tag:blogger.com,1999:blog-341158822024-03-06T15:01:42.099-05:00Stroke NotesNotes from stroke reading cerebrovascular disease acute stroke blog. These are notes to myself for my own benefit but anyone may useUnknownnoreply@blogger.comBlogger413125tag:blogger.com,1999:blog-34115882.post-72539363276742663092024-02-15T18:25:00.000-05:002024-02-15T18:26:02.516-05:00Best Agility Writer Review by Reyman CruzHere is the best Agility Writer Review by Reyman Cruz. <div><br /></div><div><p style="color: rgb(0, 0, 0); font-family: "Times New Roman"; font-size: medium;"><strong>What is Agility Writer?</strong></p><p style="color: rgb(0, 0, 0); font-family: "Times New Roman"; font-size: medium;">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.</p><p style="color: rgb(0, 0, 0); font-family: "Times New Roman"; font-size: medium;"><strong>Top Features of Agility Writer</strong></p><ul style="color: rgb(0, 0, 0); font-family: "Times New Roman"; font-size: medium;"><li><strong>AI-Powered Writing Assistant:</strong> 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.</li><li><strong>Content Generation:</strong> 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.</li><li><strong>Content Optimization:</strong> 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.</li><li><strong>Collaboration and Team Management:</strong> The tool enables users to collaborate with team members on content projects. It provides options for sharing drafts, assigning tasks, and reviewing feedback.</li></ul><p style="color: rgb(0, 0, 0); font-family: "Times New Roman"; font-size: medium;"><strong>Benefits of Using Agility Writer</strong></p><ul style="color: rgb(0, 0, 0); font-family: "Times New Roman"; font-size: medium;"><li><strong>Time Savings:</strong> Agility Writer's AI-powered assistance can save users a significant amount of time by eliminating the need for lengthy research and editing processes.</li><li><strong>Improved Quality:</strong> The tool helps users produce high-quality content that is grammatically correct, stylistically appropriate, and optimized for SEO.</li><li><strong>Increased Productivity:</strong> By streamlining the content creation process, Agility Writer enables users to create more content in less time, boosting their productivity.</li><li><strong>Enhanced Consistency:</strong> The collaboration features of the tool ensure that all team members are working towards a consistent brand voice and style.</li></ul><p style="color: rgb(0, 0, 0); font-family: "Times New Roman"; font-size: medium;"><strong>Pricing and Plans</strong></p><p style="color: rgb(0, 0, 0); font-family: "Times New Roman"; font-size: medium;">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.</p><p style="color: rgb(0, 0, 0); font-family: "Times New Roman"; font-size: medium;"><strong>Alternatives to Agility Writer</strong></p><ul style="color: rgb(0, 0, 0); font-family: "Times New Roman"; font-size: medium;"><li><strong>Jasper (formerly Jarvis):</strong> A popular AI-powered writing tool that offers similar features to Agility Writer.</li><li><strong>Writersonic:</strong> A content writing tool that specializes in generating SEO-optimized and persuasive content.</li><li><strong>Copy.ai:</strong> A writing assistant that offers a wide range of templates and use cases, including content for marketing, social media, and e-commerce.</li></ul><p style="color: rgb(0, 0, 0); font-family: "Times New Roman"; font-size: medium;"><strong>Conclusion</strong></p><p style="color: rgb(0, 0, 0); font-family: "Times New Roman"; font-size: medium;">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. 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href="https://www.grammar.net/?s=Best%20Agility%20Writer%20Review%20by%20Reyman%20Cruz" title="Reyman Cruz">Reyman Cruz</a><br /></p></div> <p></p> -- <br /> You received this message because you are subscribed to the Google Groups "Broadcaster" group.<br /> To unsubscribe from this group and stop receiving emails from it, send an email to <a href="mailto:broadcaster-news+unsubscribe@googlegroups.com">broadcaster-news+unsubscribe@googlegroups.com</a>.<br /> To view this discussion on the web visit <a href="https://groups.google.com/d/msgid/broadcaster-news/b7f9614f-3b54-434c-aa50-0b15eb916fc8n%40googlegroups.com?utm_medium=email&utm_source=footer">https://groups.google.com/d/msgid/broadcaster-news/b7f9614f-3b54-434c-aa50-0b15eb916fc8n%40googlegroups.com</a>.<br /> Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-85311232416381945112024-02-04T16:14:00.001-05:002024-02-04T16:14:14.830-05:00Reynold Aquino: The Water Softener Expert and Plumbing Professional<p><strong><a href="https://medium.com/@reynoldaquino">Reynold Aquino</a>, 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.</strong></p>Unparalleled Expertise in Water Softener Systems:<ul><li><p><strong>Professional Background:</strong> 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.</p></li><li><p><strong>Advanced Training and Certifications:</strong> 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.</p></li><li><p><strong>Problem-Solving Abilities:</strong> 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.</p></li></ul>Comprehensive Plumbing Services:<ul><li><p><strong>Repairs and Maintenance:</strong> 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.</p></li><li><p><strong>Installation and Upgrades:</strong> 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.</p></li><li><p><strong>Emergency Services:</strong> 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.</p></li></ul>Customer-Centric Approach:<ul><li><p><strong>Personalized Solutions:</strong> 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.</p></li><li><p><strong>Transparent Communication:</strong> 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.</p></li><li><p><strong>Exceptional Customer Service:</strong> 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.</p></li></ul>Industry Recognition and Contributions:<ul><li><p><strong>Awards and Accolades:</strong> 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.</p></li><li><p><strong>Educational Initiatives:</strong> 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.</p></li><li><p><strong>Community Involvement:</strong> 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.</p></li></ul>Conclusion:<p>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.</p> <p></p> -- <br /> You received this message because you are subscribed to the Google Groups "Broadcaster" group.<br /> To unsubscribe from this group and stop receiving emails from it, send an email to <a href="mailto:broadcaster-news+unsubscribe@googlegroups.com">broadcaster-news+unsubscribe@googlegroups.com</a>.<br /> To view this discussion on the web visit <a href="https://groups.google.com/d/msgid/broadcaster-news/d71aa811-a664-4209-8660-345d4160b7aan%40googlegroups.com?utm_medium=email&utm_source=footer">https://groups.google.com/d/msgid/broadcaster-news/d71aa811-a664-4209-8660-345d4160b7aan%40googlegroups.com</a>.<br /> Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-57102459709530255792024-02-02T18:01:00.000-05:002024-02-02T18:02:03.288-05:00Best Online Jobs for Students: Earning Flexibility and Income Alongside Studies<p>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 <a href="https://www.linkedin.com/pulse/what-best-online-jobs-students-online-money-making-ideas-u2amc">Linkedin post</a>.</p><p><strong>High-Demand Online Jobs for Students:</strong></p><ul><li><p><strong>Content Creation:</strong></p><ul><li><strong>Freelance Writing:</strong> 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. <strong>Earning potential:</strong> Varies depending on experience, niche, and project scope. Some writers earn $0.10 per word, while others command $1 or more.</li><li><strong>Video Editing:</strong> 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. <strong>Earning potential:</strong> $15-$50 per hour, depending on experience and project complexity.</li><li><strong>Graphic Design:</strong> Create visual content like logos, illustrations, social media graphics, or website layouts using design software like Adobe Photoshop or Canva. <strong>Earning potential:</strong> $20-$75 per hour, depending on experience and project scope.</li></ul></li><li><p><strong>Online Tutoring:</strong> Share your knowledge and expertise by tutoring students online in various subjects. Platforms like Chegg, TutorMe, and Skooli connect tutors with students. <strong>Earning potential:</strong> $15-$50 per hour, depending on subject, experience, and platform.</p></li><li><p><strong>Virtual Assistance:</strong> Provide administrative, technical, or creative assistance to clients remotely. Tasks may include email management, scheduling appointments, data entry, or social media management. <strong>Earning potential:</strong> $10-$30 per hour, depending on experience and task complexity.</p></li><li><p><strong>Social Media Management:</strong> Manage social media accounts for businesses or individuals, including content creation, community engagement, and advertising. <strong>Earning potential:</strong> $15-$50 per hour, depending on experience, account size, and engagement metrics.</p></li><li><p><strong>Data Entry:</strong> Input data into spreadsheets or databases from scanned documents, handwritten forms, or audio recordings. <strong>Earning potential:</strong> $8-$15 per hour, depending on accuracy and speed.</p></li></ul><p><strong>Additional Online Opportunities:</strong></p><ul><li><strong>Website Testing:</strong> Provide feedback on website usability and functionality by participating in user testing sessions. <strong>Earning potential:</strong> $10-$20 per session, depending on platform and test duration.</li><li><strong>Online Surveys:</strong> Share your opinions and complete surveys on various topics to earn rewards or cash. <strong>Earning potential:</strong> Varies depending on the platform and survey length, typically $0.50-$5 per survey.</li><li><strong>Transcription:</strong> Transcribe audio or video recordings into written text. Requires good listening skills and typing accuracy. <strong>Earning potential:</strong> $10-$20 per hour, depending on experience and audio quality.</li></ul><p><strong>Choosing the Right Online Job:</strong></p><p>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.</p><p><strong>Remember:</strong></p><ul><li><strong>Time Management:</strong> 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.</li><li><strong>Legitimacy:</strong> Be cautious of scams disguised as online job opportunities. Research companies and platforms thoroughly before investing time or money.</li><li><strong>Taxes:</strong> Report your income from online jobs to the relevant authorities to comply with tax regulations.</li></ul><p>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.</p> <p></p> -- <br /> You received this message because you are subscribed to the Google Groups "Broadcaster" group.<br /> To unsubscribe from this group and stop receiving emails from it, send an email to <a href="mailto:broadcaster-news+unsubscribe@googlegroups.com">broadcaster-news+unsubscribe@googlegroups.com</a>.<br /> To view this discussion on the web visit <a href="https://groups.google.com/d/msgid/broadcaster-news/f9749434-7179-4838-8b0b-e243e69110c6n%40googlegroups.com?utm_medium=email&utm_source=footer">https://groups.google.com/d/msgid/broadcaster-news/f9749434-7179-4838-8b0b-e243e69110c6n%40googlegroups.com</a>.<br /> Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-84658671607926324412024-02-02T14:51:00.000-05:002024-02-02T14:52:00.419-05:00Understanding Water Softeners for Well Water<p>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. <strong>Water softeners are specifically designed to address these issues by removing hardness minerals from your water supply.</strong></p><p><strong>Do I Need a Water Softener for My Well Water?</strong></p><p>Whether or not you need a <a href="https://medium.com/@reynoldaquino/choosing-the-best-water-softener-for-well-water-84dad3868707">water softener for your well water</a> depends on several factors, including:</p><ul><li><strong>The hardness level of your water:</strong> 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.</li><li><strong>The problems you're experiencing:</strong> If you're noticing mineral buildup, soap scum, or other issues associated with hard water, then a softener can help.</li><li><strong>Your personal preferences:</strong> Some people simply prefer the feel of soft water for showering, washing dishes, and other tasks.</li></ul><p><strong>Types of Water Softeners for Well Water</strong></p><p>There are two main types of water softeners for well water:</p><ul><li><strong>Salt-based softeners:</strong> 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.</li><li><strong>Salt-free softeners:</strong> 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.</li></ul><p><strong>Choosing the Right Water Softener for Your Needs:</strong></p><p>When choosing a water softener for your well water, consider the following factors:</p><ul><li><strong>Your water hardness level:</strong> This will determine the size and capacity of the softener you need.</li><li><strong>Your water flow rate:</strong> Make sure the softener can handle the amount of water your home uses.</li><li><strong>Your budget:</strong> Salt-based softeners are generally less expensive than salt-free models, but you'll need to factor in the cost of salt.</li><li><strong>Your maintenance preferences:</strong> If you're not interested in regular maintenance, a salt-free softener may be a better option.</li></ul><p><strong>Additional Considerations for Well Water:</strong></p><ul><li><strong>Iron and other contaminants:</strong> 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.</li><li><strong>Professional installation:</strong> It's generally recommended to have a professional install your water softener to ensure it's properly sized and connected.</li></ul><p><strong>Benefits of Using a Water Softener for Well Water</strong></p><ul><li><strong>Reduces mineral buildup:</strong> This can prevent damage to pipes, appliances, and fixtures.</li><li><strong>Improves soap and detergent performance:</strong> Soft water allows soap and detergent to lather better, so you can use less and get better cleaning results.</li><li><strong>Softer skin and hair:</strong> Soft water can help reduce dryness and irritation.</li><li><strong>Longer lifespan for appliances:</strong> Soft water can help extend the life of your washing machine, dishwasher, and other water-using appliances.</li></ul><p><strong>Conclusion:</strong></p><p>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.</p> <p></p> -- <br /> You received this message because you are subscribed to the Google Groups "Broadcaster" group.<br /> To unsubscribe from this group and stop receiving emails from it, send an email to <a href="mailto:broadcaster-news+unsubscribe@googlegroups.com">broadcaster-news+unsubscribe@googlegroups.com</a>.<br /> To view this discussion on the web visit <a href="https://groups.google.com/d/msgid/broadcaster-news/c714f619-55bd-409e-910e-989729d77c61n%40googlegroups.com?utm_medium=email&utm_source=footer">https://groups.google.com/d/msgid/broadcaster-news/c714f619-55bd-409e-910e-989729d77c61n%40googlegroups.com</a>.<br /> Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-71490148895223626762024-01-28T15:50:00.001-05:002024-01-28T15:50:40.616-05:00Water Softener for Well Water: A Comprehensive Guide<strong>What is a Water Softener and How Does it Work?</strong><p>A water softener is a device that removes hardness from water, typically by exchanging calcium and magnesium ions for sodium ions. This process, <a href="https://www.linkedin.com/pulse/how-does-water-softener-work-well-reynold-aquino-2wcyc/">known as ion exchange</a>, occurs within a resin bed, which is composed of small, porous beads made of a material called ion-exchange resin.</p><strong>Why is a Water Softener Needed for Well Water?</strong><p>Well water often contains high levels of dissolved minerals, including calcium and magnesium, which cause hardness. Hard water can create several problems, such as:</p><ol><li><strong>Scale Buildup</strong>: Hard water can cause scale buildup in pipes, appliances, and fixtures, reducing their efficiency and lifespan.</li><li><strong>Soap Scum</strong>: Hard water can make it difficult to create a lather with soap, resulting in soap scum buildup on surfaces.</li><li><strong>Dry Skin and Hair</strong>: Hard water can strip away natural oils from skin and hair, leading to dryness and irritation.</li><li><strong>Reduced Detergent Effectiveness</strong>: Hard water can reduce the effectiveness of detergents, making it harder to clean clothes and dishes.</li></ol><strong><a href="https://www.linkedin.com/pulse/how-choose-right-water-softener-well-reynold-aquino-jde9c">How to Choose the Right Water Softener for Well Water</a>:</strong><ol><li><strong>Water Hardness Level</strong>: 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.</li><li><strong>Flow Rate</strong>: 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.</li><li><strong>Grain Capacity</strong>: 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.</li><li><strong>Type of Water Softener</strong>: 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.</li><li><strong>Brand and Reputation</strong>: 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.</li></ol><strong><a href="https://www.linkedin.com/pulse/how-install-water-softener-well-reynold-aquino-wbknc">How to Install and Maintain a Water Softener for Well Water</a>:</strong><ol><li><strong>Proper Installation</strong>: 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.</li><li><strong>Regular Regeneration</strong>: 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.</li><li><strong>Salt Replenishment</strong>: 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.</li><li><strong>Maintenance:</strong> 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.</li></ol><strong><a href="https://www.linkedin.com/pulse/what-benefits-using-water-softener-well-reynold-aquino-k8noc">Benefits of Using a Water Softener for Well Water</a>:</strong><ol><li><strong>Improved Water Quality</strong>: Treated water has a reduced mineral content, improving the taste, smell, and appearance of the water.</li><li><strong>Reduced Scale Buildup</strong>: This can save you money by extending the lifespan of your appliances.</li><li><strong>Softer Skin and Hair</strong>: Softened water can help to improve the health of your skin and hair.</li><li><strong>More Effective Laundry and Dishwashing</strong>: Softened water can improve the performance of detergents and soaps.</li><li><strong>Increased Energy Efficiency</strong>: Softened water can help to improve the efficiency of water heaters and other appliances that use water.</li></ol><strong>Conclusion:</strong><p>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.</p> <p></p> -- <br /> You received this message because you are subscribed to the Google Groups "Broadcaster" group.<br /> To unsubscribe from this group and stop receiving emails from it, send an email to <a href="mailto:broadcaster-news+unsubscribe@googlegroups.com">broadcaster-news+unsubscribe@googlegroups.com</a>.<br /> To view this discussion on the web visit <a href="https://groups.google.com/d/msgid/broadcaster-news/9aa09de1-81fa-4c7e-ad67-17431e4b7165n%40googlegroups.com?utm_medium=email&utm_source=footer">https://groups.google.com/d/msgid/broadcaster-news/9aa09de1-81fa-4c7e-ad67-17431e4b7165n%40googlegroups.com</a>.<br /> Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-57796083702582243542023-10-27T17:01:00.000-05:002023-10-27T17:16:08.553-05:00Collaboration requestHi there
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<br>ThomsUnknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-40342177598389796652023-04-23T13:02:00.000-05:002023-04-23T13:02:26.781-05:00Pearls Orthostatic tremor<script type="text/javascript">
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var pageTracker = _gat._getTracker("UA-3639768-12");
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</script><div><br /></div><div>Occurs in legs on standing</div><div>truncal and abdominal involvement are rare</div><div><br /></div><div>may be enhanced by palpation "thrill"</div><div>auscultation (continuous thumping" helicopter sign</div><div>surface emg - helicopter sign</div><div>high frequency 13-18 hz very characteristic on emg especially surface EMG</div><div><br /></div><div>primary v secondary (orthostatic tremor +)</div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-969786916939692922022-07-31T08:37:00.003-05:002022-07-31T08:37:27.408-05:00Pearls cavernous malformationDiagnose with mri coupled with genetic testing<script type="text/javascript">
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</script><div><br /></div><div>Most prevalent gene iskrit1/ccm1 esp among Hispanics</div><div><br /></div><div>18 Japanese had mgc4607/ccm2 </div><div><br /></div><div>Look for extra cns involvement esp eye ( retina) and cutaneous vascular malformations</div><div><br /></div><div>Two Chinese families had ccm1 and mgc460/ccn2</div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-42083550469122286872022-07-13T08:36:00.001-05:002022-07-13T08:36:53.205-05:00Movementis<p style="text-align: center;"><span style="font-size: 18pt; color: #843fa1;"><strong><em>The 2022 International Conference</em></strong></span></p> <p style="text-align: center;">on</p> <p style="text-align: center;"><span style="font-size: 24pt;"><a href="https://trk-gra-ughr.gevailia.com/ga/click/2-80547900-2795-10630-18224-41549-2f1d307d0c-f8ec467ede"><strong>MOVEMENT and COGNITION</strong></a></span></p> <p style="text-align: center;"><strong>Sorbonne</strong></p> <p style="text-align: center;"><strong>PARIS</strong></p> <p style="text-align: center;">31.8.2022 – 2.9.2022</p> <p style="text-align: center;"> </p> <p style="text-align: center;">For Registration, Abstracts submission or questions:</p> <p style="text-align: center;"><span style="font-size: 24pt;"><a href="https://trk-gra-ughr.gevailia.com/ga/click/2-80547900-2795-10630-18224-41550-1f46de3659-f8ec467ede">www.movementis.com</a></span></p> <p style="text-align: center;">or</p> <p style="text-align: center;">Contacts: <a href="mailto:office@movementis.com">office@movementis.com</a></p> <p style="text-align: center;"> </p> <p style="text-align: center;"><a href="https://trk-gra-ughr.gevailia.com/ga/unsubscribe/2-80547900-2795-10630-18224-7f89b191bea1d59-f8ec467ede">Unsubscribe me from this mailing list</a></p> <img src="https://trk-gra-ughr.gevailia.com/ga/open/2-80547900-2795-10630-18224-f8ec467ede" height="2" width="3" alt="">Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-36161323801827283622022-03-21T16:04:00.001-05:002022-03-21T16:04:10.655-05:00essential tremor devices1. Pen Again<script type="text/javascript">
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branches<br />
<br />
meningohypophyseal trunk<br />
inferior hypophyseal artery<br />
<br />
supraclinoid segment<br />
c4<br />
ophthalmic artery<br />
superior hypophyseal a<br />
posterior communicating<br />
anterior choroidal</div>
Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-76757256465861332842019-04-30T10:17:00.000-05:002019-04-30T10:17:09.698-05:00HEPARIN INDUCED THROMBOCYTOPENIA (HIT)<div dir="ltr" style="text-align: left;" trbidi="on">
Antibodies v. factor 4 platelets complexes<br />
10 x more common with heparin than with LMWH<br />
20-50 percent get arterial or venous thrombosis<br />
platelet count is less than fifty percent normal<br />
may use a direct thrombin inhibitor eg. argabotran<br />
<br />
basic science notes<br />
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.<br />
<br />
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</div>
Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-10521526358786759522019-04-30T09:55:00.000-05:002019-04-30T10:19:07.518-05:00Statins on vessels basic science<div dir="ltr" style="text-align: left;" trbidi="on">
Increase synthesis, decrease degradation of LDL receptors on heptatocytes<br />
-LFT's increase in one percent<br />
- tissue factor is PRO coagulant in enthothelial surface as is Va, F VIII<br />
-heparin and prostacyclin are anticoagulants in endothelium, also NO, enodog tpa, heparin like substance<br />
<br /></div>
Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-49641356730819563222019-04-24T13:12:00.000-05:002019-04-30T08:25:12.475-05:00RE: pfo Studies<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">I have included 2 articles :</span><span style="color: black; font-family: "arial" , "sans-serif";"><o:p></o:p></span></h1>
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<span style="color: black; font-family: "arial" , "sans-serif";">Transcranial Doppler to detect right</span><span style="color: black; font-family: "cambria math" , "serif";">‐</span><span style="color: black; font-family: "arial" , "sans-serif";">to</span><span style="color: black; font-family: "cambria math" , "serif";">‐</span><span style="color: black; font-family: "arial" , "sans-serif";">left shunt in cryptogenic acute ischemic stroke<o:p></o:p></span></h1>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;"><a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Palazzo%20P%5BAuthor%5D&cauthor=true&cauthor_uid=30506983" id="brb31091-cr-0001">Paola Palazzo</a>,<sup><img alt="corresponding author" border="0" id="_x0000_i1025" src="https://www.ncbi.nlm.nih.gov/corehtml/pmc/pmcgifs/corrauth.gif" /> 1 , 2 </sup><a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Ingrand%20P%5BAuthor%5D&cauthor=true&cauthor_uid=30506983" id="brb31091-cr-0002">Pierre Ingrand</a>,<sup> 3 </sup><a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Agius%20P%5BAuthor%5D&cauthor=true&cauthor_uid=30506983" id="brb31091-cr-0003">Pierre Agius</a>,<sup> 4 </sup><a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Belhadj%20Chaidi%20R%5BAuthor%5D&cauthor=true&cauthor_uid=30506983" id="brb31091-cr-0004">Rafik Belhadj Chaidi</a>,<sup> 5 </sup>and <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Neau%20J%5BAuthor%5D&cauthor=true&cauthor_uid=30506983" id="brb31091-cr-0005"> Jean<span style="font-family: "cambria math" , "serif";">‐</span>Philippe Neau</a><sup> 1 </sup><o:p></o:p></span></div>
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<sup><span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">I include this for your review because it is 2019, because <b>all</b> the patients were done brachial, and because the references are very well done. It does not address the femoral route</span></sup><span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;"><o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif";">Sensitivity of brachial versus femoral vein injection of agitated saline to detect right</span><span style="color: black; font-family: "cambria math" , "serif";">‐</span><span style="color: black; font-family: "arial" , "sans-serif";">to</span><span style="color: black; font-family: "cambria math" , "serif";">‐</span><span style="color: black; font-family: "arial" , "sans-serif";">left shunts with Transcranial Doppler<o:p></o:p></span></h2>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;"><a href="https://onlinelibrary.wiley.com/action/doSearch?ContribAuthorStored=Gevorgyan%2C+Rubine">Rubine Gevorgyan MD</a> <o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;"><a href="https://onlinelibrary.wiley.com/action/doSearch?ContribAuthorStored=Perlowski%2C+Alice" id="a2_Ctrl">Alice Perlowski MD</a> <o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;"><a href="https://onlinelibrary.wiley.com/action/doSearch?ContribAuthorStored=Shenoda%2C+Michael" id="a3_Ctrl">Michael Shenoda MD</a> <o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;"><a href="https://onlinelibrary.wiley.com/action/doSearch?ContribAuthorStored=Mojadidi%2C+M+Khalid" id="a4_Ctrl">M. Khalid Mojadidi MD</a> <o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;"><a href="https://onlinelibrary.wiley.com/action/doSearch?ContribAuthorStored=Agrawal%2C+Harsh" id="a5_Ctrl">Harsh Agrawal MD</a> <o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;"><a href="https://onlinelibrary.wiley.com/action/doSearch?ContribAuthorStored=Tobis%2C+Jonathan+M" id="a6_Ctrl">Jonathan M. Tobis MD</a> <o:p></o:p></span></div>
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<span class="epub-state"><span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">First published: </span></span><span class="epub-date"><span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">09 January 2014</span></span><span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;"><o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;"><a href="https://doi.org/10.1002/ccd.25391">https://doi.org/10.1002/ccd.25391</a><o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">Cited by: <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/ccd.25391#citedby-section"> 4</a><o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">Conflict of interest: Nothing to report.<o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;"><a href="https://onlinelibrary.wiley.com/doi/full/10.1002/ccd.25391"><span class="extra-text">Read the</span> full text</a><o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;"><a href="https://onlinelibrary.wiley.com/doi/epdf/10.1002/ccd.25391" title="Article ePDF"><span style="text-decoration: none;"><img alt="ePDF" border="0" id="_x0000_i1026" src="https://onlinelibrary.wiley.com/products/pericles/releasedAssets/images/pdf-icon.png" /></span>PDF</a><o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;"><a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/ccd.25391" id="0e406ce9-5c43-4e2d-b741-e0b43d1f1865_Ctrl">Tools</a><o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">Transcranial Doppler (TCD) can detect a right</span><span style="color: black; font-family: "cambria math" , "serif"; font-size: 10.0pt;">‐</span><span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">to</span><span style="color: black; font-family: "cambria math" , "serif"; font-size: 10.0pt;">‐</span><span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">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.<o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">Patients presenting to the cardiac catheterization laboratory for percutaneous closure of a patent foramen ovale (PFO) were enrolled. Power M</span><span style="color: black; font-family: "cambria math" , "serif"; font-size: 10.0pt;">‐</span><span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">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.<o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">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.<o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">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.<o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">I have included this second article from 2014 as responsive to your note. <o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">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. <o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">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 <u>in which satisfactory valsalva has been noted</u> along with a negative good quality cTCD for RLS leaves the circumstance to appear to be truly cryptogenic. <o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">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<o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">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<o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">-----Original Message-----<br /> From: djacobs272 <djacobs272@aol.com><br /> To: adam.waldman <adam.waldman@orlandohealth.com>; mmenkin <mmenkin@aol.com>; ca.rosado <ca.rosado@gmail.com>; dhj1.strokenotes <dhj1.strokenotes@blogger.com><br /> Sent: Wed, Apr 24, 2019 9:39 am<br /> Subject: pfo Studies<o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">from Thaler DE and Cramer SC Paradoxical embolism in stroke in Caplan LR, Biller J. Uncommon Causes of Stroke<o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">"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).<o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">Caplan, Louis R.; Biller, José. Uncommon Causes of Stroke (pp. 565-567). Cambridge University Press. Kindle Edition. <o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">full citations for above:<o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">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.<o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">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.<o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">ALL MY TAKE<o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">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<o:p></o:p></span></div>
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<span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">DJ<o:p></o:p></span></div>
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Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-71743477416082056252019-04-24T12:09:00.001-05:002019-04-29T21:22:31.043-05:00Re: pfo Studies<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="color: black; font-family: arial; font-size: x-small;"><span style="font-size: x-small;">I have included 2 articles :</span><br /> </span></h1>
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<span style="color: black; font-family: arial; font-size: x-small;">Transcranial Doppler to detect right‐to‐left shunt in cryptogenic acute ischemic stroke</span></h1>
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<span style="color: black; font-family: arial; font-size: x-small;"><a class="affpopup" href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Palazzo%20P%5BAuthor%5D&cauthor=true&cauthor_uid=30506983" id="brb31091-cr-0001">Paola Palazzo</a>,<sup><img alt="corresponding author" src="https://www.ncbi.nlm.nih.gov/corehtml/pmc/pmcgifs/corrauth.gif" /></sup><sup> 1 ,</sup><sup> 2 </sup> <a class="affpopup" href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Ingrand%20P%5BAuthor%5D&cauthor=true&cauthor_uid=30506983" id="brb31091-cr-0002">Pierre Ingrand</a>,<sup> 3 </sup> <a class="affpopup" href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Agius%20P%5BAuthor%5D&cauthor=true&cauthor_uid=30506983" id="brb31091-cr-0003">Pierre Agius</a>,<sup> 4 </sup> <a class="affpopup" href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Belhadj%20Chaidi%20R%5BAuthor%5D&cauthor=true&cauthor_uid=30506983" id="brb31091-cr-0004">Rafik Belhadj Chaidi</a>,<sup> 5 </sup> and <a class="affpopup" href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Neau%20J%5BAuthor%5D&cauthor=true&cauthor_uid=30506983" id="brb31091-cr-0005">Jean‐Philippe Neau</a><sup> 1 <br /> </sup></span></div>
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<span style="color: black; font-family: arial; font-size: x-small;"><sup><span style="font-size: x-small;">I include this for your review because it is 2019, because <b>all</b> the patients were done brachial, and because the references are very well done. It does not address the femoral route</span></sup></span></div>
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<span style="color: black; font-family: arial; font-size: x-small;">Sensitivity of brachial versus femoral vein injection of agitated saline to detect right‐to‐left shunts with Transcranial Doppler</span></h2>
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<span style="color: black; font-family: arial; font-size: x-small;"><span class="epub-state">First published: </span><span class="epub-date">09 January 2014</span></span></div>
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<span style="color: black; font-family: arial; font-size: x-small;"><a aria-label="Digital Object Identifier" class="epub-doi" href="https://doi.org/10.1002/ccd.25391">https://doi.org/10.1002/ccd.25391</a></span></div>
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<span style="color: black; font-family: arial; font-size: x-small;">Cited by: <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/ccd.25391#citedby-section">4</a></span></div>
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<span style="color: black; font-family: arial; font-size: x-small;">Conflict of interest: Nothing to report.</span></div>
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</span></nav><section class="article-section article-section__abstract" data-lang="en" id="section-1-en" lang="en"><span style="color: black; font-family: arial; font-size: x-small;"> <h3 class="article-section__header main main">
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Background</h3>
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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.</div>
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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.</div>
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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.</div>
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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.</div>
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<span style="font-size: x-small;">I have included this second article from 2014 as responsive to your note. <br /> </span></div>
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<span style="font-size: x-small;"> 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. <br /> </span></div>
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<span style="font-size: x-small;"> 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 <u>in which satisfactory valsalva has been noted</u> along with a negative good quality cTCD for RLS leaves the circumstance to appear to be truly cryptogenic. <br /> </span></div>
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<span style="font-size: x-small;">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<br /> </span></div>
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<span style="font-size: x-small;"> 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<br /> </span></div>
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Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-33794407933434012019-04-24T08:38:00.000-05:002019-04-24T08:39:01.915-05:00pfo Studies<font color='black' size='2' face='arial'> <div>from Thaler DE and Cramer SC Paradoxical embolism in stroke in Caplan LR, Biller J. Uncommon Causes of Stroke</div> <div><br> </div> <div><br> </div> <div>"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).</div> <div>Caplan, Louis R.; Biller, José. Uncommon Causes of Stroke (pp. 565-567). Cambridge University Press. Kindle Edition. </div> <div><br> </div> <div>full citations for above:</div> <div><br> </div> <div>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.</div> <div><br> </div> <div>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.</div> <div><br> </div> <div>ALL MY TAKE</div> <div>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</div> <div>DJ</div> <div> </div> </font>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-81409260032791300162019-03-31T20:28:00.002-05:002019-03-31T20:28:37.017-05:00High risk cardiac embolism<div dir="ltr" style="text-align: left;" trbidi="on">
Atrial fibrillation<br />
mechanical valve<br />
LAA thrombus<br />
Anterior wall MI<br />
endocarditis<br />
aortic sclerosis<br />
dilated cardiomyopathy<br />
PFO/ASA<br />
atrial flutter<br />
aortic dissection<br />
atrial myxoma</div>
Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-18103055789243223652019-03-31T20:26:00.000-05:002019-03-31T20:26:27.102-05:00diffuse meningocerebral angiomatosis<div dir="ltr" style="text-align: left;" trbidi="on">
older adults<br />
livedo reticularis<br />
dementia<br />
seiozures<br />
brain infarcts<br />
demyelination</div>
Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-57339298693917163992019-03-31T20:01:00.002-05:002019-03-31T20:14:09.437-05:00Protein C and warfarin, tests and Factor V Leiden mutation<div dir="ltr" style="text-align: left;" trbidi="on">
warfarin decreases protein C level, so can't measure it if they are on warfarin<br />
<br />
Activated protein C resistance is SCREENING TOOL for Factor V Leiden mutation<br />
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.<br />
<br />
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<br />
<br />
Warfarin also causes a rapid fall in Factor VII (extrinsic pathway). Heparin decreases skin necrosis</div>
Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-81268819137923708222019-03-31T19:55:00.003-05:002019-03-31T19:55:41.629-05:00essential thrombocytosis<div dir="ltr" style="text-align: left;" trbidi="on">
no Philadelphia chromosome<br />
aspirin helps esp if erythromelalgia is present</div>
Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-32908934912250949772019-03-31T19:54:00.001-05:002019-03-31T19:54:44.684-05:00Polycythemia vera<div dir="ltr" style="text-align: left;" trbidi="on">
+ Phil chromosome<br />
Increased Hct<br />
HA<br />
vertigo<br />
vision changes<br />
seizures<br />
"ruddy " complexion<br />
<br />
Signs<br />
retinal engorgement<br />
papilledema<br />
<br />
Rx<br />
phlebotomy<br />
hydroxyurea<br />
steroids</div>
Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-79187902617356638932019-03-31T19:47:00.000-05:002019-03-31T19:47:04.882-05:00Measuring extrinsic, intrinsic and common pathways<div dir="ltr" style="text-align: left;" trbidi="on">
PT measures extrinsic and common pathways, is sensitive to low levels of Factors 7,10, tissue factor<br />
<br />
intrinsic pathway - includes factors 8,9,11,12 also prekallikrein<br />
PTT is elevated if deficient factors 8,9, also SLE, heparin tx<br />
PTT is low in hypercoagulable state<br />
<br />
Common pathway includes Factors V, X, prothrombin and fibrinogen<br />
<br />
VWB disease- VWF depends on ristocetin induced aggluctination, decreased Factor 8, False positive occurs in inflammation, pregnancy, estrogen therapy<br />
<br />
Vitamin K dependent factors decreased by coumadin include : extrinsic<br />
prothrombinm F VII, F X but not VIII,XI, XII</div>
Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-84655870114564433842019-03-31T19:30:00.000-05:002019-03-31T19:30:12.367-05:00Long QT interval<div dir="ltr" style="text-align: left;" trbidi="on">
Associations sudden death, syncope, presyncope<br />
classic Torsades de pointe<br />
Rapid V TACH above or below line EKG<br />
med causes : amiodarone, disopyramide, procainamide, quinidine, Haldol, sotalol, methadone, emycin<br />
<br /></div>
Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-28539560307627317052019-03-31T19:26:00.001-05:002019-03-31T19:27:39.682-05:00Aortic dissection<div dir="ltr" style="text-align: left;" trbidi="on">
chest pain<br />
syncope<br />
Horner's<br />
<br />
Association- may result from coarctation(coarctation also causes fusiform aneurysm)<br />
IN men gtr than 50 due to HTN<br />
if less than 50 due to Marfan's or to pregnancy</div>
Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-34115882.post-37090112785902334112019-03-31T19:20:00.001-05:002019-03-31T19:20:16.704-05:00PFO pearls<div dir="ltr" style="text-align: left;" trbidi="on">
fossa ovalis of septum in in right atrium. Limbus with horseshoe shaped valve ovalis. Ostium primum- fetal<br />
ostium secondum opens<br />
<br />
PFO prevalence 40-60 % in patients with migraine + aura</div>
Unknownnoreply@blogger.com0