen a few 4/5 rated cards multiple times. I am going to stop flagging new topics and let my question count dwindle down. It's overwhelming right now.

How much are you getting assigned?

 

[001100010010011]

I was flagging 3-5 cards per day lately, more during break. My question count is at 626 right now. I'm 87.5% banked and hoping to finish the rest by the end of February so I can begin focusing solely on qbanks and shoring up topics I need practice on.

 

[addy]

Holy hell...now I feel like a wimp for feeling irked by being assigned 75+ cards (which happens like 1x per week; generally 30-ish), but I'm only 20% banked, Step 1 in March 2015. When did you start? When's your exam?

 

[mcloaf]

Holy hell...now I feel like a wimp for feeling irked by being assigned 75+ cards (which happens like 1x per week; generally 30-ish), but I'm only 20% banked, Step 1 in March 2015. When did you start? When's your exam?

On a sort of related note, I was talking to a friend the other day about this and trying to figure out what the daily card load would be if you were 100% banked and mastered.

I'm about 25% banked right now and 95% mastered, and if I look out to 4 weeks on my schedule (my daily loads get skewed up by the new cards I'm adding that are 2 and 3) I see around 20 q's/day, which I assume are all the cards that I've rated 4/5. Does mean that if you made it to 100% banked and mastered the daily card load would only be around 80-100 for maintenance? I can get behind that. Maybe this math has been done already by somebody smarter and I missed it. Certainly my numbers aren't precise and could be off if, for example, I happen to have mostly tagged cards with fewer associated concepts so far.

 

[WhizoMD]

On a sort of related note, I was talking to a friend the other day about this and trying to figure out what the daily card load would be if you were 100% banked and mastered.

I'm about 25% banked right now and 95% mastered, and if I look out to 4 weeks on my schedule (my daily loads get skewed up by the new cards I'm adding that are 2 and 3) I see around 20 q's/day, which I assume are all the cards that I've rated 4/5. Does mean that if you made it to 100% banked and mastered the daily card load would only be around 80-100 for maintenance? I can get behind that. Maybe this math has been done already by somebody smarter and I missed it. Certainly my numbers aren't precise and could be off if, for example, I happen to have mostly tagged cards with fewer associated concepts so far.

I'm at 89% Banked/94% Mastered and I average ~350 review questions each day. I've been adjusting things so they don't go beyond my step date in a few months, but even without adjustments I think you'd be well over 80-100/day after reaching 100%

 

[mcloaf]

I'm at 89% Banked/94% Mastered and I average ~350 review questions each day. I've been adjusting things so they don't go beyond my step date in a few months, but even without adjustments I think you'd be well over 80-100/day after reaching 100%

Interesting. I thought my math seemed too good to be true.

 

[Frazier]

I imagine the increase isn't linear partly due to the fact that some topics have a lot more questions than others.

So, say FC only consisted of a total of 6 Topics.

Topic 1: 2 Questions
Topic 2: 4 Questions
Topic 3: 4 Questions
Topic 4: 12 Questions
Topic 5: 24 Questions
Topic 6: 20 questions

If you happen to do Topics 1, 2, and 3 first...you will be 50% banked, and likely have only 1-2 questions assigned each day (if that).

However, once you get it 100% banked and the whole range of Topics down, the daily questions will seem disproportionately higher (i.e. not the 2-4 questions predicted from extrapolation when we were at 50%).

Ignoring my arbitrary numbers, I think you get the idea.

....now back to studying 🙂

 

[Bancrofti]

I'm at 89% Banked/94% Mastered and I average ~350 review questions each day. I've been adjusting things so they don't go beyond my step date in a few months, but even without adjustments I think you'd be well over 80-100/day after reaching 100%

When did you start the program though? I think that plays a major factor.

I remember when I first started banking a decent number of cards consistently and I would have something like 80-100 questions/day and I thought it sucked. Then I heard people say they had way more so I told myself to stop complaining. While I'm comfortably able to get through 150-200 qs/day now, I think if my question load got to 250+, then I'd have to wean off it.

 

[WhizoMD]

When did you start the program though? I think that plays a major factor.

I remember when I first started banking a decent number of cards consistently and I would have something like 80-100 questions/day and I thought it sucked. Then I heard people say they had way more so I told myself to stop complaining. While I'm comfortably able to get through 150-200 qs/day now, I think if my question load got to 250+, then I'd have to wean off it.

I started at the end of May last year and now flag 4 new topics/day. The question load isn't as bad as it looks; since I've been banking steadily, the amount of new material makes up an ever smaller amount of my daily review as time goes by, so the majority of the review questions are things I've seen >10 times at this point.

 

[001100010010011]

I started at the end of May last year and now flag 4 new topics/day. The question load isn't as bad as it looks; since I've been banking steadily, the amount of new material makes up an ever smaller amount of my daily review as time goes by, so the majority of the review questions are things I've seen >10 times at this point.

Do you make sure you really know a topic before you rate it 4/5? I'm under 80% mastered because I keep flagging new cards and have been reluctant to just rate 4's and 5's.

 

[WhizoMD]

Do you make sure you really know a topic before you rate it 4/5? I'm under 80% mastered because I keep flagging new cards and have been reluctant to just rate 4's and 5's.

Short answer: yes

When I was just starting (summer and less other banked things to juggle) I just rated things progressively higher each time I saw them, stopping at 4 for a bit then on to 5.
When classes started up again I banked according to the curriculum and kept all new things at 3 max until the school exam. After the exam I'd rate all of that material 4/5.
Now (a bit ahead of the curriculum), I just rate 4/5 when I'm reasonably confident that I'll remember it in ~10 days.

Apart from a few nagging topics (eg. multi-function thigh muscles ), retention has been ok.

Also, I adjust 5s down to ~31-45 days because I'm not confident in my ability to remember anything after 120 days

 

[ulikedaggers]

No- vitamin A also works this way. My understanding is that only vitamin A and vitamin D use zinc fingers

Hmm thanks for that.. We were told that all of them are zn-fingers. Perhaps maybe they're just keeping it general for now since it isn't a point of emphasis.

 

[Apoplexy__]

Do you make sure you really know a topic before you rate it 4/5? I'm under 80% mastered because I keep flagging new cards and have been reluctant to just rate 4's and 5's.

I did this too. My mastery actually got down to 58%. I got pretty worried about that, until I started UWorld and have been completely reassured. I wouldn't let it scare you.

 

[sanj238]

I did this too. My mastery actually got down to 58%. I got pretty worried about that, until I started UWorld and have been completely reassured. I wouldn't let it scare you.

How are your Uworld averages?

 

[Apoplexy__]

How are your Uworld averages?

I've only done 260 questions so far, but I'm at 78%.

 

[addy]

I'm VERY liberal about rating things 4/5, per advice from this thread earlier in the year

 

[ulikedaggers]

How many topics do you guys flag each day on top of the topic(s) you covered that day in class?

 

[HLxDrummer]

At the start I would flag a few from MS1 but now I can hardly keep up with the stuff we do in class. I just do the number needed to keep my daily load manageable. Maybe 2-4 new topics/day total.

 

[docterspaceman]

Looking at "Tumor suppressors and Associated tumors". Are there any opinions on whether it is important to know the different chromosomes that tumor suppressors are found on?
APC-5q; p16-9p; WT1-11p; Rb and BRCA2-13q, etc.

Seems excessively low-yield (not found in FA, not mentioned in class), but I could totally be missing something. I normally love firecracker, but this card seems questionable to me.

You guys think we can we try to work together to create a list of non-essential cards or particularly low yield cards or questions to flag as "never see again"? For things that are blatantly low-yield (I can't imagine there's that much though).

 

[Bancrofti]

Looking at "Tumor suppressors and Associated tumors". Are there any opinions on whether it is important to know the different chromosomes that tumor suppressors are found on?
APC-5q; p16-9p; WT1-11p; Rb and BRCA2-13q, etc.

Seems excessively low-yield (not found in FA, not mentioned in class), but I could totally be missing something. I normally love firecracker, but this card seems questionable to me.

You guys think we can we try to work together to create a list of non-essential cards or particularly low yield cards or questions to flag as "never see again"? For things that are blatantly low-yield (I can't imagine there's that much though).

I actually didn't even question that when I saw it, thinking it was fairly high yield. I remember having a qbank question dealing with the location of APC gene. The part I thought was low yield IMO was which arm of the chromosome things were on.

 

[001100010010011]

It's a strong clue about which tumor suppressor gene you've lost. It'll come in handy in a question stem.

 

[docterspaceman]

Oh man, you guys are awesome. Thanks for the help!

 

[ulikedaggers]

So today is the first day I'm reading the topic before doing the questions (I usually just flag and then try and answer questions). My question is if I recall something perfectly from the card, but otherwise wouldn't have known the answer (i.e. what spinal level does the SMA start) should I still give it a 5?

It's a strong clue about which tumor suppressor gene you've lost. It'll come in handy in a question stem.

Even if it's low yield, there's no reason to "never show again". If you feel like something is low yield, don't spend more than a minute glancing at it. In the end it won't cost you much time and will be worth it if you remember some random minutiae from a "low yield card" that ends up giving you an exam answer.

 

[Bancrofti]

So today is the first day I'm reading the topic before doing the questions (I usually just flag and then try and answer questions). My question is if I recall something perfectly from the card, but otherwise wouldn't have known the answer (i.e. what spinal level does the SMA start) should I still give it a 5?

I think everything is preference. How much is it going to change your daily load if you're flagging consistently? If you have to go 2 weeks without seeing the question again, will you really remember the answer completely?

Early on in flagging things, at one point I would only rate a question a maximum of 3, unless it was something I knew everything about even before flagging the topic. Now, I don't have as much time to have cards pile up like that, so I rate them a 4 if I remembered it from reading beforehand and again, 5 only if I knew the answer to that question before I even read the card.

 

[001100010010011]

I do the same thing. And I think it's fair to just rate them highly and move on. At the very least, it's comparable to just reading FA.

 

[ulikedaggers]

Thanks for the input guys.

 

[ulikedaggers]

Anyone have a good cell bio source? Firecracker is saying that CyclinA-CDK2 is required for DNA synthesis, but in class we learned that CyclinD and CyclinE are the main ones at the G1 checkpoint.

 

[Apoplexy__]

G1-S transition: CyclinD-CDK4 /CyclinE-CDK2
G2-M transition: CyclinB-CDK1 , with CyclinA-CDK2 formed in S phase that also facilitates the G2-M transition

Source: Robbins 8e, pgs. 285-286

 

[ulikedaggers]

G1-S transition: CyclinD-CDK4 /CyclinE-CDK2
G2-M transition: CyclinB-CDK1 , with CyclinA-CDK2 formed in S phase that also facilitates the G2-M transition

Source: Robbins 8e, pgs. 285-286

Ah I see, thank you. So the problem is just what specific step FC is talking about.

Wait, which Robbins is this? I just looked at my Robbins 8e and page 285 is about hyperlipidemias.

 

[Apoplexy__]

Ah I see, thank you. So the problem is just what specific step FC is talking about.

Wait, which Robbins is this? I just looked at my Robbins 8e and page 285 is about hyperlipidemias.

Yeah. I'd probably just stick with what you remember from class. The ref is from big daddy Robbins.

 

[ulikedaggers]

Yeah. I'd probably just stick with what you remember from class. The ref is from big daddy Robbins.

That's the same Robbins I'm using. Really strange, lol.

 

[Apoplexy__]

That's the same Robbins I'm using. Really strange, lol.

Uhhhh hahaha. Well it's in Ch. 7, Neoplasia.

 

[ulikedaggers]

How does a right-to-left shunt cause RVH in tetralogy of fallot? I thought the RVH was caused by the pulmonary stenosis... And wouldn't right to left shunting decrease the amount of blood in the RV and thus reduce the volume needing to be pumped by the RV?

 

[Isradoc16]

How does a right-to-left shunt cause RVH in tetralogy of fallot? I thought the RVH was caused by the pulmonary stenosis... And wouldn't right to left shunting decrease the amount of blood in the RV and thus reduce the volume needing to be pumped by the RV?

In tetralogy of fallot, you have both a stenotic pulmonary valve AND an overriding aorta. The underlying problem can be thought of as the AP septum forming unevenly, making the pulmonary trunk (PT) too narrow, and the Aorta too wide. Since the septum isn't in the midline, it doesn't join with the muscular part of the ventricular septum, and you have an overriding aorta creating a VSD. This would create a left to right shunt, until eisenmenger's syndrome kicks in.

The RVH would happen because of pulmonic stenosis and the increased blood volume due to the VSD.

I hope that answered your question?




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[ulikedaggers]

In tetralogy of fallot, you have both a stenotic pulmonary valve AND an overriding aorta. The underlying problem can be thought of as the AP septum forming unevenly, making the pulmonary trunk (PT) too narrow, and the Aorta too wide. Since the septum isn't in the midline, it doesn't join with the muscular part of the ventricular septum, and you have an overriding aorta creating a VSD. This would create a left to right shunt, until eisenmenger's syndrome kicks in.

The RVH would happen because of pulmonic stenosis and the increased blood volume due to the VSD.

I hope that answered your question?




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Yeah, it makes sense that the RV would be overburdened if there is a left to right shunt. FC says that there is a right to left shunt though, which is why I am confused.

I haven't had cardio yet (we learned about this briefly in embryo though) so maybe that's the problem. I'm assuming that left-to-right and right-to-left shunts are exactly as they sound (blood going from left to right and vice versa)?

 

[Isradoc16]

Yeah, it makes sense that the RV would be overburdened if there is a left to right shunt. FC says that there is a right to left shunt though, which is why I am confused.

I haven't had cardio yet (we learned about this briefly in embryo though) so maybe that's the problem. I'm assuming that left-to-right and right-to-left shunts are exactly as they sound (blood going from left to right and vice versa)?

Which card is that in? The congenital heart disease card only mentions right to left shunting in the context of a 'tet spell', which, based on their description, is a temporary thing that occurs during crying. I think with Tetralogy, it is generally a L-to-R shunt because of the VSD.

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[ulikedaggers]

It's basic science > embryology > development > embryologic derivatives - ectoderm.

it says (emphasis added)

Tetralogy of Fallot is caused by abnormal migration of neural crest cells into the truncus arteriosus resulting in abnormal spiraling of the AP (aorticopulmonary) septum → AP septum is displaced anteriorly and to the right of where is should be →
1. Aorta is too big—overriding aorta
2. Pulmonary trunk is too small—pulmonic stenosis
3. Membranous ventricular septal defect → right-to-left shunt → cyanosis
4. Right ventricular hypertrophy (boot-shaped heart on chest x-ray)—secondary to the increased workload caused by having to pump an abnormally high blood volume (due to the right-to-left shunt) out through a stenotic pulmonary outflow tract

Everything makes sense except I would have expected a left to right shunt, as you said.

 

[Isradoc16]

It's basic science > embryology > development > embryologic derivatives - ectoderm.

it says (emphasis added)

Everything makes sense except I would have expected a left to right shunt, as you said.

So I think this is an example of firecracker having some poor editing.

According to the cardio card on congenital defects the typical presenting symptom is cyanosis caused by a temporary right to left shunt. The explanation given is that crying increases the pulmonary pressure creating a situation where the pulmonary circulation has higher pressure than the systemic, causing blood to go in the opposite direction, causing cyanosis. The general situation would be left to right though.

I think the embryo card just wrote the presenting symptom with the quick point of why you get that symptom and ignored the actual pathophys.



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[Isradoc16]

Okay, I checked Robbins and I'm all wrong. It IS actually right to left. It all depends on the degree of pulmonary stenosis. In really mild tetralogy, it can be left to right because it would resemble an isolated VSD.

I think the reason it's right to left is just because of the overriding aorta -- the tighter the pulmonary trunk and the more the aorta overrides the septum, the more blood leaving the right ventricle will enter the systemic instead of pulmonary circulation ---> right to left.

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[ulikedaggers]

Okay, I checked Robbins and I'm all wrong. It IS actually right to left. It all depends on the degree of pulmonary stenosis. In really mild tetralogy, it can be left to right because it would resemble an isolated VSD.

I think the reason it's right to left is just because of the overriding aorta -- the tighter the pulmonary trunk and the more the aorta overrides the septum, the more blood leaving the right ventricle will enter the systemic instead of pulmonary circulation ---> right to left.

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Thanks for checking Robbins. I still don't quite understand how the right-to-left shunt contributes to the hypertrophy though. If it's a right-to-left shunt, the RV is getting the same volume of blood it would get in a normal heart. I get that pulmonary stenosis leads to RVhypertrophy, but why does a right to left shunt contribute as well?

For example, if the RV wasn't strong enough to pump systemically, the blood would just collect in the LV and the LV would pump as it normally does. Maybe I just need to accept it for now and wait until I learn about it in cardio...

 

[Isradoc16]

Thanks for checking Robbins. I still don't quite understand how the right-to-left shunt contributes to the hypertrophy though. If it's a right-to-left shunt, the RV is getting the same volume of blood it would get in a normal heart. I get that pulmonary stenosis leads to RVhypertrophy, but why does a right to left shunt contribute as well?

For example, if the RV wasn't strong enough to pump systemically, the blood would just collect in the LV and the LV would pump as it normally does. Maybe I just need to accept it for now and wait until I learn about it in cardio...

The reason would be the same as with an isolated pulmonic stenosis, in both cases the RV has to pump against significantly higher pressures than it would in a normal heart. Pumping against the higher pressure will cause it to hypertrophy. (This is the bottom line)

In a pulmonic stenosis, there isn't an increase in the volume of blood in the right ventricle, just an increase in the required pressure because the opening for outflow is smaller.

In cardio you'll learn about preload vs afterload. You are thinking of increased volume which is an example of increased preload, but both pulmonic stenosis and the overriding aorta (introducing systemic pressures) would increase the afterload.



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[Bancrofti]

I wonder how old the Goljan audio lectures are?

FC says bats are the most common cause of transmission of rabies in the US, but Goljan said skunks are. CDC website doesn't give the #1 cause (that I saw), just the common animals responsible. Wikipedia agrees though, saying almost all domestic cases are due to bat bites.

 

[addy]

It's bats. In practice, even if you think you've been in vaguely the same vicinity as a bat, you'll get a rabies vaccine. IDK about skunks these days (or ever..)

 

[Isradoc16]

I wonder how old the Goljan audio lectures are?

FC says bats are the most common cause of transmission of rabies in the US, but Goljan said skunks are. CDC website doesn't give the #1 cause (that I saw), just the common animals responsible. Wikipedia agrees though, saying almost all domestic cases are due to bat bites.

Funny, I had this exact conversation with someone earlier today

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[Myxedema]

FC says bats are the most common cause of transmission of rabies in the US, but Goljan said skunks are. CDC website doesn't give the #1 cause (that I saw), just the common animals responsible. Wikipedia agrees though, saying almost all domestic cases are due to bat bites.

Harrison's, 18th Ed., Chapter 195, p. 1611: "...North American wildlife reservoirs, including bats, raccoons, skunks, and foxes, have endemic infection, with involvement of one or more rabies virus variants in each species. “Spillover” of rabies to other wildlife species and to domestic animals occurs. Bat rabies virus variants are present in every state except Hawaii and are responsible for most indigenously acquired human rabies cases in the United States. Raccoon rabies is endemic along the entire eastern coast of the United States. Skunk rabies is present in the midwestern states, with another focus in California. Rabies in foxes occurs in Texas, New Mexico, Arizona, and Alaska."