The document discusses the risks and management of neuraxial anesthesia in patients receiving anticoagulant or antiplatelet medications. It states that while neuraxial techniques can reduce thromboembolic risks, anticoagulants are still often needed and precautions must be taken with neuraxial blocks. The timing of medication discontinuation, monitoring of coagulation parameters, and catheter management varies depending on the specific agent and dosing regimen. Neurological monitoring is important when combining these techniques due to the rare but serious risk of spinal hematoma.
new technique for pain management ,described by dr forero ,it can replace epidural anesthesia,paravertebral anesthesia and other regional blocks.it can be used for both acute and chronic painful conditions
Ropivacaine is a recently launched local anesthetic in Iran. Because of its more safety profile, it would be an appropriate substitution for routinely used LA, Bupivacaine.
new technique for pain management ,described by dr forero ,it can replace epidural anesthesia,paravertebral anesthesia and other regional blocks.it can be used for both acute and chronic painful conditions
Ropivacaine is a recently launched local anesthetic in Iran. Because of its more safety profile, it would be an appropriate substitution for routinely used LA, Bupivacaine.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
2. Improvement in patient outcomes,
including mortality and major morbidity
has been demonstrated with neuraxial
techniques, particularly with epidural
anesthesia and analgesia.
It is due to the attenuation of the
hypercoagulable response and the
associated reduction in the frequency of
thromboembolism.
3. Although this beneficial effect of neuraxial
techniques is recognized but the effect is
insufficient as the sole method of
thromboprophylaxis.
Consequently, anticoagulant, antiplatelet,
and thrombolytic medications have been
increasingly used in the prevention and
treatment of thromboembolism.
4. Long-term anticoagulation with warfarin
is often indicated for patients with a
history of VTE, mechanical heart valves,
and atrial fibrillation.
In addition, patients with bare metal or
drug-eluting coronary stents require
antiplatelet therapy with aspirin and
thienopyridine derivatives (e.g,
clopidogrel) for varying durations.
5. Coagulation defects are the principal risk
factors for regional anesthesia.
Spinal hematoma is a rare but potentially
devastating complication of regional
anesthesia.
Trauma to epidural veins in the presence of
coagulopathies may result in large
hematoma.
6. Patient with spinal hematoma presents
with severe back pain and neurological
deficit.
Diagnosis is confirmed by MRI.
Decompression laminectomy is required to
preserve neurologic functions.
Neuraxial blockade should be performed
cautiously in the presence of prophylactic
anticoagulation.
7. Pain management is based on appropriate
timings of needle placement and catheter
removal.
Clinician should have familiarity with
pharmacology of hemostasis altering drugs,
clinical studies as well as the case reports of
spinal hematoma.
8. An 81-year-old woman whose clopidogrel had
been discontinued for 7 days before elective
fasciotomy under spinal anesthesia.
Lumbar puncture was traumatic and required
multiple attempts/levels. She received 2 doses
of LMWH, 8 and 40 hrs after lumbar puncture.
Four hours after the second dose, she had
difficulty in voiding, which progressed to
numbness and weakness, patient underwent
decompressive laminectomy.
Traumatic tap, residual clopidogrel effect, and moderately reduced
renal function were causes.
9. This issue has been addressed in a consensus
statement from the American Society for
Regional Anesthesia (
www.asra.com/consensus/intro.shtml)
13. Mechanism of action:
Interferes with the synthesis of Vit K
dependant clotting factors
1. II, VII, IX and X.
2. Anticoagulation of proteins C, and S.
14. Half life: 40 hours
Dosage: 2-15 mg / day
Monitoring: PT and INR
15. Caution should be made in performing
neuraxial block in patients recently
discontinued warfarin therapy.
The anticoagulant therapy must be
stopped (ideally 4 – 5 days before
performing the block).
Monitor PT/INR prior to initiation of the
block.
No Regional Anesthesia if in combination
of other drugs affecting the clotting.
16. If the first dose given 24 hrs earlier- check
PT/INR
Patients receiving warfarin during
epidural analgesia do PT/INR on daily
basis.
Check PT/INR before catheter removal if
initial doses of warfarin are given more
than 36 hours preoperatively.
Epidural catheters can be removed if INR
is < 1.5.
17. Neurological testing of motor and sensory
functions should be done.
Minimize the degree of motor and sensory
block.
If INR > 3, Hold warfarin
Reduced doses of warfarin in patients with
enhanced drug response.
19. Mechanism of action:
Accelerates the inactivation of factors IIa,
IXa, Xa, XIa, and XIIa by the serine protease
inhibitor, Antithorombin III (AT III).
20. Half life:1 to 1.5 hours.
Dose:
Bolus: 80 units / kg or 5000 units
Maintenance: 15 units / kg / hr or 700
to 2000 units / day
Monitoring: aPTT.
21. For mini dose prophylaxis :
No contraindication. Hold morning dose.
Check platelet count
22. In pts with combined neuraxial blocks and
intraoperative anticoagulation,
Avoid regional anesthesia with other
coagulopathies.
Avoid RA in patients with medications of
clotting inhibitors in combination.
Delay Heparin dose up to one hour after
needle placement.
23. Remove catheter 4 hours stopping the dose
and start the dose again after one hour.
Check for motor and sensory blockade.
Consider minimal dose of local anesthetics
for early detection of spinal hematoma.
24. Combining neuraxial techniques with full
anticoagulation of cardiac surgery
Insufficient data and experience to
determine the risk of hematoma.
Postoperative monitoring of neurological
functions.
Selection of solutions to minimize sensory
and motor blockade.
25. Mechanism of action: Inhibit clotting factor Xa
more than IIa.
Examples
Deltaparin
Enoxaparin
Tinzaparin
26. Half-life: Three to four times more than
Haparin
Doses:
Deltaparin: 2500-5000 u / day
Enoxaparin: 30-40 mg / day
Tinzaparin:175 u / day
27. Monitoring of anti – Xa level is not
recommended.
No RA in patients taking other clotting
inhibitors in addition.
In the presence of blood during needle and
catheter placement.
Delay LMWH therapy for 24 hours
Should be discussed with the surgeon.
28. Preoperative LMWH:
1. Thromboprophylaxis: Needle placement
should be delayed up to 10 – 12 hours.
2. Treatment doses: A delay of at least 24 hours
is recommended.
3. No RA if the dose is given in morning
preoperatively.
29. Postoperative LMWH: may undergo RA
technique, but removal of the catheter
depends upon total daily dose and
timing.
a. Twice daily dose:
increased risk of spinal hematoma.
First dose of LMWH should not be
administered 24 hours postoperatively.
Catheters should be removed prior to
initiation of thrombo-prophylaxis.
LMWH dose should be started after 2 hours
removing the catheter.
30. b. Single daily dose:
First dose should be administered 6 – 8 hours
postoperatively.
Second dose after 24 hours and catheters may be
safely maintained.
Catheters should be removed after 12 hours of last
LMWH dose.
LMWH dose can be started after two hours.
31. ASPIRIN and NSAIDS
Thienopyridine derivatives
Platelet GP IIb/IIIa antagonists
32. MECHANISM OF ACTION:
Blocks cyclooxygenase. Cyclooxygenase is
responsible for the production of
thromboxane A2 which inhibits platelet
aggregation and causes vasoconstriction.
DURATION OF ACTION:
Irreversible effect on platelets. Effect of
aspirin lasts for the life of the platelet which
is 7-10 days. Long term use of aspirin may
lead to a decrease in prothrombin production
and result in a lengthening of the PT.
33. MECHANISM OF ACTION:
Inhibits cyclooxygenase by decreasing tissue
prostaglandin synthesis.
DURATION OF ACTION:
Reversible. Duration of action depends on
the half life of the medication used and can
range from 1 hour to 3 days.
35. Either medication alone does not increase
risk.
Need to scrutinize dosages, duration of
therapy and concomitant medications
that may affect coagulation.
No wholly accepted laboratory tests. A
normal bleeding time does not indicate
normal homeostasis. An abnormal
bleeding time does not necessarily
indicate abnormal homeostasis.
36. History of bruising easily
History of excessive bleeding
Female gender
Increased age
38. MECHANISM OF ACTION:
Interfere with platelet membrane function
by inhibition of adenosine diphosphate (ADP)
induced platelet-fibrinogen binding.
DURATION OF ACTION:
Thienopyridine derivatives exert an
irreversible effect on platelet function for
the life of the platelet.
39. DC ticlopidine for 14 days prior to a neuraxial
block.
DC clopidogrel for 7 days prior to a neuraxial
block.
There is no accepted laboratory tests for
these medications.
41. Mechanism of action: Non peptide inhibitors
of GP IIb / IIIa receptor
Doses:
Abciximab. Dose:250 micrograms / kg
Eptifibatide. Dose:180 microgram / kg
Tirofiban. Dose: 10 micrograms / kg
42. No wholly accepted test including the
bleeding time.
Careful preoperative assessment is
necessary,
Easy bruisability
Excessive bleeding
Female gender
Increasing age
43. Platelet GIIb/IIIa Inhibitors:
RA should be avoided 2 days for abciximab and 4-
8 hours for eptifibatide and tirofiban therapy.
If administrated postoperatively following RA,
the patient should be monitored neurologically.
45. Although the plasma half life of thrombolytic drugs is
mainly hours, it may take days for the thrombolytic
effect to resolve.
46. No RA in the presence of these drugs.
In patients with catheters already in and
with sudden initiation of these drugs,
Neuraxial monitoring is necessary which should not be
more than 2 hour interval.
Infusion should be limited to drugs minimizing sensory
and motor blockade.
Fibrinogen level measurement.
No definite recommendation regarding the removal of
catheters.
47. An 84-year-old man received an uncomplicated
epidural steroid injection in the morning.
He developed chest pain later that day, was
admitted to the hospital, diagnosed with an
acute myocardial infarction, and treated with
tissue plasminogen activator and heparin
. He subsequently developed back pain and
paraplegia. Magnetic resonance imaging
demonstrated an epidural hematoma extending
from T10 to the sacrum.
48. Patients scheduled for thrombolytic therapy
must be inquired for history of neuroaxial
block.
Patients who received thrombolytic
therapy ,neuroaxial block is contraindicated,
no time interval is outlined.
49.
50. Antithrombotic medication for DVT
prophylaxis
Binds with antithrombin III which
neutralizes factor Xa.
Peak effect in 3 hours with half life of 17-
21 hours
Irreversible effect
Need further clinical experience to
formulate guidelines
Black box warning similar to the LMWH
51. Bivalirudin- thrombin inhibitor used in
interventional cardiology.
Lepirudin used to treat heparin-induced
thrombocytopenia.
Caution advised. No recommendations
related to limited clinical experience.
52. Dabigatran etexilate
Is a prodrug that inhibits both free and clot-bound
thrombin.
The drug is absorbed from the
gastrointestinal tract with a bioavailability of
5%.
The half-life is 8 hrs after a single dose and
up to 17 hrs after multiple doses.
Prolongs the aPTT
53. Rivaroxaban
Is a potent selective and reversible oral
activated factor Xa inhibitor.
Inhibition is maintained for 12 hrs.
Monitored with the PT, aPTT.
For Dabigatran etexilate and Rivaroxaban,
the lack of information regarding the
specifics of block performance and the
prolonged half-life warrants a cautious
approach.
54. For patients undergoing deep plexus or
peripheral block, recommendations regarding
neuraxial techniques, should also be applied
similarly.
55. In the absence of a large series of neuraxial
techniques in the pregnant population,
receiving prophylaxis or treatment of VTE,
ASRA guidelines (derived mainly from
surgical patients) should be applied to
parturient.
56. These consensus statements represent the collective
experience of recognized experts in neuraxial
anesthesia and anticoagulation. They are based on
case reports, clinical series, pharmacology,
hematology, and risk factors for surgical bleeding.
Alternative anesthetic and analgesic techniques
should be used for the patients, who are at
unacceptable risk.
The patient's coagulation status should be optimized
at the time of spinal or epidural needle/catheter
placement, and the level of anticoagulation must be
carefully monitored during the period of epidural
catheterization.
57. Indwelling catheters should not be removed in
the presence of therapeutic anticoagulation
because this significantly increase the risk of
spinal hematoma.
Vigilance in monitoring is critical to allow early
evaluation of neurologic dysfunction and prompt
intervention.
Protocols must be in place for urgent magnetic
resonance imaging and hematoma evacuation if
there is a change in neurological status.
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