Thursday, February 15, 2024

Best Agility Writer Review by Reyman Cruz

Here is the best Agility Writer Review by Reyman Cruz. 

What is Agility Writer?

Agility Writer is a content writing tool designed to streamline the content creation process for businesses and individuals. It leverages AI technology to assist users in generating high-quality written content, including articles, blog posts, website copy, and more.

Top Features of Agility Writer

  • AI-Powered Writing Assistant: Agility Writer utilizes AI algorithms to provide real-time guidance and suggestions during the writing process. It helps users optimize content for clarity, tone, grammar, and style.
  • Content Generation: The tool offers a variety of templates and frameworks to help users quickly create different types of content, such as SEO-friendly articles, persuasive marketing copy, and engaging social media posts.
  • Content Optimization: Agility Writer analyzes user-generated content and provides recommendations for improving readability, structure, and overall effectiveness. It suggests synonyms, alternative phrases, and potential areas for expansion.
  • Collaboration and Team Management: The tool enables users to collaborate with team members on content projects. It provides options for sharing drafts, assigning tasks, and reviewing feedback.

Benefits of Using Agility Writer

  • Time Savings: Agility Writer's AI-powered assistance can save users a significant amount of time by eliminating the need for lengthy research and editing processes.
  • Improved Quality: The tool helps users produce high-quality content that is grammatically correct, stylistically appropriate, and optimized for SEO.
  • Increased Productivity: By streamlining the content creation process, Agility Writer enables users to create more content in less time, boosting their productivity.
  • Enhanced Consistency: The collaboration features of the tool ensure that all team members are working towards a consistent brand voice and style.

Pricing and Plans

Agility Writer offers a range of pricing plans to suit different needs and budgets. Plans start at $19 per month for the Basic plan, which provides access to the core writing assistant and content generation features. The Premium plan, priced at $49 per month, includes additional features such as advanced content optimization, collaboration tools, and priority support.

Alternatives to Agility Writer

  • Jasper (formerly Jarvis): A popular AI-powered writing tool that offers similar features to Agility Writer.
  • Writersonic: A content writing tool that specializes in generating SEO-optimized and persuasive content.
  • Copy.ai: A writing assistant that offers a wide range of templates and use cases, including content for marketing, social media, and e-commerce.

Conclusion

Agility Writer is a valuable tool for businesses and individuals seeking to enhance their content creation process. Its AI-powered features, content generation capabilities, and collaboration tools can help users save time, improve quality, and increase productivity. While there are alternative options available, Agility Writer's comprehensive feature set and competitive pricing make it a solid choice for a wide range of users.


Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz Reyman Cruz

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Sunday, February 04, 2024

Reynold Aquino: The Water Softener Expert and Plumbing Professional

Reynold Aquino, a highly skilled and experienced plumber, has established himself as a renowned water softener expert. With his extensive knowledge in the plumbing industry and a deep understanding of water treatment systems, he has dedicated his career to providing exceptional services and solutions to his clients.

Unparalleled Expertise in Water Softener Systems:
  • Professional Background: Reynold Aquino possesses a wealth of experience as a licensed plumber, specializing in the installation, repair, and maintenance of water softener systems. His expertise extends to various types of water softeners, including salt-based, potassium-based, and magnetic water softeners.

  • Advanced Training and Certifications: He has undergone rigorous training programs and obtained certifications from leading organizations in the plumbing industry. These certifications demonstrate his proficiency in water treatment technologies, ensuring he stays at the forefront of industry advancements.

  • Problem-Solving Abilities: Reynold Aquino's ability to diagnose water quality issues and identify the most suitable water softener system for his clients' needs sets him apart. He excels at analyzing water conditions, determining the appropriate capacity, and recommending the best course of action to achieve optimal water quality.

Comprehensive Plumbing Services:
  • Repairs and Maintenance: Reynold Aquino offers prompt and efficient repair services for plumbing issues, including leaky faucets, clogged drains, malfunctioning water heaters, and faulty pipes. His expertise enables him to diagnose problems accurately and provide long-lasting solutions.

  • Installation and Upgrades: He specializes in installing new plumbing fixtures, appliances, and water filtration systems. His attention to detail and commitment to quality ensure that each installation is completed to the highest standards.

  • Emergency Services: Reynold Aquino understands the urgency of plumbing emergencies. He is available 24/7 to respond to emergency calls, providing immediate assistance to minimize damage and inconvenience.

Customer-Centric Approach:
  • Personalized Solutions: Reynold Aquino takes a personalized approach to each client's needs. He conducts thorough evaluations of their water quality and plumbing systems to tailor customized solutions that address their specific requirements.

  • Transparent Communication: He is committed to clear and transparent communication throughout the entire process. Reynold Aquino explains complex plumbing issues in a simplified manner, ensuring clients understand the recommended solutions and have all their questions answered.

  • Exceptional Customer Service: Reynold Aquino's dedication to customer satisfaction is evident in his prompt response times, meticulous attention to detail, and willingness to go the extra mile to exceed expectations.

Industry Recognition and Contributions:
  • Awards and Accolades: Reynold Aquino's expertise has been recognized through numerous industry awards and accolades. He has received recognition for his exceptional work, including the "Plumber of the Year" award from the local plumbing association.

  • Educational Initiatives: He is passionate about sharing his knowledge and expertise with the next generation of plumbers. Reynold Aquino conducts regular training sessions and workshops, providing valuable insights and hands-on experience to aspiring plumbers.

  • Community Involvement: Reynold Aquino actively participates in community initiatives and charitable organizations. He donates his time and resources to support causes related to water conservation and improving access to clean water in underserved areas.

Conclusion:

Reynold Aquino stands out as a premier water softener expert and plumbing professional. His dedication to providing exceptional services, coupled with his extensive knowledge, expertise, and customer-centric approach, has earned him a reputation as a trusted and reliable professional in the industry.

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Friday, February 02, 2024

Best Online Jobs for Students: Earning Flexibility and Income Alongside Studies

Juggling studies with part-time work can be challenging, but online jobs offer students a unique advantage: flexibility. Whether you're seeking a steady income stream or occasional cash injections, numerous online opportunities cater to diverse skills and interests. You can read more in this Linkedin post.

High-Demand Online Jobs for Students:

  • Content Creation:

    • Freelance Writing: Craft compelling articles, blog posts, website copy, or social media content for businesses and individuals. Platforms like Upwork, Fiverr, and Contently connect writers with clients. Earning potential: Varies depending on experience, niche, and project scope. Some writers earn $0.10 per word, while others command $1 or more.
    • Video Editing: Edit and polish video content for YouTube channels, social media ads, or explainer videos. Utilize editing software like Adobe Premiere Pro or Final Cut Pro. Earning potential: $15-$50 per hour, depending on experience and project complexity.
    • Graphic Design: Create visual content like logos, illustrations, social media graphics, or website layouts using design software like Adobe Photoshop or Canva. Earning potential: $20-$75 per hour, depending on experience and project scope.
  • Online Tutoring: Share your knowledge and expertise by tutoring students online in various subjects. Platforms like Chegg, TutorMe, and Skooli connect tutors with students. Earning potential: $15-$50 per hour, depending on subject, experience, and platform.

  • Virtual Assistance: Provide administrative, technical, or creative assistance to clients remotely. Tasks may include email management, scheduling appointments, data entry, or social media management. Earning potential: $10-$30 per hour, depending on experience and task complexity.

  • Social Media Management: Manage social media accounts for businesses or individuals, including content creation, community engagement, and advertising. Earning potential: $15-$50 per hour, depending on experience, account size, and engagement metrics.

  • Data Entry: Input data into spreadsheets or databases from scanned documents, handwritten forms, or audio recordings. Earning potential: $8-$15 per hour, depending on accuracy and speed.

Additional Online Opportunities:

  • Website Testing: Provide feedback on website usability and functionality by participating in user testing sessions. Earning potential: $10-$20 per session, depending on platform and test duration.
  • Online Surveys: Share your opinions and complete surveys on various topics to earn rewards or cash. Earning potential: Varies depending on the platform and survey length, typically $0.50-$5 per survey.
  • Transcription: Transcribe audio or video recordings into written text. Requires good listening skills and typing accuracy. Earning potential: $10-$20 per hour, depending on experience and audio quality.

Choosing the Right Online Job:

Consider your skills, interests, available time, and desired income level when selecting an online job. Research different platforms, compare earning potential, and read reviews to find opportunities that align with your goals. Remember, building a strong online presence and portfolio can enhance your credibility and attract better clients or projects.

Remember:

  • Time Management: Online jobs offer flexibility, but managing your time effectively is crucial to balance work and studies. Set clear schedules, communicate deadlines clearly, and avoid multitasking to optimize productivity.
  • Legitimacy: Be cautious of scams disguised as online job opportunities. Research companies and platforms thoroughly before investing time or money.
  • Taxes: Report your income from online jobs to the relevant authorities to comply with tax regulations.

By exploring these diverse online opportunities and approaching them strategically, students can successfully earn income while gaining valuable skills and experience, all while maintaining academic focus.

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Understanding Water Softeners for Well Water

Having well water comes with its own set of unique challenges, one of which is hard water. Hard water contains high levels of dissolved minerals like calcium and magnesium, which can cause a variety of problems in your home, from mineral buildup in pipes and appliances to dry skin and hair. Water softeners are specifically designed to address these issues by removing hardness minerals from your water supply.

Do I Need a Water Softener for My Well Water?

Whether or not you need a water softener for your well water depends on several factors, including:

  • The hardness level of your water: You can get your water tested by a professional or use a home test kit to determine the hardness level. Generally, water with a hardness level above 7 grains per gallon (gpg) is considered hard and can benefit from softening.
  • The problems you're experiencing: If you're noticing mineral buildup, soap scum, or other issues associated with hard water, then a softener can help.
  • Your personal preferences: Some people simply prefer the feel of soft water for showering, washing dishes, and other tasks.

Types of Water Softeners for Well Water

There are two main types of water softeners for well water:

  • Salt-based softeners: These are the most common type and use ion exchange to remove hardness minerals. They require regular regeneration with salt, which can be a maintenance burden for some users.
  • Salt-free softeners: These use various technologies, such as template-assisted crystallization (TAC) or magnetic fields, to reduce hardness. They don't require salt but may be less effective than salt-based softeners in some cases.

Choosing the Right Water Softener for Your Needs:

When choosing a water softener for your well water, consider the following factors:

  • Your water hardness level: This will determine the size and capacity of the softener you need.
  • Your water flow rate: Make sure the softener can handle the amount of water your home uses.
  • Your budget: Salt-based softeners are generally less expensive than salt-free models, but you'll need to factor in the cost of salt.
  • Your maintenance preferences: If you're not interested in regular maintenance, a salt-free softener may be a better option.

Additional Considerations for Well Water:

  • Iron and other contaminants: If your well water contains iron or other contaminants, you may need a combination water treatment system that includes a softener and an additional filter.
  • Professional installation: It's generally recommended to have a professional install your water softener to ensure it's properly sized and connected.

Benefits of Using a Water Softener for Well Water

  • Reduces mineral buildup: This can prevent damage to pipes, appliances, and fixtures.
  • Improves soap and detergent performance: Soft water allows soap and detergent to lather better, so you can use less and get better cleaning results.
  • Softer skin and hair: Soft water can help reduce dryness and irritation.
  • Longer lifespan for appliances: Soft water can help extend the life of your washing machine, dishwasher, and other water-using appliances.

Conclusion:

Water softeners can be a valuable investment for homeowners with well water. By considering your specific needs and water quality, you can choose the right softener to enjoy the benefits of soft water throughout your home.

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Sunday, January 28, 2024

Water Softener for Well Water: A Comprehensive Guide

What is a Water Softener and How Does it Work?

A water softener is a device that removes hardness from water, typically by exchanging calcium and magnesium ions for sodium ions. This process, known as ion exchange, occurs within a resin bed, which is composed of small, porous beads made of a material called ion-exchange resin.

Why is a Water Softener Needed for Well Water?

Well water often contains high levels of dissolved minerals, including calcium and magnesium, which cause hardness. Hard water can create several problems, such as:

  1. Scale Buildup: Hard water can cause scale buildup in pipes, appliances, and fixtures, reducing their efficiency and lifespan.
  2. Soap Scum: Hard water can make it difficult to create a lather with soap, resulting in soap scum buildup on surfaces.
  3. Dry Skin and Hair: Hard water can strip away natural oils from skin and hair, leading to dryness and irritation.
  4. Reduced Detergent Effectiveness: Hard water can reduce the effectiveness of detergents, making it harder to clean clothes and dishes.
How to Choose the Right Water Softener for Well Water:
  1. Water Hardness Level: The first step in choosing a water softener is to determine the hardness level of your well water. There are several ways to do this, including purchasing a water test kit or sending a sample of your water to a laboratory for analysis.
  2. Flow Rate: Consider the flow rate of your well water system when selecting a water softener. The flow rate is measured in gallons per minute (GPM) and determines the size of the water softener you need.
  3. Grain Capacity: The grain capacity of a water softener refers to its ability to remove hardness from water. The grain capacity is measured in kilograins (KGR) and determines how much hardness the water softener can remove before it needs to be regenerated.
  4. Type of Water Softener: There are two main types of water softeners: salt-based and salt-free. Salt-based water softeners use a process called ion exchange to remove hardness from water, while salt-free water softeners use a different process, such as template-assisted crystallization.
  5. Brand and Reputation: Consider the brand and reputation of the water softener manufacturer when making a purchase. Look for brands that are known for their quality, reliability, and customer service.
How to Install and Maintain a Water Softener for Well Water:
  1. Proper Installation: It is important to have a water softener installed by a qualified professional. Improper installation can lead to leaks, damage to the water softener, or ineffective water softening.
  2. Regular Regeneration: Water softeners need to be regenerated regularly to maintain their effectiveness. The frequency of regeneration depends on the hardness of your water and the size of the water softener.
  3. Salt Replenishment: Salt-based water softeners require regular replenishment of the salt supply. The frequency of replenishment depends on the hardness of your water and the size of the water softener.
  4. Maintenance: Water softeners should be inspected and maintained regularly to ensure proper operation and longevity. This may include cleaning the resin bed, checking for leaks, and replacing any worn or damaged parts.
Benefits of Using a Water Softener for Well Water:
  1. Improved Water Quality: Treated water has a reduced mineral content, improving the taste, smell, and appearance of the water.
  2. Reduced Scale Buildup: This can save you money by extending the lifespan of your appliances.
  3. Softer Skin and Hair: Softened water can help to improve the health of your skin and hair.
  4. More Effective Laundry and Dishwashing: Softened water can improve the performance of detergents and soaps.
  5. Increased Energy Efficiency: Softened water can help to improve the efficiency of water heaters and other appliances that use water.
Conclusion:

A water softener can be a valuable investment for well water users, providing numerous benefits and improving overall water quality. By choosing the right water softener and properly installing and maintaining it, you can enjoy the advantages of softened water throughout your home.

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Friday, October 27, 2023

Collaboration request

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Sunday, April 23, 2023

Pearls Orthostatic tremor

Occurs in legs on standing
truncal and abdominal involvement are rare

may be enhanced by palpation  "thrill"
auscultation (continuous thumping" helicopter sign
surface emg - helicopter sign
high frequency 13-18 hz very characteristic on emg especially surface EMG

primary v secondary (orthostatic tremor +)

Sunday, July 31, 2022

Pearls cavernous malformation

Diagnose with mri coupled with genetic testing

Most prevalent gene iskrit1/ccm1 esp among Hispanics

18 Japanese had mgc4607/ccm2 

Look for extra cns involvement esp eye ( retina) and cutaneous vascular malformations

Two Chinese families had ccm1 and mgc460/ccn2

Wednesday, July 13, 2022

Movementis

The 2022 International Conference

on

MOVEMENT and COGNITION

Sorbonne

PARIS

31.8.2022 – 2.9.2022

 

For Registration, Abstracts submission or questions:

www.movementis.com

or

Contacts: office@movementis.com

 

Unsubscribe me from this mailing list

Monday, March 21, 2022

essential tremor devices

1.  Pen Again

2. CALA

Tuesday, April 30, 2019

distal branches of ICA

branches

meningohypophyseal trunk
inferior hypophyseal artery

supraclinoid segment
 c4
ophthalmic artery
superior hypophyseal a
posterior communicating
anterior choroidal

HEPARIN INDUCED THROMBOCYTOPENIA (HIT)

Antibodies v. factor 4 platelets complexes
10 x more common with heparin than with LMWH
20-50 percent get arterial or venous thrombosis
platelet count is less than fifty percent normal
may use a direct thrombin inhibitor eg. argabotran

basic science notes
heparin and LMWH are indirect thrombin inhibitors as they do not act on fibrin bound thrombin.  By contrast, the direct inhibitors (hirudin, argabotran, bivalirudin) inactivate fibrin bound thrombin.

At an injury site, F VIIa (extrinsic pathway) and tissue factor are activated.  Thrombus propagates when F IXa binds to cofactor VIIIa (intrinsic pathway) and forms a complex that binds F X.  Xa binds Va to form prothrombinase that converts prothrombin to thrombin.  XI promotes Xa, final step is conversion of fibrinogen to fibrin

Statins on vessels basic science

Increase synthesis, decrease degradation of LDL receptors on heptatocytes
-LFT's increase in one percent
- tissue factor is PRO coagulant in enthothelial surface as is Va, F VIII
-heparin and prostacyclin are anticoagulants in endothelium, also NO, enodog tpa, heparin like substance

Wednesday, April 24, 2019

RE: pfo Studies


I have included 2 articles :

 

Transcranial Doppler to detect righttoleft shunt in cryptogenic acute ischemic stroke



I include this for your review because it is 2019,  because all the patients were done brachial, and because the references are very well done.  It does not address the femoral route


Sensitivity of brachial versus femoral vein injection of agitated saline to detect righttoleft shunts with Transcranial Doppler

First published: 09 January 2014
Cited by: 4
Conflict of interest: Nothing to report.

Abstract

Background

Transcranial Doppler (TCD) can detect a righttoleft shunt (RLS) with high sensitivity but has a 5% chance of a false negative study. TCD is usually performed with injection of agitated saline into an arm vein. We compared the sensitivity of TCD performed from the brachial versus femoral veins.

Methods

Patients presenting to the cardiac catheterization laboratory for percutaneous closure of a patent foramen ovale (PFO) were enrolled. Power Mmode Transcranial Doppler (Terumo 150 PMD) was conducted. After injection of a mixture of 8 cc of agitated saline, 0.5 cc of air, and 1 cc of blood into the brachial vein, embolic tracks were counted over the middle cerebral arteries. The degree of RLS was evaluated by TCD at rest, and with Valsalva at 40 mmHg aided by visual feedback with a manometer device. The test was repeated using femoral venous injections.

Results

Sixty five patients were enrolled, mean age 52, 43% male. TCD grades were significantly higher with femoral injections compared to brachial injections at rest (p<0.0001), and with the Valsalva maneuver (p<0.0001). The presence of a RLS was confirmed by intracardiac echocardiography (ICE) during cardiac catheterization in 62 (95.4%) patients.

Conclusion

The sensitivity of TCD for detection of RLS is increased when agitated saline injections are performed through the femoral vein. In patients with a high clinical suspicion for RLS, low TCD grades obtained with traditional brachial venous access should be interpreted with caution. When possible, a repeat study using femoral venous access may be considered. © 2014 Wiley Periodicals, Inc.


I have included this second article from 2014 as responsive to your note.

cTCD by brachial  injection has a 93% sensitivity and a 97% specificity.   I am not sure how much better "2X as good" is.  The introduction of a 1.5%-8% complication rate with a femoral catheter and the added cost may be justified under some circumstances.

The assumption is that the TIA or CVA is, in fact, cryptogenic,( that it has has been fully evaluated with Holter monitor, coag studies etc)     In this circumstance, negative TEE in which satisfactory valsalva has been noted along with a negative good quality cTCD for RLS leaves the circumstance to appear to be truly cryptogenic. 

The benefit of transcutanious PFO closure has always been clear to me, but the proof of benefit over ASA does require some statistical yoga.  This leaves the clear option of treating a truly cryptogenic group with ASA.  The number of spots on the MRI might help decide

I wonder if those relatively rare circumstances might be best resolved with a cardiac cath. ( especially if events are recurrent on ASA)  PVL can certainly participate in a f/u cTCD with femoral catheter.   We are not set up to do it in the PVL




-----Original Message-----
From: djacobs272 <djacobs272@aol.com>
To: adam.waldman <adam.waldman@orlandohealth.com>; mmenkin <mmenkin@aol.com>; ca.rosado <ca.rosado@gmail.com>; dhj1.strokenotes <dhj1.strokenotes@blogger.com>
Sent: Wed, Apr 24, 2019 9:39 am
Subject: pfo Studies
from Thaler DE and Cramer SC Paradoxical embolism in stroke in  Caplan LR, Biller J. Uncommon Causes of Stroke


"The choice of vein used to introduce echocardiographic contrast influences the sensitivity for PFO detection. Blood entering the right atrium via the inferior vena cava is directed towards the interatrial septum where PFOs are located whereas blood from the superior vena cava tends to be directed towards the tricuspid valve. Studies have been consistent in finding a 2.5-fold increase in diagnostic sensitivity when the contrast medium is injected via the femoral rather than the antecubital vein (Gin et al., 1993; Hamann et al., 1998).
Caplan, Louis R.; Biller, José. Uncommon Causes of Stroke (pp. 565-567). Cambridge University Press. Kindle Edition.

full citations for above:

Gin, K., Huckell, V., and Pollick, C. 1993. Femoral vein delivery of contrast medium enhances transthoracic echocardiographic detection of patent foramen ovale. J Am Coll Cardiol, 22, 1994– 2000.

Hamann, G., Schatzer-Klotz, D., Frohlig, G., et al. 1998. Femoral injection of echo contrast medium may increase the sensitivity of testing for a patent foramen ovale. Neurology, 50, 1423– 8.

ALL MY TAKE
I ASSUME ONE HUNDRED PERCENT OF OUR STUDIES BOTH TCD AND TEE BUBBLE ARE DONE THROUGH ARM VEIN BUT RHEOLOGY SHOWS FEMORAL VEIN IS 2.5 X AS GOOD.  PERHAPS WE COULD CONSIDER DOING THESE STUDIES FEMORRALLY SECOND LINE IN CHALLENGING PATIENTS SUCH AS WE HAVE HAD LATELY?  LOOK FORWARD TO EVERYONE'S THOUGHTS
DJ


Re: pfo Studies


I have included 2 articles :


Transcranial Doppler to detect right‐to‐left shunt in cryptogenic acute ischemic stroke



I include this for your review because it is 2019,  because all the patients were done brachial, and because the references are very well done.  It does not address the femoral route


Sensitivity of brachial versus femoral vein injection of agitated saline to detect right‐to‐left shunts with Transcranial Doppler

First published: 09 January 2014
Cited by: 4
Conflict of interest: Nothing to report.

Abstract

Background

Transcranial Doppler (TCD) can detect a right‐to‐left shunt (RLS) with high sensitivity but has a 5% chance of a false negative study. TCD is usually performed with injection of agitated saline into an arm vein. We compared the sensitivity of TCD performed from the brachial versus femoral veins.

Methods

Patients presenting to the cardiac catheterization laboratory for percutaneous closure of a patent foramen ovale (PFO) were enrolled. Power M‐mode Transcranial Doppler (Terumo 150 PMD) was conducted. After injection of a mixture of 8 cc of agitated saline, 0.5 cc of air, and 1 cc of blood into the brachial vein, embolic tracks were counted over the middle cerebral arteries. The degree of RLS was evaluated by TCD at rest, and with Valsalva at 40 mmHg aided by visual feedback with a manometer device. The test was repeated using femoral venous injections.

Results

Sixty five patients were enrolled, mean age 52, 43% male. TCD grades were significantly higher with femoral injections compared to brachial injections at rest (p<0.0001), and with the Valsalva maneuver (p<0.0001). The presence of a RLS was confirmed by intracardiac echocardiography (ICE) during cardiac catheterization in 62 (95.4%) patients.

Conclusion

The sensitivity of TCD for detection of RLS is increased when agitated saline injections are performed through the femoral vein. In patients with a high clinical suspicion for RLS, low TCD grades obtained with traditional brachial venous access should be interpreted with caution. When possible, a repeat study using femoral venous access may be considered. © 2014 Wiley Periodicals, Inc.


I have included this second article from 2014 as responsive to your note.

cTCD by brachial  injection has a 93% sensitivity and a 97% specificity.   I am not sure how much better "2X as good" is.  The introduction of a 1.5%-8% complication rate with a femoral catheter and the added cost may be justified under some circumstances.

The assumption is that the TIA or CVA is, in fact, cryptogenic,( that it has has been fully evaluated with Holter monitor, coag studies etc)     In this circumstance, negative TEE in which satisfactory valsalva has been noted along with a negative good quality cTCD for RLS leaves the circumstance to appear to be truly cryptogenic. 

The benefit of transcutanious PFO closure has always been clear to me, but the proof of benefit over ASA does require some statistical yoga.  This leaves the clear option of treating a truly cryptogenic group with ASA.  The number of spots on the MRI might help decide

I wonder if those relatively rare circumstances might be best resolved with a cardiac cath. ( especially if events are recurrent on ASA)  PVL can certainly participate in a f/u cTCD with femoral catheter.   We are not set up to do it in the PVL





pfo Studies

from Thaler DE and Cramer SC Paradoxical embolism in stroke in  Caplan LR, Biller J. Uncommon Causes of Stroke


"The choice of vein used to introduce echocardiographic contrast influences the sensitivity for PFO detection. Blood entering the right atrium via the inferior vena cava is directed towards the interatrial septum where PFOs are located whereas blood from the superior vena cava tends to be directed towards the tricuspid valve. Studies have been consistent in finding a 2.5-fold increase in diagnostic sensitivity when the contrast medium is injected via the femoral rather than the antecubital vein (Gin et al., 1993; Hamann et al., 1998).
Caplan, Louis R.; Biller, José. Uncommon Causes of Stroke (pp. 565-567). Cambridge University Press. Kindle Edition.

full citations for above:

Gin, K., Huckell, V., and Pollick, C. 1993. Femoral vein delivery of contrast medium enhances transthoracic echocardiographic detection of patent foramen ovale. J Am Coll Cardiol, 22, 1994– 2000.

Hamann, G., Schatzer-Klotz, D., Frohlig, G., et al. 1998. Femoral injection of echo contrast medium may increase the sensitivity of testing for a patent foramen ovale. Neurology, 50, 1423– 8.

ALL MY TAKE
I ASSUME ONE HUNDRED PERCENT OF OUR STUDIES BOTH TCD AND TEE BUBBLE ARE DONE THROUGH ARM VEIN BUT RHEOLOGY SHOWS FEMORAL VEIN IS 2.5 X AS GOOD.  PERHAPS WE COULD CONSIDER DOING THESE STUDIES FEMORRALLY SECOND LINE IN CHALLENGING PATIENTS SUCH AS WE HAVE HAD LATELY?  LOOK FORWARD TO EVERYONE'S THOUGHTS
DJ
 

Sunday, March 31, 2019

High risk cardiac embolism

Atrial fibrillation
mechanical valve
LAA thrombus
Anterior wall MI
endocarditis
aortic sclerosis
dilated cardiomyopathy
PFO/ASA
atrial flutter
aortic dissection
atrial myxoma

diffuse meningocerebral angiomatosis

older adults
livedo reticularis
dementia
seiozures
brain infarcts
demyelination

Protein C and warfarin, tests and Factor V Leiden mutation

warfarin decreases protein C level, so can't measure it if they are on warfarin

Activated protein C resistance is SCREENING TOOL  for Factor V Leiden mutation
APCR is also caused by: pregnancy, contraceptives, cancer, APL's,  so its sensitive but not specific for Factor V Leiden mutation.  APCR is NOT associated with protein C deficiency or AT 3 deficiency.

Factor V causes a 2-10 x risk of lifetime clots, venous not arterial.  High in Europeans, lower in Asians and African Americans. Its AUT DOMINANT. Anticoagulate if present and multiple events or if one severe event. PT G20210A gene mutation also confers only a venous risk.  Additive risk with contraceptives and with each other

Warfarin also causes a rapid fall in Factor VII (extrinsic pathway). Heparin decreases skin necrosis

essential thrombocytosis

no Philadelphia chromosome
aspirin helps esp if erythromelalgia is present

Polycythemia vera

+ Phil chromosome
Increased Hct
HA
vertigo
vision changes
seizures
"ruddy " complexion

Signs
retinal engorgement
papilledema

Rx
phlebotomy
hydroxyurea
steroids

Measuring extrinsic, intrinsic and common pathways

PT measures extrinsic and common pathways, is sensitive to low levels of Factors 7,10, tissue factor

intrinsic pathway - includes factors 8,9,11,12 also prekallikrein
PTT is elevated if deficient factors 8,9, also SLE, heparin tx
PTT is low in hypercoagulable state

Common pathway includes Factors V, X, prothrombin and fibrinogen

VWB disease- VWF depends on ristocetin induced aggluctination, decreased Factor 8, False positive occurs in inflammation, pregnancy, estrogen therapy

Vitamin K dependent factors decreased by coumadin include : extrinsic
prothrombinm F VII, F X   but not VIII,XI, XII

Long QT interval

Associations sudden death, syncope, presyncope
classic Torsades de pointe
Rapid V TACH above or below line EKG
med causes :  amiodarone, disopyramide, procainamide, quinidine, Haldol, sotalol, methadone, emycin

Aortic dissection

chest pain
syncope
Horner's

Association- may result from coarctation(coarctation also causes fusiform aneurysm)
IN men gtr than  50 due to HTN
if less than 50 due to Marfan's or to pregnancy

PFO pearls

fossa ovalis of septum in in right atrium.  Limbus with horseshoe shaped valve ovalis.  Ostium primum- fetal
ostium secondum opens

PFO prevalence 40-60 % in patients with migraine + aura

Wolff Parkinson White WPW syndrome

atrial tachycardia and accessory pathways
decreased PR interval
Delta wave in QRS complex
Avoid CCB's and beta blockers

Lip (a) and stroke risk

increased in women and in African Americans
correlates with LDL
is an independent predictor of stroke  and vascular death in older men

predictors of hemorrhage in AVM

Increased age
hemorrhagic presentation
deep location
exclusive deep venous drainage

NOT
headache
seizure
gender
size
aneurysm on nodal vessels

Malaria

encephalopathy
preceding petechial rash
rarely presents as stroke
don't give steroids.

APMPPE acute posterior mulitofocal placoid pigment epitheliopathy

chorioretinal disease of the young with strokes and aseptic meningitis

white dot syndromes
associated with TB and many other infections and associations
retinal abnormalities after return of vision
rare CNS involvement
rapid bilateral central vision either simultaneously or sequentially
choroidal vasculitis

Eye findings
anterior and posterior uveitis
papillities
RAPD
serous detachment, edema, hemorrhages and episcleritis
CRVO
revascularization
antecedent vaccinations
41 percent have prodromic flu
association with Harada disease
MS like disease
pseudotumor

male = female but more men get CNS complications that include

aseptic meningitis
lymphocytic pleocytosis and increased protein

territorial strokes esp PCA but also MCA and deep
PACNS
granulomatous angiitis
treat with steroids

Spinal hematoma due to coagulation issues

Back pain
radiculopathy
get an MRI

spinal cord stroke

most common type ASA
PSA is rare
artery of Adamkiewicz from right 30 percent and joins the ASA

hypereosinophilia syndrome

spectrum

stroke
encephalopathy
multifocal motor neuropathy

first stage asymptomatic
second stage development of thrombi
third stage myocardial fibrosis

Dural AVF of brain

Most common
transverse and sigmoid sinus

Aneurysm of cavernous sinus

diplopia
facial pain
headache
decreased acuity
VI n paresis is more common than II n paresis

in contrast supraclinoid aneurysm causes bitemporal anopias

Wyburn Mason syndrome

large tortuous arteries and veins
racemose retina

affects one eye
retinal , facial, oral and intracranial AVM
intracranial avm usually is ipsilateral optic nerve temporal lobe and middle and posterior fossae
nonhereditary
believed to derive from seventh week mesoderm
retinal AVM are often stable but 25 percent of time are not and cause complications
orbital AVM correlate with proptosis and with intracranial avm's
oral maxillofacial AVM can result in feared bleeding especially after dental extraction or from nose without warning or provocation

Signs and symptoms include

HA
cephalic bruit
HH and HP

ddx:
Sturge Weber--
von Hippel Lindau

Von Hippel Lindau

hemangiomablastoma in brain, cord, and retina
cysts kidneys liver and pancreas
70 percent develop clear cell CA kidney

Autosomal dominant deletions/mutations in tumor suppressor gene 3p25

Churg Strauss

allergic rhinitis
nasal polyps
asthma
eosinophilia
increased IgE

Cerebral amyloid angiopathy genetic forms

Annual bleed risk ten percent.

Dutch type

Icelandic type (young)

Named stroke syndromes

Benedicts' syndrome-- lesion in midbrain ventral and tegmentum affecting CTS,IIIn, red nucleus, cerebellothalamic fibers leads to contralateral weakness, facial weakness, ipsilateral abducens, chorea

Millard Gubler-- medial pons affects VI n, and CST get ipsilateral VI n. paresis and contralateral HP

Foville's -- dorsal pons  , above with extension into tegmentum, affects PPRF get ipsilateral facial paresis, conjugate gaze paresis also

Weber's-  medial midbrain.  ipsilateral IIIn and cerebral peduncle with HP

Claude's-  midbrain and dorsal tegmentum-- ipsilateral IIIn, red nucleus  HP + ataxia contralateral (pupil dilated, and eye is down and out)

Raymond Cestan s-- ventral pons-  CST + MLF produces INO, contralateral HP and loss adduction side of lesion

Hemiplegic migraine mimicking stroke

Usually + auras then headache
gene mutation of P/Q VGCC CAC NA1A on chromosome 19p13 that encodes pore forming subunit of P/Q type VDCO's Men=women

menkes syndrome

ATP7a  X linked

small and large vessel disease

growth failure
hypotonia
blue sclerae
seizures
brittle hair

Malignant atrophic papulosis

young adults
skin lesions
GI symptoms
infarcts and hemorrhages

Kawasaki syndrome

mucocutaneous lymph node syndrome

affects skin and mucous membranes of kids and young adults

Clinical

fever then skin lesions
conjunctivitis
lymphadenopathy
stroke- ischemic, SAH, MI

Intracranial hemorrhage in infants

ruptured subependymal vessels in germinal matrix in premature infants
Half occur in first day of life, 90 percent in first four days

Subdural hemorrhage
symptoms change in level of consciousness, seizures, tough to see on CT or differentiate from cerebellar hemorrhage treat conservatively or surgically.

CVT neonates have more involvement than adults of straight sinus or deep venous system

Periventricular leukomalacia

associated with prematurity
occurs in one third of CP patients under 1000 grams
one fourth of those have secondary minor hemorrhages
44 percent have spastic diplegia

Neonates with strokes hypercoagulable associations

59 percent have one or more prothrombotic risk factors esp. increased lipoprotein (a) (45/125, then Factor V leiden  (32/125) or protein S deficiency (one patient) which is much more rare

1:4000 term babies have strokes usually MCA left more than right due to flow with PDA Patent ductus arteriosus

half are normal later in infancy

Stroke mortality is dramatically higher in neonates with high death rate especially for ICH

Catheters cause 80 percent of deep vein thrombosis in newborns, 60 percent inolder children.  Noncatheter associated arterial thrombosis is rare

Alternating hemiplegia of childhood

sporadic
may start at 2-18 months
poor prognosis
mental retardation and choreoathetosis associated
symptoms regress with sleep
a benign older form exists

Aneurysms in babies

rare
less than one percent of all SAH
Usually present with SAH
more commonly occur at MCA whereas GIANT aneurysms are more common in posterior circulation

AVM vein of Galen

features

high output heart failure due to shunting

may lead to hydrocephalus
AVM's are number one cause of hydrocephalus in children
nonalternating hemicranial pain
bruits occur in more than half

Carotid endarterectomy complications and contraindications

complications-- should be less than six percent

include

transient cranial neuropathy of nerves VII, X, and XII
MI and stroke

contraindications

large or disabling stroke
contralateral laryngeal palsy

few aspirin studies in stroke with a few of take away points

Dutch trial 1991  30 mg aspirin was as good as 283 mg
CAST  aspirin was better than placebo
MATCH   aspirin plus Plavix had little increased benefit but more bleeding
CHANCE trial  Chinese trial favored dual antiplatelet drugs for 90 days
IST trial 1997-- aspirin in first 48 hours led to better outcome
CAPRIE trial clopidogrel was superior to aspirin IF peripheral vascular disease is present otherwise they are same
CHARISMA trial  Dual antiplatelet treatment is dangerous for primary prevention
ESPS 2  Aggrenox was superior to aspirin alone.
PROFESS trial 2007  Aggrenox v. Plavix showed no difference between the two

intracranial dissection

in pediatrics, sixty percent are in anterior circulation and only those recurred.  In posterior circulation, most occur near C1-2 level.

Ehlers Danlos type 4- vascular type VED

features

Col3a1 gene codes for type 3 procollagen
autosomal dominant
arterial dissection and rupture
risk of SMT
thin translucent skin
typical facies
porencephaly

may NOT have hyperelastic skin
diagnose with death during childbirth, hemorrhage after minor trauma or surgery, bowel rupture
median survival 51
Aneurysms are common in VED but VED is not common in aneurysms. No 1 vessel is ICA
Complications of catheterization as high as 67 percent with 17 percent mortality
CCF are common as are dissections of many vessels

Tangier disease

features


autosomal dominant
low HDL, apo1
decreased LDL
mildly increased TG
mutations in binding cassette transporter A1 (ABDA1)
abnormal reverse cholesterol transport
orange tonsils
peripheral neuropathy
cerebrovascular and cardiovascular disease.

Causes of stroke in pediatric populations

CARDIOEMBOLIC

atrial fibrillation
myxoma
infective endocarditis
PFO
fat emboli

CEREBRAL VENOUS THROMBOSIS

orbital infection
cavernous sinus thrombosis
leukemia

CVT presents with seizures and acute illness
especially affects SSS and lateral more than straight sinus

Distribution

42 % ICH
32 % SAH
17 % ischemic stroke

Alagille syndrome

autosomal dominant
arteriodysplastic syndrome with multiorgan involvement
mutation in Jagged 1 gene, ligand for notch receptor.

clinical
peculiar facies
chronic cholestasis
buttery vertebral arch
polycystic kidneys

usually affects GI/cardiovascular/pulmonary
stroke can occur
reports of aneurysmal SAH and moya moya

PHACE syndrome

PHACE POSTERIOR FOSSA MALFORMATION HEMANGIOMAS, ARTERIAL ANOMALIES AND COARCTATION OF AORTA, OTHER CARDIAC DEFECTS AND EYE DEFECTS,

clinical
posterior fossa malformations
MASSIVE facial hemangiomas
arterial cerebrovascular disease, eye abnormalities

Associations: Dandy Walker cyst
women more than men
stroke
moya moya
sternal clefting
supraumbilical abdominal raphe may occur
coarctation and other cardiac deficits

Lemierre's syndrome

postanginal sepsis. This is a rare complication of pharyngeal infection with FUSOBACTERIUM NECROPHORUM.  a gram negative rod occurring in immunocompromised kids or adults.  It may involve meningitis, cerebral venous thrombosis, stroke, subdural emyema, ICA stenosis.  Patients given antibiotics and surgery usually survive.

Sunday, September 16, 2018

Tenecteplase v altepalse

Campbell BCV et al. Tenecteplase versus altepalse before thrombectomy for ischemic stroke.  NEJM 378: 1573-1582.

Tenecteplase is more fibrin specific and has longer activity than alteplase.  101 patients were assigned to .25 mg/kgof tenecteplase and 101 to 0.9 mg/kg alteplase within 4.5 hours of onset.  . The primary outcome was repercussion of more than 50 percent of the involved ischemic territory or absent retrievable thrombus at time of angiography.  Secondary outcome was mRS at ninety days.  

Primary outcome was achieved in 22 % of tenecteplase patients, ten percent of altepalse patients p= 0.002, clinical difference of twelve percentage points.  sICH occurred in  1 percent of each group.  90 day mRS was also better , 2 v. 3 (p=0.04).  

EXTEND 1A, NIH sponsored trial.  

editorial  Baird AE. Paving the way for improved treatment of acute stroke with tenecteplase. NEJM  378:  1635-6.  

Notes that alteplase helps only a small portion of the patients with large clots, so time between tap and groin puncture is key.  Drug has a long half life, can be administed as a bolus,  doubled the rate of recanalization and averted the need for some thrombectomies. This is a second phase two trial and a phase 3 trial is needed.

In a study of patients with mild stroke who were not expected to proceed to thrombectomy,  superiority of tenecteplase at a dose of .4 mg/kg  v. alteplase was NOT shown.    Additional ongoing trials including TASTE and ATTEST2  have not reported.  Campbell also did NOT show a decrease between thrombolysis and thrombectomy in tenecteplase treated patients in another trial.

Management of antiphospholipid syndrome-- pearls

from Garcia D. and Erkan D. Diagnosis and management of the antiphospholipid syndrome. NEJM 378; 2010:2021.  

1.  Ten percent of healthy blood donors are positive for apl  antibodies and one percent are positive for lupus anticoagulant; however after one year, only one percent remain positive, so rechecking titers is key. Its rare for a truly healthy person to  remain positive. Transient apl is common during infections.

2.  Prevalence by underlying condition of persisting moderate to high risk apl antibody profiles:  SLE, 20-30 percent;  women with pregnancy complications, six percent;  patients with venous thrombosis, ten percent;  MI, 11 percent; patients less than fifty with stroke, 17 percent.  

3.  Clinical presentation pearls: among pregnant women, most occur after ten weeks of pregnancy (those in earlier period more likely have genetic anomalies causing miscarriage).  Patients with venous thromboembolism most likely have lower extremity or pulmonary emboli.  

4.  Other clinical features include pulmonary hypertension, livedo reticularis, thrombocytopenia, hemolytic anemia, acute or chronic renal vascular lesions, and moderate or severe cognitive impairment.  

5.  Other lab features to note:  LA test best correlates with clinical events, but may be misleading among patients on warfarin or DOACs.  For ELISA, moderate to high titers ( greater than 40 GPL or 99th percentile of cal or anti B2GP1correlate better with outcomes than lower titers; IgG is more strongly associated with bad clinical events than IgA.  

6. Treating traditional risk factors and avoiding estrogen  is very important.

7.  Anticoagulation for primary prevention or use of aspirin for primary prevention is still controversial.  For patients with persistent apl syndrome and provoked thrombosis, eg. by surgery, or for those with impersistent apl ab's, the benefit of prolonged anticoagulation is "less certain."  

8. Treatment of "warfarin failures" is not known, but options include high intensity warfarin to INO 3-4, addition of aspirin or plaquenil or statin, use of a different anticoagulant such as a  LMWH or a combination.  There is insufficient evidence about DOACs.  

9. Catastrophic apl syndrome includes ARF, ARDS and adrenal hemorrhage.  Diagnosis is definite with involvement of three or more organs and a persistently positive test.  Early treatment with anticoagulants, steroids, IVIG and PLEX is indicated.  

10. Treatment in pregnancy is with low quality evidence, use of low dose aspirin and LMWH,  

if platelets are more than 50 K, no acute therapy
if platelets are more than 20 K, first line is steroids and IVIG not splenectomy
for warm mediated HA steroids are used first
ARF with thrombotic microangiopathy is usually treated with PLEX
Valve disease with high risk use ASA or warfarin for high risk vegetations

APS criteria-- once clinical event (venous or arterial) and/or fetal loss after ten weeks and/or 3 sequential miscarriages before 10 weeks  AND either present LA, ACL ab, or antiB2glycoprotein

Rivaroxabin for stroke prevention after embolic stroke of undetermined source

Hart RG. Rivaroxabin for stroke prevention after embolic stroke of undetermined source.  NEJM; 378: 2191-2201.  

Study tested  15 MG rivaroxaban v. 100 mg of aspirin with presumed embolic but undetermined source, with no arterial stenosis,lacunae or identified cardioembolic source.7213 patients were enrolled at 459 sites. Study was halted at eleven months with non superiority. Primary outcome was recurrent ischemic or hemorrhage stroke and primary safety measure was bleeding.   Recurrent stroke was 4.7 percent is both groups.  Bleeding occurred in 1.8 percent of rivaroxaban group, 0.7 percent of aspirin group ( p<0 .001="" a="" and="" bleeding.="" div="" effective="" had="" higher="" more="" nbsp="" not="" of="" onclusion:="" rate="" rivaroxaban="" was="">

NAVIGATE ESUS trial-- New approach rivaroxaban inhibition of factor Xa in a global trial versus aspirin to prevent embolism in embolic stroke of undetermined source.

The primary outcome of any stroke or systemic embolism slightly and non significantly favored rivaroxaban (5.1 v. 4.8 percent) There were hemorrhagic strokes in 0.4 v. 0.1 in respective groups (statistically significant but low effect size).  

Atrial fibrillation was not excluded prior to randomization.  About 12 percent of patients with cryptogenic stroke have undiagnosed atrial fibrillation.  PFO's were excluded. 

Comment-- Study is conclusive for unselected group, but what about for selected group with an educated guess of etiology? That could happen through selection of patients with certain ECHO characteristics , for example  left atrial hypertrophy or intracranial stenosis.  While one may argue that would be overkill to do the study, in the prior negative warfarin studies (WASID) patients never maintained their INR's within range..  

Power was very high to determine outcome.  Risk of stroke in first 11 months was about five percent.  


Risk of stroke after a TIA

Amarenco P., et al.  Five year risk of stroke after TIA or Minor ischemic stroke. NEJM; 378: 2182-2190.

Methods: TIA registry from 2009-2011, 21 countries, 4789 patients.  Outcome was composite ischemic brain or heart or death.  

results rate of stroke,coronary syndrome or death was 6.4 percent in the first year, 6.4 percent infers 2-5.  ABCD2 score predicted a higher rate of stroke if score was greater than or equal to 4.  The presence of a brain lesion on imaging was not important. 

Saturday, September 15, 2018

POINT trial

Johnston SC et al. Clopidogrel and aspirin in acute ischemic stroke and high risk TIA.  NEJM; 379:215-225  

Gotta, JC.  Antiplatelet therapy after ischemic stroke or TIA. NEJM 379:291 (editorial)

Chinese trial (CHANCE) previously showed a benefit of dual anti platelets in a Chinese population for a short period after stroke.  This study was a  RCT 1:1 of minor ischemic stroke  (NIHSS of 3 or less) or high risk TIA (ABCD2>4) to receive clopidorel loading dose (600 mg on day one, then 75 mg per day) plus aspirin 50-325 mg po daily (dual anti platelets or DAP), v. aspirin alone.  Primary outcome was the risk of composite ischemic events (Stroke, MI, or CV death). 4881 patients at 269 sites internationally.  After 84 percent enrollment, the trial was halted when trial showed less major ischemic events AND higher risk of major hemorrhage at 90 days than mono therapy.  The effect size was fairly small, with 6.5 % risk in DAP, 5.0 % in aspirin alone.  Major hemorrhage occurred in 0.9 % of DAP, 0.4 percent of aspirin alone. This was a ninety day trial.  

Commment- basic math shows 1.5 percent less major ischemic events, 0.5 percent more major hemorrhage with DAP.  Previously Chinese trial (CHANCE) showed 32 % decreased stroke recurrence with DAP and no increased hemorrhages.

James Grotta- Most of the prevented events were ischemic strokes arguably the most important outcome after TIA/minor stroke.  Most of the bleeding were systemic, nonfatal,nonintracranial hemorrhages.  Most of the benefit occurred int he first week, most of the hemorrhages occurred later.  DAP should be confined to a limited time, eg. the first three weeks.