Step 1 Complicated Concepts Thread

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TheSeanieB

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ASK AND ANSWER TOUGH QUESTIONS RELATED TO STEP 1.

Starting with me:
physiologic chloride shift - When CO2 diffuses into a RBC, it quickly converts with H2O to H+ and HCO3- so that CO2 will continue to passively diffuse into the RBC. The HCO3- is then excreted into the plasma by a Cl-/HCO3- exchanger. When the RBC enters the pulmonary capillaries, the process reverses. HCO3- is taken up by exchange for a Cl-. It combines with H+ to creates CO2 +H2O. The CO2 then diffuses out of the RBC and ultimately into the alveoli. This process allows for maximal CO2 excretion by a RBC.

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Friends,
needed some help with 2 questions I came across:

#1. 40 year old male presents with easy fatigability, weakness, weight loss, anorexia, and left upper abdomen discomfort. His leukocyte count is 70 X 10^3/ mcl consisting of predominantly PMN's and metamyelocytes. There are occasional basophils, eosinophils, myelocytes and a few blast cells. The platelet count is elevated (>1000 X 10^3/ mcl)

He has:
A. ALL
B. AML
C. CML
D. Multiple Myeloma
E. Reactive thrombocytosis

Let's go step-by-step. Elements of myeloid series are elevated, so a myeloid neoplasm is more likely. Elevated count of more mature elements apart from blast cells make CML a more likely option. However, based solely on the information given above, it wouldn't be possible to choose the type of myeloid neoplasm. Still, the peripheral smear is closer to CML. This diagnosis would also be supported by some clues given in the clinical information: age would most likely preclude ALL, left upper abdomen discomfort is consistent with splenic infarction (massive splenomegaly is seen in CML --> can lead to splenic infarcts). Based on all this, the answer should be CML.

The patient's condition will most likely:
A. Involve lymph node metastasis
B. Precipitate in Renal disease
C. resolve after therapy
D. Terminate in Blast crisis
E. Terminate in DIC

Without treatment, CML progresses into first an accelerated phase, then a blast crisis. So the answer should be choice D.

#2. A 56 year old male undergoes a bilateral orchiectomy after diagnosis of androgen sensitive carcinoma of the prostate. Androgen ablation therapy in this patient is designed to inhibit which of the following mechanisms of cell signaling?

A. Activation of tyrosine kinase activity within androgen receptor
B. Coupling of the transmembrane androgen receptor to G proteins
C. Generation of androgen activated cellular second messengers
D. Stimulation of activity of Ser/Thr kinases within prostate
E. Transcription factor activity of the androgen receptor.

The question basically asks this: "Which type of receptor does testosterone have?" Testosterone is a steroid hormone, so its receptor would be similar to other type of steroid hormone receptors: An intracellular receptor, which, upon the binding of its ligand, would translocate into the nucleus and act as a transcription factor in controlling gene expression. So, the answer should be choice E.
 
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Let's go step-by-step. Elements of myeloid series are elevated, so a myeloid neoplasm is more likely. Elevated count of more mature elements apart from blast cells make CML a more likely option. However, based solely on the information given above, it wouldn't be possible to choose the type of myeloid neoplasm. Still, the peripheral smear is closer to CML. This diagnosis would also be supported by some clues given in the clinical information: age would most likely preclude ALL, left upper abdomen discomfort is consistent with splenic infarction (massive splenomegaly is seen in CML --> can lead to splenic infarcts). Based on all this, the answer should be CML.



Without treatment, CML progresses into first an accelerated phase, then a blast crisis. So the answer should be choice D.



The question basically asks this: "Which type of receptor does testosterone have?" Testosterone is a steroid hormone, so its receptor would be similar to other type of steroid hormone receptors: An intracellular receptor, which, upon the binding of its ligand, would translocate into the nucleus and act as a transcription factor in controlling gene expression. So, the answer should be choice E.

Thank you,

after listening to the goljan heme onc, it made ALOT more sense
 
Let's go step-by-step. Elements of myeloid series are elevated, so a myeloid neoplasm is more likely. Elevated count of more mature elements apart from blast cells make CML a more likely option. However, based solely on the information given above, it wouldn't be possible to choose the type of myeloid neoplasm. Still, the peripheral smear is closer to CML. This diagnosis would also be supported by some clues given in the clinical information: age would most likely preclude ALL, left upper abdomen discomfort is consistent with splenic infarction (massive splenomegaly is seen in CML --> can lead to splenic infarcts). Based on all this, the answer should be CML.



Without treatment, CML progresses into first an accelerated phase, then a blast crisis. So the answer should be choice D.




The question basically asks this: "Which type of receptor does testosterone have?" Testosterone is a steroid hormone, so its receptor would be similar to other type of steroid hormone receptors: An intracellular receptor, which, upon the binding of its ligand, would translocate into the nucleus and act as a transcription factor in controlling gene expression. So, the answer should be choice E.

I was thinking it'd resolve with treatment due to the high efficacy and specificity of imatinib... maybe "resolve" is too powerful of a word. Goes to show how many assumptions we're expected to make. Hopefully on the real deal they'll be more clear.
 
Ok this is kind of dumb, but why does hyperparathyroidism cause increased in alk phos?

Wouldn't an increase in PTH directly act on osteblasts to indirectly activate osteoclasts and so you would have an increase in acid phosphatase?

Maybe you have an increase in both? Thanks for the clarification!
 
Can anyone tell me how hyperglycemia inhibits growth hormone. (e.g. glucose tolerance test)? I don't think it's via insulin.
 
I think it is literally through glucose levels.

Yeah, I thought this related to the cascade of various hormones that get released as serum glucose drops. Glucagon - cortisol - GH - epi, or something like that. Don't remember the glucose #'s, but you when you give fasting glucose, should shut down GH production in physiologically normal adult as glucose comes up.
 
Ok this is kind of dumb, but why does hyperparathyroidism cause increased in alk phos?

Wouldn't an increase in PTH directly act on osteblasts to indirectly activate osteoclasts and so you would have an increase in acid phosphatase?

Maybe you have an increase in both? Thanks for the clarification!

I would guess you have an increase in both. Apparently alkaline phosphotase is needed to pull phosphate into the newly formed bone?

http://pathlabs.rlbuht.nhs.uk/bone_specific_alp.pdf
 
Ok this is kind of dumb, but why does hyperparathyroidism cause increased in alk phos?

Wouldn't an increase in PTH directly act on osteblasts to indirectly activate osteoclasts and so you would have an increase in acid phosphatase?

Maybe you have an increase in both? Thanks for the clarification!

You've got it right: PTH acts directly on osteoblasts, so you'd expect an osteoblastic marker to be elevated. Like tiedyeddog mentioned above, ALP is a marker for osteoblastic activity. It breaks down pyrophosphate (which is an inhibitor of mineralization) and ultimately leads to crystallization of phosphate. In short, osteoblasts perform bone mineralization via ALP. Roughly 50% of total ALP activity in the body comes from osteoblasts.
 
Can anyone tell me how hyperglycemia inhibits growth hormone. (e.g. glucose tolerance test)? I don't think it's via insulin.

Indeed it is not, at least not directly. Blood glucose levels are sensed by the hypothalamus and if they're elevated, somatostatin is secreted from there to act on GH-releasing cells (somatotrophs) in anterior pituitary and inhibit GH secretion. Conversely, low blood glucose levels result in GHRH secretion, which leads to GH secretion.

So is insulin somehow here? Yes it is: Insulin can be used in the testing of pituitary hormone deficiencies. The reason why such methods are needed (instead of just measuring the blood levels of the hormones themselves) is because of the pulsatile secretion pattern. For instance, if you suspect GH deficiency, you may give insulin to cause insulin-induced hypoglycemia, and then collect blood to measure GH levels. If GH levels fail to become elevated, then a diagnosis of GH deficiency may be given.
 
Why do you not get splenomegaly with aplastic anemia, like you do with other disorders causing pancytopenia?
 
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Aplastic anemia is due to damage to bone marrow and its stem cells. So you cant MAKE new RBC and WBC.

I think most of the other disorders that cause Pancytopenia is not due to inability to make the cells but either the cells made are messed up or something is going around killing cells. Blood cells, make a round through the spleen for fitness check. If the macrophages in spleen see anything wrong with cell, the cell gets taken out. Let say normally 1/10 cells are taken out by macrophages, and now due to some problem 7/10 cells have some defect and need to be taken out. This leads to work hypertrophy for the spleen since its doing more work than normal.

Gojan(audio) explained that the symptoms seen in most anemia is based on whether there is intravascular(in blood vessel) hemolysis or extravascular(spleen) hemolysis.
 
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Definitely increased in glycolysis since it is an allosteric stimulator of PFK1

I doubt it is increased in GNG since it is an allosteric inhibitor of FBPase1

Also, insulin activates protein phosphatase 1 which dephosphorylates the PFK2/FBPase2 enzyme --- activating the PFK2 enzyme and stimulating glycolysis

In summary:

Insulin --> PP1 --> PFK2 activity --> more F26BP --> glycolysis
Glucagon --> PKA --> FBPase2 activity --> less F26BP --> gluconeogenesis

In a fasting state, you have glucagon, which increases cAMP and thus PKA, which phosphorylates the PFK2/FBPase2 enzyme --- inactivating PFK2, activating FBPase2 - this breaks down F26BP, those allowing gluconeogenesis to function
 
Definitely increased in glycolysis since it is an allosteric stimulator of PFK1

I doubt it is increased in GNG since it is an allosteric inhibitor of FBPase1

Also, insulin activates protein phosphatase 1 which dephosphorylates the PFK2/FBPase2 enzyme --- activating the PFK2 enzyme and stimulating glycolysis

In summary:

Insulin --> PP1 --> PFK2 activity --> more F26BP --> glycolysis
Glucagon --> PKA --> FBPase2 activity --> less F26BP --> gluconeogenesis

In a fasting state, you have glucagon, which increases cAMP and thus PKA, which phosphorylates the PFK2/FBPase2 enzyme --- inactivating PFK2, activating FBPase2 - this breaks down F26BP, those allowing gluconeogenesis to function

Yeah that's what I thought but I missed a question that steers me another way
 
hmm i might be wrong, even though I just checked with first aid and it seems to confirm what i said... would you mind posting the question?

It's an NBME question and it's why I didn't post it, didn't want to spoil it. I put it under the NBME post, hopefully someone will let me in on it. I'm horrible at biochem and just wanted to make sure I wasn't missing a simple concept.
 
Indeed it is not, at least not directly. Blood glucose levels are sensed by the hypothalamus and if they're elevated, somatostatin is secreted from there to act on GH-releasing cells (somatotrophs) in anterior pituitary and inhibit GH secretion. Conversely, low blood glucose levels result in GHRH secretion, which leads to GH secretion.

So is insulin somehow here? Yes it is: Insulin can be used in the testing of pituitary hormone deficiencies. The reason why such methods are needed (instead of just measuring the blood levels of the hormones themselves) is because of the pulsatile secretion pattern. For instance, if you suspect GH deficiency, you may give insulin to cause insulin-induced hypoglycemia, and then collect blood to measure GH levels. If GH levels fail to become elevated, then a diagnosis of GH deficiency may be given.

jesus, how do you know this stuff? did you write step 1? lol
 
If a vignette describes pain after eating in an elderly individual, is it more likely to be ischemic colitis or a gastric ulcer? Would they have to provide more clues or is one clearly the better answer?
 
jesus, how do you know this stuff? did you write step 1? lol

:)

If a vignette describes pain after eating in an elderly individual, is it more likely to be ischemic colitis or a gastric ulcer? Would they have to provide more clues or is one clearly the better answer?

Indeed, they would provide more clues.

Peptic ulcer: A middle-aged gentleman presents with chronic stomach pain. He describes a dull, gnawing pain in the epigastrium. He gets somewhat relief from OTC antacid tablets. He adds that he recently realized his stools became darker and thicker in consistency. He does not describe nausea, vomiting or weight loss. He has a 40 pack-year history of smoking. Physical examination is non-contributory. Stool guaiac test is positive

Ischemic colitis: An elderly gentlemen presents with acute left-sided stomach pain*. He describes this pain occurring after meals**. He adds that he has attacks of diarrhea with bright red blood mixed with his stools***. Physical examination shows LUQ pain and tenderness****.

* Clue 1: Ischemic colitis typically affect watershed areas --> left sided pain. PUD is epigastric
** Clue 2: Association with meals is more typical for ischemic colitis. PUD may or may not be associated with meals.
*** Clue 3: Hematochezia is more characteristic for ischemic colitis (lower GI bleeding), whereas melena is more typical for PUD (upper GI bleeding)
**** Clue 4: Physical examination is generally normal in PUD (unless complications arise, of course). LUQ tenderness is characteristic of ischemic colitis.

I think it is more important to differentiate between ischemic colitis and acute mesenteric ischemia. AMI can be considered the equivalent of MI/stroke for intestines. It can certainly kill people if not caught. Abdominal pain out of proportion with physical examination is very characteristic of AMI.
 
:)



Indeed, they would provide more clues.

Peptic ulcer: A middle-aged gentleman presents with chronic stomach pain. He describes a dull, gnawing pain in the epigastrium. He gets somewhat relief from OTC antacid tablets. He adds that he recently realized his stools became darker and thicker in consistency. He does not describe nausea, vomiting or weight loss. He has a 40 pack-year history of smoking. Physical examination is non-contributory. Stool guaiac test is positive

Ischemic colitis: An elderly gentlemen presents with acute left-sided stomach pain*. He describes this pain occurring after meals**. He adds that he has attacks of diarrhea with bright red blood mixed with his stools***. Physical examination shows LUQ pain and tenderness****.

* Clue 1: Ischemic colitis typically affect watershed areas --> left sided pain. PUD is epigastric
** Clue 2: Association with meals is more typical for ischemic colitis. PUD may or may not be associated with meals.
*** Clue 3: Hematochezia is more characteristic for ischemic colitis (lower GI bleeding), whereas melena is more typical for PUD (upper GI bleeding)
**** Clue 4: Physical examination is generally normal in PUD (unless complications arise, of course). LUQ tenderness is characteristic of ischemic colitis.

I think it is more important to differentiate between ischemic colitis and acute mesenteric ischemia. AMI can be considered the equivalent of MI/stroke for intestines. It can certainly kill people if not caught. Abdominal pain out of proportion with physical examination is very characteristic of AMI.

If anything you say shows up on my exam, I owe you a beer IRL. Thanks a lot, man.
 
No problem, good luck for tomorrow.

dude you have been making incredibly helpful posts on the step 1 board since last august haha... WHO ARE YOU??

but for real, have you taken step 1 already, just had a long time to study and are really well prepared, whats the deal? lol
 
dude you have been making incredibly helpful posts on the step 1 board since last august haha... WHO ARE YOU??

but for real, have you taken step 1 already, just had a long time to study and are really well prepared, whats the deal? lol

He's the hero SDN deserves... and also the one it needs right now.
 
All of you are very kind. I'm an IMG, I registered here back when I started to have an interest to take USMLE. Unfortunately, work was too busy to study for the exam. Now that I'm done with work, I'm studying full time and hope to take the exam within the next three months.
 
All of you are very kind. I'm an IMG, I registered here back when I started to have an interest to take USMLE. Unfortunately, work was too busy to study for the exam. Now that I'm done with work, I'm studying full time and hope to take the exam within the next three months.

Don't get too greedy man...just go get your 275 tomorrow!


EDIT: Question:

What all do we have to know about HBV (a DNA virus) having a reverse transcriptase?
 
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All of you are very kind. I'm an IMG, I registered here back when I started to have an interest to take USMLE. Unfortunately, work was too busy to study for the exam. Now that I'm done with work, I'm studying full time and hope to take the exam within the next three months.

Now I'm reading all your posts with an English accent (my assumption of anyone international... except Phloston, his posts are Australian). It's very nice.
 
Can someone help me break down/verify the specific structures affected in these three diseases:

1. Friedrich Ataxia
-Dorsal spinocerebellar tract and dorsal column (is this correct?)

2. Vitamin E deficiency
-Dorsal spinocerebellar tract and dorsal column (is this correct?)

3. Subacute Combined Degeneration (B12 def)
-Dorsal column and LCST only. Or spinorecebellar tract too? (is this correct?)

Page 429 of FA 2013 says that all 3 structures are affected by Vit B12 or E deficiency but I don't buy it...
 
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Can someone help me break down/verify the specific structures affected in these three diseases:

1. Friedrich Ataxia
-Dorsal spinocerebellar tract and dorsal column (is this correct?)

2. Vitamin E deficiency
-Dorsal spinocerebellar tract and dorsal column (is this correct?)

3. Subacute Combined Degeneration (B12 def)
-Dorsal column and LCST only. Or spinorecebellar tract too? (is this correct?)

Page 429 of FA 2013 says that all 3 structures are affected by Vit B12 or E deficiency but I don't buy it...

HY Neuroanatomy says that it is all 3 for subacute, and that Friedrich ataxia has the same spinal cord pathology as subacute.

First aid say that Vitamin E def and b12 def have the same pathology.

I'll just assume all 3 have the same lol.
 
HY Neuroanatomy says that it is all 3 for subacute, and that Friedrich ataxia has the same spinal cord pathology as subacute.

First aid say that Vitamin E def and b12 def have the same pathology.

I'll just assume all 3 have the same lol.

I guess I must've seen something different in Uworld that produced some conflict when I read over it again in first aid. thanks for the clarification
 
HY Neuroanatomy says that it is all 3 for subacute, and that Friedrich ataxia has the same spinal cord pathology as subacute.

First aid say that Vitamin E def and b12 def have the same pathology.

I'll just assume all 3 have the same lol.

Yeah, UW said vitamin E deficiency mimics Friedrich's ataxia, so I guess we've come full circle?
 
Dumb molecular bio question

DNA methylation - important for mismatch repair (template strand is methylated) AND cytosine is methylated to decrease transcription

Histone methylation - only to inactivate transcription --- important in Huntingtons

Is the above correct? Thanks!
 
Dumb molecular bio question

DNA methylation - important for mismatch repair (template strand is methylated) AND cytosine is methylated to decrease transcription

Histone methylation - only to inactivate transcription --- important in Huntingtons

Is the above correct? Thanks!

DNA methylation is in line with how I learned it. Histone methylation: on the FA errata, it says it can either activate or repress depending on the context. IDK what that means.
 
Dumb molecular bio question

DNA methylation - important for mismatch repair (template strand is methylated) AND cytosine is methylated to decrease transcription

Histone methylation - only to inactivate transcription --- important in Huntingtons

Is the above correct? Thanks!

Huntington's is DNA methylation. CG rich repeats, so gets muted. I thought.
 
Huntington's is DNA methylation. CG rich repeats, so gets muted. I thought.

you might be thinking of fragile x, which would definitely be dna methylation with CGG repeats.

huntingtons is CAG, so it might not..

or maybe i am wrong, because i originally thought that about huntingtons too, but vaguely remember a uworld question telling me otherwise.. but i might be wrong

UWorld question 840... the answer makes sense given the other choices, but i still don't understand why its histone compared to dna. oh well haha
 
you might be thinking of fragile x, which would definitely be dna methylation with CGG repeats.

huntingtons is CAG, so it might not..

or maybe i am wrong, because i originally thought that about huntingtons too, but vaguely remember a uworld question telling me otherwise.. but i might be wrong

Hmm...


MYXEDEMA!!!!!!
 
All right... collagen synthesis. SO annoying

Preprocollagen = translated chain
Pro alpha collagen = hydroxylated chains
Procollagen = triple helix formation after glycosylation
Tropocollagen = insoluble version after extracellular cleavage
Collagen Fibrils = crosslinked tropocollagen

Is this right??
 
Hmm...


MYXEDEMA!!!!!!

Exactly what I was thinking.

All right... collagen synthesis. SO annoying

---Intracellular/ER---
Preprocollagen = translated chain
Pro alpha collagen = hydroxylated chains (Vitamin C deficiency)
Procollagen = triple helix formation after glycosylation
---Extracellular---
Tropocollagen = insoluble version after extracellular cleavage (defective cleavage in Ehlers-Danlos type III)
Collagen Fibrils = crosslinked tropocollagen (OH-Lys to Lys)

Is this right??

Looks good to me, completed the thought in relation to pathophys.
 
Dumb molecular bio question

DNA methylation - important for mismatch repair (template strand is methylated) AND cytosine is methylated to decrease transcription

Histone methylation - only to inactivate transcription --- important in Huntingtons

Is the above correct? Thanks!

Cytosine methylation = gene silencing. Now, this gene silencing can be physiological (genomic imprinting, X chromosome inactivation in females) or pathological (cancer cells).

Now then, what is the deal with mismatch repair and DNA methylation? This brings us back to the pathogenesis of colorectal carcinoma: As I'm sure everyone knows here, one such pathway is very well defined, which is the APC ---> K-ras --> p53 sequence. As mutations accumulate in the mucosa, adenomas, then carcinomas develop. But this is not the whole story. When researchers went back and investigate, they found out that there are certain types of colorectal cancer which did not follow this sequence. These cancers were found in younger patients, and tend to be right-sided (along with other features). And these cancers typically did not have K-ras or p53 mutations. Further analysis revealed that these tumors showed microsatellite instability.

So what is a "microsatellite" then? Like the name suggests, these are small, repeating sequences of DNA, typically found in non-coding regions of the genome. But the issue with colorectal carcinoma is that those microsatellite regions within the coding or promoter regions become mutated (hence the "instability"). And when they become mutated, they decrease the expression of that gene. One example is BAX: microsatellite gets mutated --> Less BAX expression --> Less apoptosis --> Cancer cells can survive.

Then what makes those microsatellite regions become mutated? That brings us back to mismatch repair: As you know, DNA replication is not perfect and there are plenty of chemical and physical mutagens around us. So when these mismatch errors occur, mismatch repair enzymes such as hMLH1 and hMSH2, as their name suggests, find and repair those mismatches. But, if these enzymes are not present, mismatch errors accumulate and create the mutations mentioned above.

We have now come one step closer to the cause: We know that expression of certain key genes can be decreased because of microsatellite instability, and microsatellite instability can be caused by defects in mismatch repair. Then, what causes those defects in mismatch repair? The reason can be (a) inherited and (b) acquired. The most important inherited cause of mismatch repair defect is Lynch syndrome (HNPCC). These patients have an inherited defect of mismatch repair genes, which creates microsatellite instability, which causes change in gene expression of key enzymes.

Finally, this brings us to (b): Acquired. For reasons not yet clear, some people tend to have epigenetic changes involving these mismatch repair genes. One prominent example is hypermethylation of the promoter regions involved in coding of mismatch repair genes. Because of this, expression of these repair genes get decreased. These promoter regions contain repeating sequences of CpG (CpG islands), so colorectal cancers arising from this initial defect is termed as CpG Island Methylator Phenotype (CIMP) So, whether it is inherited (HNPCC) or acquired (CIMP), decrease in mismatch repair genes result in microsatellite instability, which causes the problems I've mentioned above.

After this long winded discussion, I'll leave it that you're correct in saying that histone methylation is seen in Huntington's. Other epigenetic changes can also be seen involving histones, such as histone acetylation. In fact, there are drugs which target histone deacetylators, such as vorinostat, a drug used in the treatment of cutaneous T-cell lymphoma.
 
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Can someone help me break down/verify the specific structures affected in these three diseases:

1. Friedrich Ataxia
-Dorsal spinocerebellar tract and dorsal column (is this correct?)

2. Vitamin E deficiency
-Dorsal spinocerebellar tract and dorsal column (is this correct?)

3. Subacute Combined Degeneration (B12 def)
-Dorsal column and LCST only. Or spinorecebellar tract too? (is this correct?)

Page 429 of FA 2013 says that all 3 structures are affected by Vit B12 or E deficiency but I don't buy it...

First Aid is correct here: Whether it is vitamin B12 or vitamin E deficiency, or Friedreich ataxia, three tracts are affected (1) Dorsal columns: Loss of vibration, position, proprioception, etc., (2) Spinocerebellar tract: Limb ataxia, and (3) Corticospinal tract: Spastic paralysis (i.e. UMN signs).
 
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