The document discusses strategies for preventing secondary strokes or TIAs, including evaluating the mechanism of the initial event, localizing symptoms to determine if they are anterior or posterior circulation, and initiating the best medical, surgical, or endovascular treatment based on findings; it also stresses the importance of aggressively controlling modifiable risk factors like hypertension, smoking, diabetes, and hyperlipidemia to reduce long-term risk of recurrence.
This is a group powerpoint presentation that I created for our university assignment - it explores the imaging pathways a worker in the medical imaging department would take with a patient suffering from a Transient Ischaemic Attack (TIA).
This is a group powerpoint presentation that I created for our university assignment - it explores the imaging pathways a worker in the medical imaging department would take with a patient suffering from a Transient Ischaemic Attack (TIA).
Anaesthesia in Cardiac Patients for Non-cardiac SurgeryRashad Siddiqi
The reader should be able to:
(1) identify factors which will lead to increased cardiovascular risk for patients undergoing non-cardiac surgery
(2) decide which patients require further cardiovascular testing
(3) make optimization plan for such patients
(4) understand the principles of anaesthesia for patients with cardiac disease
Hypertrophic cardiomyopathy
European society of cardiology guidelines,2014
Prevention of sudden cardiac death
Left ventricular outflow tract obstruction
Stroke is a leading cause of death and disability. All doctors should have a basic knowledge about stroke management. This presentation gives a summary of treatment options in acute brain stroke.
Anaesthesia in Cardiac Patients for Non-cardiac SurgeryRashad Siddiqi
The reader should be able to:
(1) identify factors which will lead to increased cardiovascular risk for patients undergoing non-cardiac surgery
(2) decide which patients require further cardiovascular testing
(3) make optimization plan for such patients
(4) understand the principles of anaesthesia for patients with cardiac disease
Hypertrophic cardiomyopathy
European society of cardiology guidelines,2014
Prevention of sudden cardiac death
Left ventricular outflow tract obstruction
Stroke is a leading cause of death and disability. All doctors should have a basic knowledge about stroke management. This presentation gives a summary of treatment options in acute brain stroke.
STROKE is also known as CVA. (cerebrovascular accident). it is a medical emergency. damage to the brain from interruption of its blood supply .early action can reduce brain damage and other complication.
signs and symptoms slur words or difficulty understanding speech.
principles of preoperative evaluation and preparation.pptxMahmood Hasan Taha
The importance of preoperative assessment and evaluation to prepare the patient to surgical procedure is directly proportional with the degree of successful of any surgical procedure.
So, good preoperative assessment and evolution is necessary to avoid the morbidity and mortality that expected to the surgical procedures.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
1. Management of TIA/Stroke:
Preventing a Second Event
Robert D. Brown, Jr., MD, MPH
Department of Neurology
Mayo Clinic, Rochester
November, 2010
American College of Physicians Meeting
Minneapolis, MN
3. Case: Transient
Weakness and Speech Dysfunction
68 year old woman with 20 minutes of right
upper extremity weakness and “difficulty
finding the correct word”
One day earlier, 5 minute episode of
darkness and blurring in the left eye
Prior history
– Mild hypertension
– Mild hyperlipidemia
– On no medications
Exam: systolic bruit over left neck
– BP 160/88
4. Stroke Prevention:
Secondary Prevention Strategies
Mechanism evaluation
Intervention
– Carotid endarterectomy
– Carotid angioplasty with stent placement
Selection of antithrombotic agent
Risk factor control
5. Management Decisions After TIA/CI
Step-Wise Approach to Optimize Stroke Prevention
1) Are the symptoms caused by a TIA or
ischemic stroke?
2) Localize the symptoms: anterior or posterior
circulation
3) What is the mechanism?
4) Initiate the best medical, surgical or
endovascular means of stroke prevention
6. Management Decisions After TIA/CI
Step-Wise Approach to Optimize Stroke Prevention
1) Are the symptoms caused by a TIA or ischemic
stroke?
2) Localize the symptoms: anterior or posterior
circulation
3) What is the mechanism?
4) Initiate the best medical, surgical or
endovascular means of stroke prevention
7. Management Decisions After TIA/CI
Step-Wise Approach to Optimize Stroke Prevention
1) TIA/CI versus other cause of symptoms:
Are the symptoms caused by a TIA or ischemic
stroke? Seizure
2) Localize the symptoms: anterior or posterior
Migraine
circulation
Hemorrhage (SDH, EDH, intracerebral)
3) What is the mechanism?
Metabolic (hypoglycemia, other)
4) Initiate the best medical, surgical or
Transient global amnesia
endovascular means of stroke prevention
Other non-vascular cause:
MS, tumor, infection
8. Management Decisions After TIA/CI
1) Are the symptoms caused by a TIA or
ischemic stroke?
2) Localize the symptoms: anterior or posterior
circulation
3) What is the mechanism?
4) Initiate the best medical, surgical or
endovascular means of stroke prevention
10. Functional Anatomy
Posterior Circulation:
Vertebrobasilar system
In isolation or in combination
diplopia
dysarthria
ataxic gait or limbs
unilateral or bilateral visual
facial sensation change or weakness
vertigo
unilateral or bilateral motor / sensory
changes
11. Management Decisions After TIA/CI
Step-Wise Approach to Optimize Stroke Prevention
1) Are the symptoms caused by a TIA or Stroke?
2) Localize the symptoms: anterior or posterior
circulation
3) What is the mechanism?
4) Initiate the best medical, surgical or
endovascular means of stroke prevention
12. Defining the Mechanism of a TIA or
Cerebral Infarction:
Four Major Categories
1. Cardiac: ~30%
– Arrhythmia
– Dilated cardiomyopathy, recent MI,
other structural disorders
– Cardiac mass lesions
– Valve disease 2
– Venous source with right-to-left shunt
2. Large vessel disease: 15-20%
– Atherosclerosis 1
– Dissection, fibromuscular dysplasia
13. Defining the Mechanism of a TIA or
Cerebral Infarction:
Four Major Categories
3. Small vessel disease: 15-20%
– Atherosclerosis, hypertension, smoking,
diabetes 4
– Infectious 3
– Non-infectious arteritis
4. Hematologic: <5%
– Polycythemia, thrombocytosis,
sickle cell disease
– Lupus anticoagulant positivity,
anticardiolipin antibodies
14. Anterior Circulation TIA or Ischemic Stroke
Step 1: Evaluate for Large Artery Stenosis
Carotid ultrasound, MRA or CTA
Step 2: Consider Cardiac Source of embolus
Transesophageal Echocardiography
Step 3: Consider intracranial stenosis
Brain MRA or CTA
Step 4: Baseline eval is negative.
The carotid ultrasound, TEE, and MRA are negative.
15. Anterior Circulation TIA or Ischemic Stroke
Step 1: Evaluate for Large Artery Stenosis
Carotid ultrasound, MRA or CTA
Step 2: Consider Cardiac Source of embolus
Transesophageal Echocardiography
Step 3: Consider intracranial stenosis
Brain MRA or CTA
Step 4: Baseline eval is negative.
The carotid ultrasound, TEE, and MRA are negative.
16. Symptomatic Carotid Artery
Occlusive Disease: CEA Guidelines
♦ Carotid stenosis, >70%
♦ NASCET data: stroke risk ipsilateral to carotid stenosis
♦ Surgical outcome: 9% over 2 years
♦ Medical management: 26% over 2 years
♦ Absolute risk reduction: 8.5% per year. NNT: 12
♦ Carotid stenosis, 50-69%
♦ NASCET data: stroke risk ipsilateral to carotid stenosis
♦ Surgical outcome: 16% over 5 years
♦ Medical management: 22% over 5 years
♦ Absolute risk reduction: 1.2% per year. NNT: 83
♦ Carotid stenosis <50%
♦ No benefit
17. What is the Role of
Carotid Angioplasty/Stenting?
Carotid Revascularization
Endarterectomy
vs. Stent Trial (CREST)
New England Journal of Medicine,
May, 2010
18. CREST
Primary and Secondary Endpoints
Primary endpoint
– Peri-procedural a composite of:
• Any clinical stroke
• Myocardial infarction
• Death
– Post-procedural
• Ipsilateral stroke up to 4 years
Secondary endpoint
– Differential efficacy based on symptomatic status,
gender and age
19. CREST
Results
Primary endpoint
– Carotid angioplasty/stenting: 7.2% / 4 years
– Carotid Endarterectomy: 6.8% / 4 years
– P value 0.51
Peri-procedural stroke
– CAS 4.1 % CEA 2.3% HR 1.79, p=0.01
Peri-procedural MI
– CAS 1.1% CEA 2.3% HR 0.50, p=0.03
20. CREST
Conclusions
Similar Primary Endpoint driven by differences in
peri-operative stroke and MI
– More MIs after CEA
– More strokes after CAS
CEA and CAS have similar net outcomes though the
individual risks vary, lower stroke with CEA and
lower MI with CAS
Younger patients may have improved efficacy with
CAS and older patients have improved efficacy with
CEA
21. Symptomatic Carotid Disease:
Carotid Angioplasty/Stenting
Medicare/Coverage Issues
Medicare coverage for carotid artery stenting
is restricted to:
– Patients who would be at high risk of
complications from CEA, and
– Have symptomatic narrowing of the carotid
artery of 70 percent or more
22. Cerebrovascular Update
Secondary Prevention
Aspirin? Warfarin? Clopidogrel? Dipyridamole?
– Selecting the best anti-thrombotic therapy after
TIA or ischemic stroke
23. Selecting an Anti-Platelet Agent for
Secondary Prevention: Conclusions
Decision based on mechanism identified, co-morbid conditions, cost,
potential side effects, & other medical illnesses
♦ Aspirin, clopidogrel and aspirin/ER dipyridamole are appropriate
initial therapies in non-cardioembolic CI, when no clear indication
for warfarin
♦ Aspirin intolerance or aspirin allergy: clopidogrel indicated
♦ Aspirin/ER dipyridamole may be more effective than aspirin alone
♦ Clopidogrel may be more effective than aspirin
♦ No clear difference between ASA/DP and clopidogrel
♦ Aspirin in combination with clopidogrel only indicated for selected
acute coronary syndromes, and after angioplasty/stenting
24. Selecting an Anti-Thrombotic Agent
for Secondary Prevention:
Antiplatelet Agent Summary
Decision based on mechanism identified, co-morbid conditions, cost,
Combination ASA, Clopidogrel? NO
potential side effects, & other medical illnesses
MATCH, Lancet 2004
CHARISMA, NEJM 2006
♦ Aspirin, clopidogrel and aspirin/ER dipyridamole are appropriate
initial therapies in non-cardioembolic CI, when no clear indication
Combination ASA, Dipyridamole? YES
for warfarin
ESPS-2, J Neurol Sci 1997
♦ Aspirin intolerance or aspirin allergy: clopidogrel indicated
ESPRIT, Lancet 2006
♦ Aspirin/ER dipyridamole may be more effective than aspirin alone
♦ Combination ASA, Clopidogrel:
Clopidogrel may be more effective than aspirin
Which is better? NEITHER
♦ Aspirin in combination with clopidogrel only indicated for
PROFESS, NEJM 2008
selected acute coronary syndromes, and after
angioplasty/stenting
25. Selecting an Anti-Platelet Agent for
Secondary Prevention: Conclusions
Decision based on mechanism identified, co-morbid conditions, cost,
potential side effects, & other medical illnesses
♦ In general, warfarin not indicated for non-cardioembolic ischemic
stroke unless very specific indications present
26. Clopidogrel:
FDA Black Box Warning, Background
Effectiveness of clopidogrel is dependent on its activation
to an active metabolite by the cytochrome P450 (CYP)
system, mainly CYP2C19
– Enzyme effectiveness dependent on the genotype of that
enzyme
• 2 normal metabolism alleles should have fully
functional metabolism
• 2 loss-of-function alleles will have poor metabolizer
status
• The overall clinical relevance of these loss-of-
function alleles continues to be evaluated
27. Clopidogrel:
FDA Black Box Warning, Recommendations
For urgent indications: use standard clopidogrel
loading and dosing.
– Administration should not be delayed pending
genetic testing
For longer term use:
– For those patients who are already on clopidogrel
and doing well, continue clopidogrel and genetic
testing is not indicated
28. Clopidogrel:
FDA Black Box Warning, Recommendations
If an antithrombotic medication other than clopidogrel
would be indicated, it would be reasonable to use an
alternative to clopidogrel
If clopidogrel is indicated for long-term use: consider
(not mandatory) CYP2C19 genetic testing. If testing is
performed:
– If 2 non-metabolizer alleles are present, use an
alternative to clopidogrel if possible*
– If 1 non-metabolizer allele is present, consider use
of an alternative to clopidogrel*
*The efficacy of higher dose clopidogrel use is unclear in this situation,
and is not recommended.
29. Selecting an Anti-Thrombotic Agent
for Secondary Prevention:
When is Warfarin Indicated?
Probable cardiac source of embolus
– Use depends on specific cardiac findings
Aortic arch: thrombus or mobile debris
Hypercoagulable states
Extracranial dissection with TIA or CI
Recurrent events on aspirin?
– Typically use alternative anti-platelet agent and not a/c,
although this has not been proven
Intracranial stenosis? WASID data, NEJM 2005
Not beneficial in “non-cardioembolic” ischemic stroke in
aggregate: Publication: WARSS, NEJM 2001
30. Cardiac issues: secondary prevention
♦AF: warfarin proven in multipleof TIA/Ischemic Stroke
Step 2: Consider Cardiac Source studies, INR 2-3
Transesophageal Echocardiography
♦No indication for combination therapy
♦Aspirin 325 mg if unable to take warfarin
♦Recent MI: if LV thrombus noted, NORMAL: 2-3
ABNORMAL: warfarin INR
Cardiac or Aortic Source No cardiac source
♦Use aspirin as well for ischemic CAD
♦Cardiomyopathy: warfarin or aspirin acceptable
Warfarin,
♦Rheumatic mitral valve disease: warfarin INR 2-3
surgery
Continue evaluation
♦Mitral valve prolapse: anti-platelet therapy
♦Prosthetic valve, recurrence on A/C: add aspirin
Risk Factor
~81 Control
mg per day to warfarin, INR 2.5 - 3.5
31. Case: Transient
Weakness and Speech Dysfunction
68 year old woman with 20 minutes of right
upper extremity weakness and “difficulty
finding the correct word”
One day earlier, 5 minute episode of
darkness and blurring in the left eye
Prior history
– Mild hypertension
– Mild hyperlipidemia
– On no medications
Exam: systolic bruit over left neck
– BP 160/88
32. Management Decisions After TIA/CI
Step-Wise Approach to Optimize Stroke Prevention
1) Are the symptoms caused by a TIA or Stroke? yes
2) Localize the symptoms: anterior or posterior
circulation Anterior/carotid
3) What is the mechanism? Carotid u/s: high-grade stenosis
4) Initiate the best medical, surgical Carotid endarterectomy
or endovascular means of stroke Aspirin, 325 mg per day
prevention
Can we do anything more?
33. Modifiable Risk Factors To Be
Assessed Simultaneously With Mechanism
Defining the
mechanism alone is
NOT enough:
Risk Factor Control
35. Strategies in Secondary
Prevention After Stroke or TIA
Robert D. Brown, Jr., MD, MPH
Department of Neurology
Mayo Clinic, Rochester
November, 2010
American College of Physicians Meeting
Minneapolis, MN