Podcasts about Moca

Trifulca Media Presenta:La Pandemia Urbana Con, Alex Torres y Omar Vázquez quienes entrevistan al cantante Puertorriqueño nacido en Moca, quien esta dando sus pasos en la Música Urbana. Nos habla de sus nuevos temas #NombreyApellido y #BuenosDías . Sigan a Kenny https://www.facebook.com/share/16iveRoGpb/?mibextid=wwXIfrhttps://www.instagram.com/kennyyofficial?igsh=ZnIyeDV3dmNqaG0wTienda De La Trifulca - La TrifulcaFacebook - https://ppppppppppppppQ XS www.facebook.com/a TrifulcaMedia?mibextid=LQQJ4d .p opiokcInstagram - https://www.instagram.com/latrifulcamedia?igsh=MW1yNGE2NnY0N2pyYw==Threads - https://www.threads.net/@latrifulcamediaYouTube - https://youtube.com/@trifulcamedia?si=Spotify - https://open.spotify.com/show/2Nki4huLPMwYftru08gFYV?si=Z2AMDLjRSiOc2U_LVUXRpwApple Podcast - https://podcasts.apple.com/us/podcast/trifulca-media/id1459553025#kennyy#BuenosDías #NombreyApellido #musicaurbana #reggaeton #jaywheeler#lapandemiaurbana #podcast#pr#trifulcamedia

Episode 475 / Banks VioletteBanks Violette is an artist born in Ithaca, NY who lives and works in Ithaca, NY. He recieved his BFA from the School of Visual Arts  and an MFA from Columbia University. He's had numerous solo shows including ones at MoCa, Connecticut, Gladstone Gallery, Blum & Poe, Thaddeus Ropac, Maureen Paley, Team Gallery, Rodolphe Janssen, and the Whitney Museum to name just a few. He's had scores of group shows all over the globe from the Museum of Modern Art to the Warhol Museum and his work is in the collections of The Coppel Foundation, MexicoThe Ellipse Foundation, Portugal, The Centre Pompidou, Paris, France, Frank Cohen Collection, Manchester, England The Jumex Foundation, Mexico, Los Angeles County Museum of Art, Los Angeles, Migros Museum für Gegenwartskunst, Zurich, Switzerland Musée d'Art Moderne et Contemporain, Geneva, Switzerland Museum of Contemporary Art, Los Angeles, Museum of Modern Art, New York, The OverHolland Collection, Amsterdam, The Netherlands The Saatchi Collection, London, UK, The Solomon R. Guggenheim Museum, New York, Frederick R. Weisman Art Foundation, Los Angeles and the Whitney Museum of American Art, New York. 

Tune in to today's episode as we are diving back into the world of cryptozoology with a classic cryptid - and that my friends is none other than El Chupacabra(s). In this episode we'll get into the origins of this strange creature taking a look at the Puerto Rico sightings of the mid-90s as well as some other mysterious encounters including the Moca Vampire. We'll also look at how the myths and tales evolved over time and if there are any viable theories as to what was terrorizing the island of Puerto Rico all those years ago. Was it an alien? a dog/coyote hybrid? a government experiment gone wrong? or perhaps a demon? tune in to find out... All of this and more in this episode! Music Credit: Clyde Lewis - El Chupacabra Song

In the dark, away from attention, the metaverse grows, thrives even, with the introduction and assistance of AI. AI agents peopling metaverse worlds. AI-generated avatars. But one of the most interesting possibilities of an AI-integrated metaverse is AI architecture, not just for the speed with which virtual 3D structures can be created but the newfound intricacy. It's an entirely new avenue for artistry, both in 3D worlds, and also full-stop, a new frontier. Today, Colborn and Max talk with MOCA's resident Metaverse architect, Untitled,XYZ about UnMuseums,  a collection of AI-generated architectures and his final flourish for MOCA ROOMs. The nitty-gritty of process, conception, outcome, and consequence, expect all of that and more on today's episode of MOCA LIVE.

This episode explores the trends, secrets, and future of luxury and high-street retail in Los Angeles and beyond with Jay Luchs, Vice Chairman of Newmark.The Crexi Podcast explores various aspects of the commercial real estate industry in conversation with top CRE professionals. In each episode, we feature different guests to tap into their wealth of CRE expertise and explore the latest trends and updates from the world of commercial real estate.  In this episode, Shanti Ryle, Director of Content Marketing at Crexi, sits down with Jay, one of Los Angeles's most prominent retail commercial real estate brokers. They discuss Jay's background, his journey from aspiring actor to leading real estate broker, and his significant transactions, including deals with top global fashion brands and high-profile real estate deals along Rodeo Drive and Melrose Avenue. Jay shares insights into the world of luxury retail, the challenges and strategies in securing prime retail locations, and the importance of genuine connections and caring about the community's landscape. They also explore the impact of social media on retail, the dynamics of leasing and buying in high-demand areas, and Jay's perspective on the future of retail in Los Angeles.Introduction and Guest WelcomeJay Luxe's Background and Career HighlightsEarly Career and Transition to Real EstateChallenges and Strategies in Real EstateSpecialization in Retail LeasingNotable Deals and Community ImpactLuxury Retail and Market InsightsUnderstanding Real Estate PricingLocation and Rent DynamicsChallenges in Leasing and Landlord-Tenant RelationshipsImportance of Taxes and Broker RepresentationRetail Landscape and Market TrendsRestaurant Real Estate DynamicsFuture of Retail and Real Estate InsightsRapid Fire Questions and Closing Thoughts About Jay Luchs:Jay Luchs is Vice Chairman at Newmark and one of Los Angeles' most recognizable commercial real estate brokers, known for his “For Lease” and “Leased” signs across the city. He specializes in retail, office, and investment sales, representing top global fashion brands, entertainment companies, and emerging retailers. Luchs has completed major transactions for clients such as LVMH, Louis Vuitton, Dior, Celine, KITH, James Perse, and Equinox, including high-profile deals along Rodeo Drive, Melrose Avenue, and Sunset Boulevard.He played a key role in LVMH's $200 million purchase of the Luxe Hotel and the $122 million sale of 457-459 N Rodeo Drive to the Rueben Brothers. He's also helped launch first stores for brands like Alo Yoga and James Perse, and secured pop-up and permanent spaces for brands like Supreme, SKIMS, and Fear of God.In addition to retail, Luchs places corporate offices for fashion and entertainment clients, including Tom Ford, H&M, STAUD, and Brunel cuccinelli and various lvmh offices. He's also active in the local art and restaurant scenes, helping galleries like Gagosian and restaurants such as Craig's, Avra, and Tao Group find key locations across LA.Luchs and his team represent over 125 landlord listings in premier areas such as Rodeo Drive, Abbot Kinney, and Malibu. A top producer at Newmark since 2014, he has closed several billion dollars in deals. Originally from Maryland, Luchs graduated from the University of Virginia and has lived in Los Angeles since 1995. He serves on MOCA's Acquisition and Collections Committee. If you enjoyed this episode, please subscribe to our newsletter and enjoy the next podcast delivered straight to your inbox. For show notes, past guests, and more CRE content, please check out Crexi's blog. Ready to find your next CRE property? Visit Crexi and immediately browse 500,000+ available commercial properties for sale and lease. Follow Crexi:https://www.crexi.com/​ https://www.crexi.com/instagram​ https://www.crexi.com/facebook​ https://www.crexi.com/twitter​ https://www.crexi.com/linkedin​ https://www.youtube.com/crexi

In this enlightening episode, we engage in an in-depth discussion with Melissa Gainey, the esteemed founder of In The Garden Counseling, LLC, located in Lexington, South Carolina. As a Licensed Professional Counselor, Melissa brings a wealth of experience to the table, including cognitive behavioral therapy, a topic of growing relevance in our society. The conversation delves into the nuances of cognitive assessments, including a notable test administered to President Donald Trump, which Melissa graciously conducts on our host, Barrett Gruber. We explore the multifaceted nature of cognitive health, touching upon its implications for aging individuals and their families, as well as the broader societal context. Ultimately, this dialogue aims to illuminate the critical importance of mental health awareness and the resources available to those navigating these challenges.Make sure to check out ZJZ Designs Visit In The Garden Counseling LLC for a list of Melissa's Services.MoCA 8.3 English Test (pdf)Montreal Cognitive AssessmentIn The Garden Counseling LLC - Counseling in Lexington, SCClick here for Episode Show Notes!Click Here to see available advertising packages!Click Here for information on the "Fair Use Copyright Notice" for this podcast.Mentioned in this episode:BIG Media LLC Copyright 2025This Podcast is a product of BIG Media LLC and Copyright 2025 Visit https://barrettgruber.com for more from BIG Media LLC!BIG Media LLCEverplay Sports and Social LeagueSummer Sports are registering through May 21st, 2025! Visit https://everplaysports.com Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/trinity/all-stars-show License code: O9PSCKXIEBKXKSRYEverplay Sports & Social League

Jose Duran (b. 1979, Moca, Dominican Republic) is a painter, designer, and sculptor creating fantastical worlds of cosmopolitan opulence and sumptuous, even dangerous foliage. Duran's practice is anchored in extensive research of practices of survival, celebration, vengeance, sabotage, and aspirational desires in Black communities. He draws from baroque and rococo interiors to create scenes of architectural lavishness and femininity, producing complex compositions anchored in whimsy and play. Duran centers Black feminine figures as a reclamation of their contributions to European markers of taste, and as retribution for their forced labor under colonial rule. Duran's fantasies retrospectively place Black women at the center of his lavish interiors, where they reap the fruits of their labor. His practice is an ode to the dreams and aspirations of his late mother, who, between the Bronx and the Dominican Republic, would imbue in the artist a taste for cosmopolitanism and beauty. Photo credit: Nelson Castillo Artist https://joseduran.studio/ Hannah Traore Gallery https://hannahtraoregallery.com/exhibition/aleluya/ James Fuentes https://jamesfuentes.com/exhibitions/elena NY Times https://www.nytimes.com/2024/05/10/style/roze-traore-hannah-traore-gallery.html Art Speak https://www.artspeak.nyc/home/2024/2/13/jose-duran Island Origins Magazine https://islandoriginsmag.com/dominican-artist-jose-duran-aleluya/ Arthap https://arthap.com/hap/opening-jose-duran-aleluya/ Idiom Studio https://idiomastudio.com/jose-duran-caught-between-fantasy-reality/

Neste episódio, comparo MOCA x MEEM — vantagens e desvantagens de cada teste e em quais cenários usar um ou outro no consultório. Participe do Clube da Cognição do GeriClass, nossa comunidade gratuita de médicos interessados em avaliação cognitiva. Clica no link abaixo pra entrar! Entre para o Clube da Cognição do GeriClass https://chat.whatsapp.com/GrEQmgL1hWtBpyl67t8CpY

«Hacía ocho años que tenía en jaque a todo el Cibao. Se presentaba de improviso en Santiago, desaparecía y al otro día abaleaba un soldado en Salcedo.... Se dijo que era brujo; que cuando lo quería, se hacía invisible. Se le temía como a un dios implacable. El Gobierno despachó cientos de hombres tras él, y el ejército llenaba la cárcel de pobres campesinos, sospechosos de encubrirle. Nada.... »... Me llenó de sorpresa verlo tan sereno... como si no fuera el objeto de una caza feroz y larga. Llevaríamos más de media hora allí. Él había contado innumerables episodios de su vida y parecía muy cansado. Tenía una voz triste.... Él era campesino, joven.... »—Quique. Quizá yo pueda serle útil sin faltarle a mi conciencia. »—No, amigo, no tiene que faltarle; sólo lo quería pa conversar con usté. Me parece que no voy a durar mucho, y como de mí se habla tanto, no quería morirme sin que siquiera un hombre supiera que de no acosarme como un perro con rabia, esto se hubiera evitao.... »... Torné a verlo. Ni miraba ni se movía. Negro, triste y perseguido... »—No piense mal, Quique. ¿Por qué va a morirse usté? »—Es que tengo que morirme, amigo.... He pasao muchos años poniéndole el frente al diablo y llevándome en claro a muchos vagamundos; pero hace unos quince días que me pasó una cosa muy mala, y dende entonces ni an duermo.... Quique había estado rondando por Licey en pos de un compadre enfermo, y los soldados lo velaron. Ellos no acertaban nunca, porque la fama de Quique les hacía temblar el pulso a los mejores. Además, no se cuidaban de que hubiera o no gente. Mejor si la había, porque así se propalaba la noticia de que se había enfrentado al temible Quique Blanco, y eso, claro, podía proporcionar algún ascenso. Así, ese día una niña cruzaba cerca del fuego. La cogió una bala de Quique. Él la vio caer, y de golpe sintió que se le aflojaba el corazón. »—Dende ese día ando como loco, amigo. Cierro los ojos y la veo cayendo. Era una pobre criatura. No me lo perdono, amigo, y quisiera tener el poder de Dios pa devolvérsela a su mama.... »—¿Usté tiene hijos, Quique? —pregunté. »—No, amigo. Si hubiera tenío uno... »Adiviné el resto. En su lógica primitiva, dar su hijo en pago de la muerta era una solución. ¡Y eso lo pensaba él, que no sabía cómo se quiere a un hijo!... »Dos días después... me encontré con la noticia de que un muchacho de Moca había sorprendido a Quique Blanco durmiendo y le había destrozado la cabeza de un tiro con el revólver del propio muerto. Más tarde supe que habían paseado el cadáver por todos los pueblos del Cibao, para que la gente no creyera que seguía vivo.»1 Este cuento del ilustre escritor cibaeño Juan Bosch, uno de sus Cuentos escritos antes del exilio y por lo tanto antes de que llegara a ser presidente de la República Dominicana, nos recuerda que Dios sí dio a su Hijo en pago de la muerte que merecía cada uno de nosotros a causa de nuestro pecado, y que, a diferencia de lo que sucedió luego de que mataron a Quique Blanco, no había cadáver suyo que pudiera pasearse por los pueblos de Judea o de Galilea «para que la gente no creyera que seguía vivo». Porque Jesucristo resucitó,2 y hoy quiere que lo busquemos de todo corazón para que lleguemos a conocerlo en persona como Él realmente es, un Dios poderoso pero clemente y compasivo.3 Carlos ReyUn Mensaje a la Concienciawww.conciencia.net 1 Juan Bosch, «La verdad», Cuentos escritos antes del exilio (Santo Domingo: Edición Especial, 1974), pp. 38‑47. 2 Jn 3:16‑17; Ro 4:25; 6:23; 1Co 15:3‑4 3 Éx 34:6; Neh 9:17; Sal 86:15

Por km2 y por población Haina que empezó ayer el velatorio de 21 ciudadanos y mantiene a tres desaparecidos es el municipio más afectado por el desastre de la discoteca Jet Set.Baní reporta doce decesos, Yaguate cinco, Moca tres…Institucionalmente el Banco Popular cinco decesos, el Reservas tres, el ADN dos muertes.Cito estos ejemplos porque no hay que repetir que esta tragedia ha tocado el país en pleno.Las autoridades informaron el cambio en el protocolo de búsqueda a rescate de cuerpos. Las declaraciones del ministro de salud a partir de los informes forenses es clara. La mayoría no sobrevivió a la lluvia de cemento e infraestructura pesada que les cayó encima. El trauma les produjo la muerte inmediata.Hay que reconocer el trabajo de las autoridades tanto en el operativo de rescate como en la organización para evitar la desinformación.La centralización de la data en el COE ha evitado la manipulación a pesar de eso la escoria mediática se esfuerza. Un articulo de diario libre al respecto dice que no se le puede pedir fragancia a la basura, porque solo hiede.El editorial de El Día, que ya les compartí en el canal de Whatsapp lo explica en 8 líneas “a medida que se diluía la intensidad de los trabajos de rescate, comenzaron a reaparecer los buscadores de «likes», incapaces de generar contenido con valor. Recurrieron entonces a la tergiversación, al sensacionalismo, a la invención y, sobre todo, al irrespeto a las víctimas, que no es otra cosa que revictimizarlas.Sin embargo, estos mercaderes del morbo no cargan solos con la culpa. También son responsables quienes los siguen, les comentan y, sobre todo, los premian con su aprobación digital. Mientras tengan audiencia, estas rapiñas seguirán haciendo daño, alimentadas por una sociedad que los legitima”.

Only two of them and they still managed to go on for 45 minutes?! Andrew and Martin talk polls, ethernet, guest appearances and then get deep on what things might be like if we started over. 'One Prime Plus Dot Com', the people shouted! Polls Have Consequences 00:00:00 The Poll from Episode 132 (https://social.lol/@hemisphericviews/114113731738388946)

What's good for the heart is good for the brain. Guest Brittany Butts, PhD, RN, describes helping patients understand this connection and implement actions to decrease their risk for both cardiovascular and cognitive declines. MMSE: https://muhc.ca/sites/default/files/micro/m-PT-OT/OT/Mini-Mental-State-Exam-%28MMSE%29.pdfMOCA: https://mocacognition.com/paper (official site)https://geriatrictoolkit.missouri.edu/cog/MoCA-8.3-English-Test-2018-04.pdf (PDF only)PCNA CE Course: Preventing Stroke: Applying the Guidelines https://pcna.net/online-course/preventing-stroke-applying-the-guidelines/See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

¡Bienvenidos al único programa que te trae a los especímenes más brillantes del país! ¡Esto es otro gran episodio de Bájale 2! El doctor de la muerte existe y no te atrevas hacerle un corte de pastelillo porque te va a caer a tiro limpio y luego te hace un torniquete para salvarte. Suerte que el buen doctor no estará libre para encojonarse por el voceteo en la Parguera. Abuelas molestas que le caen a cantazo limpio a sus hermanas y criminales inteligentes de Moca, esto es mucho con demasiao en otro gran programa de Bájale 2. Grabado desde GW-Cinco Studio como parte de GW5 Network #tunuevatelevisión. Puedes ver toda la programación en www.gwcinco.com. siguenos en instagram @gw_cinco Patreon: patreon.com/gw5network patreon.com/hablandopop

Join us for a special edition of The Edge of Show, recorded live in Hong Kong at Consensus and Hack Season, where the future of Web3 is being shaped in real time. This episode is packed with insights from industry pioneers driving the next evolution of blockchain, tokenization, and decentralized finance. We sat down with some of the most influential voices in the space—Mark Mayerfeld, Chief Revenue Officer at GK by Galaxy, Patrick Schabhuttl, Head of Ecosystem at Mocaverse, Asaf Nadler, CEO and Co-Founder of Addressable, Jason Lau, CEO of OKX and Gleb Gora, CEO and Co-Founder of Vortex Foundation to uncover the latest innovations and challenges defining the industry today.In this episode, we explore:The tokenization of real-world assets and how stablecoins are evolving in institutional markets.Mocaverse's vision for Web3 identity with Moca 3.0, pushing for a more seamless, user-friendly decentralized experience.How AI-driven marketing and blockchain analytics are transforming how Web3 companies connect with the right users.OKX's European expansion and how they're bridging the gap between centralized and decentralized trading.Don't miss this deep dive into the technologies and strategies shaping the next era of Web3.Support us through our Sponsors! ☕

El 59.4% de la población tiene trabajo: InegiLey del ISSSTE busca beneficiar a maestros: Sheinbaum Empleados públicos en Argentina paran laboresMás información en nuestro podcast

Neuroscientist Adrian Owen discusses his KevinMD article, "A wake-up call for dementia detection: the urgent need for precision tools across health care." Adrian highlights the alarming rate of dementia diagnoses worldwide and examines the shortcomings of outdated detection tools like MMSE, SLUMS, and MoCA. He emphasizes the need for innovative, digitally-enabled cognitive assessment tools to ensure early and accurate diagnoses. The conversation explores actionable strategies to integrate advanced neuroscience into primary care, aiming to reduce health care costs and improve patient outcomes. Our presenting sponsor is DAX Copilot by Microsoft. Do you spend more time on administrative tasks like clinical documentation than you do with patients? You're not alone. Clinicians report spending up to two hours on administrative tasks for each hour of patient care. Microsoft is committed to helping clinicians restore the balance with DAX Copilot, an AI-powered, voice-enabled solution that automates clinical documentation and workflows. 70 percent of physicians who use DAX Copilot say it improves their work-life balance while reducing feelings of burnout and fatigue. Patients love it too! 93 percent of patients say their physician is more personable and conversational, and 75 percent of physicians say it improves patient experiences. Help restore your work-life balance with DAX Copilot, your AI assistant for automated clinical documentation and workflows. VISIT SPONSOR → https://aka.ms/kevinmd SUBSCRIBE TO THE PODCAST → https://www.kevinmd.com/podcast RECOMMENDED BY KEVINMD → https://www.kevinmd.com/recommended GET CME FOR THIS EPISODE → https://www.kevinmd.com/cme I'm partnering with Learner+ to offer clinicians access to an AI-powered reflective portfolio that rewards CME/CE credits from meaningful reflections. Find out more: https://www.kevinmd.com/learnerplus

Welcome to PsychEd, the psychiatry podcast for medical learners, by medical learners. This primer covers the differential diagnosis of dementia. Hosts: Dr. Alastair Morrison (PGY-1) and Dr. Angad Singh (PGY-1) Audio editing by: Dr. Angad Singh (PGY-1) Resources: MoCA: https://dementia.talkbank.org/protocol/materials/MOCA.pdf MMSE: https://meded.temertymedicine.utoronto.ca/sites/default/files/assets/resource/document/mini-mental-state-examinationmmse.pdf Beers Criteria: American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults PsychEd Episode 49: Dementia Assessment with Dr. Lesley Wiesenfeld References: American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596 Francis, J. & Young, B. (2022). Diagnosis of delirium and confusional states. UpToDate. Retrieved January 31, 2025, from https://www.uptodate.com/contents/delirium-and-acute-confusional-states-prevention-treatment-and-prognosis Larson, E. B. (2022). Evaluation of cognitive impairment and dementia. UpToDate. Retrieved January 31, 2025, from https://www.uptodate.com/contents/evaluation-of-cognitive-impairment-and-dementia PsychDB. (2022, Oct 3). Introduction to Dementia. Retrieved January 31, 2025, from https://www.psychdb.com/geri/dementia/home PsychDB. (2024, Feb 1). Delirium. Retrieved January 31, 2025, from https://www.psychdb.com/cl/1-delirium PsychDB. (2024, Feb 9). Alzheimer's Disease. Retrieved January 31, 2025, from https://www.psychdb.com/geri/dementia/alzheimers PsychDB. (2023, Oct 12). Vascular Dementia. Retrieved January 31, 2025, from https://www.psychdb.com/geri/dementia/vascular PsychDB. (2024, Jan 23). Frontotemporal Dementia. Retrieved January 31, 2025, from https://www.psychdb.com/geri/dementia/frontotemporal PsychDB. (2024, Feb 5). Dementia with Lewy Bodies. Retrieved January 31, 2025, from https://www.psychdb.com/geri/dementia/lewy-body For more PsychEd, follow us on Instagram (@psyched.podcast), Facebook (PsychEd Podcast), and X (@psychedpodcast). You can email us at psychedpodcast@gmail.com and visit our website at psychedpodcast.org.

Jon Jordan talks to Animoca Brands' chairman Yat Siu about the rise of memecoins, the value of Telegram and TON as a distribution platform, and how AI agents could shake everything up. [3:56] What's the state of memecoins in 2025? [6:28] "We are narrative, story-telling people - money, democracy, politics are all stories." [8:32] "The part that makes me a bit negative about memes is they are being abused by snipers." [11:02] Is PENGU a pure memecoin? Can a memecoin gain utility? [13:18] Will institutions buy memecoins? There will be memecoin ETFs. But this need narrative. [16:45] "Telegram is still the most powerful distribution platform." [20:50] "TON means that Telegram will survive [22:52] Ronin demonstrates the power of community as Axie was joined by Pixels. [23:22] "In web3, they came for the money but stayed for the social." [27:01] 'AI agents can now create tokens and pay humans to do things for it.' [28:31] How Yat deals with vampire agent IP attacks such AImonica and an AI Yat agent. [29:25] AI agents will make it easier for humans to interact with blockchains and wallets. [31:54] Yat's attitude to the AImonica AI agent project. [34:47] What's next for Mocaverse and the MOCA token? [36:15] Reputation systems don't have to just be for humans, but can be for AI agents too. [37:22] How blockchains and reputation can help student loans. [38:07] Why Animoca isn't as focused on building and investing games as it once was. [38:51] "We think NFTs are going to have a pretty big comeback in 2025."

Welcome to a very special episode of Moon to Moon. Our honored guest is Mother Witch Amanda Yates Garcia, also known as The Oracle of Los Angeles. Amanda has long been someone I deeply admire as a leader of integrity, honesty, wisdom, and inspiration. Amanda is incredibly smart, wildly magnetic, and wholly grounded in her devotion.  What happened here was a gift. And it's an honor to share this conversation with you today. May it be a lantern to light your heart and to lift your spirit.   Thank you, Amanda.  Amanda Yates Garcia is a writer, witch, and the Oracle of Los Angeles. Her work has been featured in The New York Times, The LA Times, The SF Chronicle, The London Times, CNN, BRAVO, as well as a viral appearance on FOX. She has led rituals, classes and workshops on magic and witchcraft at UCLA, UC Irvine, MOCA, The Hammer Museum, LACMA, The Getty and many other venues. Amanda hosts monthly moon rituals online, and the popular Between the Worlds podcast, which looks at the Western Mystery traditions through a mythopoetic lens. Her book, Initiated: Memoir of a Witch, received a starred review from Kirkus and Publisher's Weekly and has been translated into six languages. To find out more about her work become a member of her Mystery Cult on Substack.   +++ Learn more about The Magician's Table 2025 and find out who the 13th readers are here.  Applications open Feb 14 for Early Bird weekend (Feb 14-16).  To apply that weekend, you must be on the waitlist. Join the waitlist here. +++ E M E R G E N C E  A S T R O L O G Y ⁠⁠https://brittenlarue.com/ ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Instagram: ⁠⁠⁠⁠⁠@brittenlarue ⁠⁠⁠⁠⁠⁠Order Living Astrology⁠⁠⁠⁠⁠⁠ Join my newsletter here Check out my new podcast CRYSTAL BALLERS on Spotify, Podbean, and Apple. +++ Podcast art: Angela George. Podcast music: Jonathan Koe.

MOCA is evolving, and we want you along for the ride. 2025 is a year of great change for your favorite crypto art museum, and in this episode, Max and MOCA's co-founder and Chief Technology Officer, Reneil1337, dive deep on all the exciting changes. A 10,000-piece PFP turned Agentic AI deployment interface? Supporting ai16z and Hyperfy in all kinds of creative ways? A new vision for $MOCA token? We reveal all that and more. Come find out what's got us all so jazzed up. 

Anti-amyloid therapies provide the first FDA-approved option to alter AD pathology, but an understanding of overall utility and value to patients remains in its infancy. In this episode, Teshamae Monteith, MD, FAAN, speaks with David S. Geldmacher, MD, FACP, FANA, author of the article “Treatment of Alzheimer Disease” in the Continuum® December 2024 Dementia issue. Dr. Monteith is the associate editor of Continuum® Audio and an associate professor of clinical neurology at the University of Miami Miller School of Medicine in Miami, Florida. Dr. Geldmacher is a professor and Warren Family Endowed Chair in Neurology and the director of the Division of Cognitive and Behavioral Neurology, Department of Neurology, Marnix E. Heersink School of Medicine at the University of Alabama at Birmingham in Birmingham, Alabama. Additional Resources Read the article: Treatment of Alzheimer Disease Subscribe to Continuum: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @headacheMD Transcript Full interview transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, which features conversations with Continuum's guest editors and authors who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article and have access to exclusive interviews not featured on the podcast. Please visit the link in the episode notes for more information on the article, subscribing to the journal, and how to get CME. Dr Monteith: This is Dr Teshamae Monteith. Today, I'm interviewing Dr David Geldmacher about his article on treatment of Alzheimer's disease, which appears in the December 2024 Continuum issue on dementia. Welcome to our podcast, Dr Geldmacher. How are you?  Dr Geldmacher: I'm very well, thank you. It's a pleasure to be here.  Dr Monteith: Yeah. So, why don't you introduce yourself to our audience? Dr Geldmacher: Sure. I'm David Geldmacher. I'm a professor of neurology at the University of Alabama in Birmingham and I lead the division of Cognitive and Behavioral Neurology.  Dr Monteith: So, I'm really excited about this, to personally learn, and I know that or neurology community is also really excited about this interview. So, why don't we start off with your main objective.  Dr Geldmacher: So, my main goal in the article was to review the FDA-approved pharmacologic treatments for dementia. There's lots of ways of thinking about treatment of dementia; psychosocial, caregiver support, and so forth. But I really wanted to focus on the issues of drug treatment because that's what has been our backbone for a long time and now has recently expanded.  Dr Monteith: Why don't we talk a little bit about, first of all, the boom in the field? What's that been like?  Dr Geldmacher: So, the big change in the field is over the last several years, we've had treatments become available that actually attack the underlying Alzheimer pathology, and that's new and different. For decades, we've been able to treat the symptoms of the disease, but this is the first time we've really been able to get to the root of the pathology and look toward removing amyloid plaques from the brain.  Dr Monteith: Let's step back a little bit and talk about the framework of diagnosis and how that leads into the therapeutic potential. I know you're going to dive into some of the biologics, but we should probably talk about the kind of holistic approach to considering the diagnosis. Dr Geldmacher: Sure. So, you know, when someone comes to the clinic with memory complaints, our question we have to ask is, is this neurologic origin, a structural origin like Alzheimer's disease or vascular dementia? Are there complicating factors, the software issues of mood disorders and sleep disorders and pain that can all magnify those symptoms? The clinical reasoning is a critical part of that, but in Alzheimer's disease, typically the problems revolve around difficulty forming new memories of events and activities, the episodic memory. And then it's often accompanied by changes in word finding and semantic knowledge. And those are the things that we look for in the clinic to really point toward an AD diagnosis. And then we support it with exclusion of other causes through blood work and identification of patterns of brain atrophy on MRI. And then most recently in the last couple of years, we've been able to add to that molecular imaging for amyloid with PET scans as well as, most recently, blood-based biomarkers for Alzheimer's pathology. So, it's really been a revolution in the diagnosis over these last several years.  Dr Monteith: And when approaching patients or populations of individuals, there seems to be a real full spectrum with looking at the societal burden, the biological impact, of course, risk factors of primary prevention, and now this whole area of brain health and secondary prevention. How do you kind of tie all of this together when talking to patients and family members?  Dr Geldmacher: Sure. So, the approaches for brain health apply to everyone. In basically every clinic visited, our brain aging and memory clinic, we reviewed lifestyle approaches to brain health like regular physical exercise, healthy diet, cognitive and social stimulation. And those are fundamental to the approach to everyone, whether they have cognitive impairments that are measurable or not. These are all things that are good for our brain health. And then, you know, focusing on the vascular risk factors in particular and working with the patient and their primary care team to ensure that lipids and blood sugar and blood pressure are all in good healthy ranges and being appropriately treated.  Dr Monteith: You know, there's this kind of whole considerations of clinically meaningful endpoints and clinical trials, and even when we're talking to our patients. What would you say the field has kind of identified has the best endpoints in helping patients? Would you call it impaired daily function? Is that like the best hard endpoint? Obviously, there are other things such as caregiver burden, but you know, how do you approach assessing patients? Dr Geldmacher: Defining the endpoints is very difficult. Typically, if we talk to patients and their families, they would like to have better memory or improve memory. How that applies in everyday life actually is daily function. And so, we focus very much on daily function. And when I talk about our therapies, whether they're symptomatic therapies or the new disease-modifying therapies, I really talk about maintenance of function and delays and decline or slowing of decline, helping to foster the person's independence in the activities that they have and be able to sustain that over the longer term.  Dr Monteith: And when thinking about diagnosis- and we're going to get into treatments, but when thinking about the diagnosis, and of course, it's full-spectrum from mild cognitive impairment to moderate and severe forms of dementia, but who should have CSF testing and PET imaging? Obviously, these are invasive, somewhat invasive and expensive tests. Should all people that walk in the door that have memory complaints? How do you stratify who should have tests? Dr Geldmacher: I think about this in a big funnel, basically, and the starting point of the funnel, of course, is the person with memory complaints. Then there's that neurologic reasoning. Are these memory complaints consistent with what we expect from the anatomy of Alzheimer's disease, with atrophy in in the hippocampus and temporal lobe? Do they have episodic memory loss or not? That first step is really trying to characterize, do the clinical patterns act like those of Alzheimer's disease or not? And then we follow the Academy of Neurology guidelines, looking for reversible sources of cognitive decline, things like B12 deficiency and depression, sleep disorders and the like, and try to exclude those. We start with structural imaging with everyone, and MRI, typically, that will help us understand vascular burden and patterns of atrophy, looking for things like mesial temporal atrophy or precuneus atrophy that are characteristic of Alzheimer's disease. If those things are all pointing in the direction of AD as opposed to something else, then typically before moving on to CSF or PET scan, we will use blood-based biomarkers, which are one of the big changes in the field in the last year or so, and there are now multiple panels of these available. The downside is they are typically not covered by insurance. On the other hand, they can really help us identify who is likely to have a positive PET scan or positive findings on CSF. We start to provide that counseling and information to the patient before they get to those more definitive tests. We can push people in the other direction. We can say, your blood-based biomarkers are negative or do not indicate AD as the most likely source of your condition now, so let's treat other things. Let's see what else we can focus on. The blood-based biomarkers are now, in our clinic at least, the critical choke point between the routine workout that we've always done on everyone and then the more advanced workup of proving amyloid pathology with CSF or a PET scan. Dr Monteith: How sensitive are those blood biomarkers and how early are they positive?  Dr Geldmacher: The sensitivity is generally pretty good, in the ninety plus percent range on average and it depends on which panel. And as you point out, when in the course of symptoms that they're done, we know that they become positive and presymptomatic or asymptomatic people. We're using these kinds of markers to screen people for prevention trials. So, I think when someone is symptomatic, they're a good indicator of the presence or absence of AD pathology. Now that doesn't mean the AD pathology is the sole cause of their symptoms. And so, we still need to think about those other things like sleep and mood and so forth. But they do point us in the in the direction of Alzheimer's change.  Dr Monteith: So why don't we talk about some of the more standard older treatments, and it's also important to leave with kind of some rational approach to when we start and what should we be counseling our patients on. So why don't we start with the older, you know, choline esterase inhibitors and then some of the MDA- I guess there's only one modulator, SEPTA modulator. Dr Geldmacher: So, I've been really fortunate in my career span, the time from the first of those symptomatic agents reaching the market in 1993 to seeing the disease modifying drugs enter the market now. I think most neurologists actually have entered practice after those clinical trials of the colon esterase inhibitors were published. So, one of my goals in this article was to review that primary data and what can we expect from those symptomatic drugs. We know that they are inconsistently effective in mild cognitive impairment, and the Academy of Neurology guidelines says there is not strong evidence to use them in mild cognitive impairment. But in mild AD and beyond, the cholinesterase inhibitors provide meaningful benefits. They delay decline, they can delay nursing home placement. They reduce overall costs of care. So, I think they provide real value. So, in the article I have reviewed what the data looked like on those. My approach is to start with oral Donepezil at five milligrams and increase it to ten in everyone who tolerates the five. If for whatever reason the oral Donepezil is not well tolerated, I'll switch to transdermal rivastigmine to help improve tolerability. There are very few head to head comparisons, but nothing suggests that one of the cholinesterase inhibitors is superior to the other for clinical outcomes, and there's no evidence to support conjoint use of more than one at a time. Should someone be showing decline then on typical cholinesterase inhibitor therapy - and people will, it's often delayed, but the decline will reemerge - then I will add the NMDA receptor, a modulator memantine and titrate that up to full dosing, either 10 mg twice a day for the conventional release or 22 mg extended release. And at that point we're sort of on maximal pharmacologic therapy for Alzheimer's disease. These agents can provide some benefit in other conditions, they're off-label except for Lewy body disease where rivastigmine is labeled. But they can provide benefit across different conditions. And there's some preliminary data, for instance, of acetylcholinesterase inhibitors being helpful in vascular cognitive impairment. So, I will use them, but I expect the greatest response when someone really does follow the patterns of Alzheimer's disease.  Dr Monteith: And you have a great chart, by the way, and nice figures looking at some of the meta-analyses on cognitive outcomes as well as functional outcomes. So, thank you for that.  Dr Geldmacher: In general, all of those tables favor treatment over placebo in the domains of cognition, daily function, neuropsychiatric symptoms. And it's that consistency of result that lets me know that we really are seeing a drug effect, that it's not a class effect with those, that we really are helping our patients. It's not like some studies are positive and some are negative. They are very consistently positive. Small magnitude, but consistently positive.  Dr Monteith: And I know we have a lot of patients coming in where, at least, their caregivers are complaining about agitation, and sleep is also a problem for others. And so how do you help that patient? I know you have a good algorithm that also you included in your article, but why don't you summarize how we should approach these symptoms? Dr Geldmacher: Sure. So, for nonpsychotic agitation, you know, just restlessness, wandering, pacing and so forth, my first choice is an off-label use of citalopram. And there is good clinical trials evidence to support that. if someone has psychotic agitation that is with delusions or hallucinations and so forth, I think we do need to move to the antipsychotic drugs. And the one drug that is now approved for treatment of agitation and Alzheimer's disease does fall into that antipsychotic category, along with its various black box warnings - and that's brexpiprazole. For many of our patients, getting coverage for that agent is difficult. It's not on many formularies. So, it is something I progress toward rather than start with. Similarly, for sleep, there is one approved agent for sleep, that's a dual orexin agonist. And it shows effectiveness, but can have some negative cognitive effects, and so I tend not to start with that either. My first choice when sleep is the primary issue for our patients with dementia is trazodone, and there are some small, limited studies for it's off-label used to enhance sleep. It's safe, inexpensive, often effective, and therefore it's my first choice. Dr Monteith: So, now let's get into the big conversations that everyone is having. Let's talk about the newer disease modifying anti amyloid therapies. Give us a summary dating back 2021 probably, although we can hold the preclinical work, but let's talk about what is available to our patients. Dr Geldmacher: Sure. And the development of anti-amyloid therapies goes all the way back to 1999. So, it's a pretty long course to get us to where we are today.  Dr Monteith: Yeah, that's why we limited that.  Dr Geldmacher: With that first approved agent with aducanumab in 2021, it received a limited or accelerated approval in FDA parlance. These agents, the aducanumab, lecanemab and donanemab, all approved, are known to remove amyloid pathology from the brain as measured by CSF and/or BIPET. They are amyloid lowering therapies, often called disease-modifying therapies. And across the agents there's some variable results. But if we look at the two with full approval, lecanemab and donanemab, they slow clinical progression by 25% to 35% on average. And that's measured by either cognitive measures or global measures or composite measures, but it's pretty consistent in that range of about one-third slowing. That makes it really difficult to discern in an individual patient, though, because there's so much variability in the progression of the disease already that it can be difficult to tell in one person that these drugs are working. They're also complex to use, so there's a qualification process that involves MRI to exclude things like a high tendency toward hemorrhage. It includes genetic testing for papal E4 status to help us understand the risk for complication, and then once-monthly or twice-monthly infusions with standardized schedule for MRI scanning. So, there's a lot that goes into managing these agents. And they are expensive, and we don't yet know their cost effectiveness. The cost effectiveness of the cholinesterase inhibitors was questioned when they first came out back in the 1990s, and it took five or ten years to really understand that they provided benefit to society and to individuals in those domains of quality of life and return on investment. And we're still learning about that with the disease modifying therapies.  Dr Monteith: So, two questions. One, the case that you presented was an individual having symptoms and kind of voiced their desire to be on these therapies. So, people are going to be asking, coming to clinic asking and then of course, they're going to be people that you select out. So, how do you make that decision to recommend this treatment for patients given the potential risk? Dr Geldmacher: We've got some really good guidance from appropriate use recommendation papers for aducanumab and lecanemab, and I'm expecting one from donanemab fairly soon. But the key is to identify individualized risks, and that involves knowing their APOE4 status, knowing their- whether they've had microhemorrhages in the brain previously, and then documenting that they really do have amyloid pathology with something like PET scan to establish those baselines. I talk to people about the burden of twice-monthly infusions or, now with donanemab, once-monthly infusions. And for instance, for someone who's got a working caregiver, getting to an infusion center twice a month can be a significant burden. And then if there are complications, frequent MRI scans and so forth. So, we talk about the burden of entering into this therapeutic pathway. The reality is that people who are qualified generally want it. I have relatively few folks who have said, no, these risks are more than I'm willing to accept. For decades my patients have said, anything you can do to slow this down, I'm willing to try. And now we're seeing that translated to reality with people willing to accept high-risk, high-cost treatments with the chance of slowing their individual progression.  Dr Monteith: And how do you select between the two treatments? Dr Geldmacher: So far that's been easy because donanemab's not readily available.  Dr Monteith: Outside of clinical trials, right?  Dr Geldmacher: Exactly. For prescription use, it's coming in - the first cases have now been infused - but it's not generally available. Nonetheless, what I will do for patients in this is look at the risk tables. So donanemab appears to have in general some higher rates of the Aria complications, amyloid-related imaging anomalies, and some people are going to be more risk tolerant of that for the payoff of potentially faster response. The donanemab trials restructured that. They did their first assessment of effectiveness. I had amyloid removal at six months and a significant proportion of people were eligible to discontinue treatment at six months because their amyloid was below treatable thresholds. So higher risk, perhaps faster action and fewer infusions for donanemab. Lecanemab we have more direct experience with, and between the two of them, the eighteen month outcomes are pretty much the same and indistinguishable. So are we in it for a quick hit, or are we in it for the long race? And different patients and different families will have differing opinions on where they want to accept that risk and burden and so forth. But so far, the data don't indicate a lot of difference in their longer-term outcomes. We still have plenty to learn.  Dr Monteith: And so, it sounds like, as you mentioned, we're looking at eighteen months out for kind of a hard outcome, and that there is a lot of variability in response rate. How are you tracking patients- you know about the imaging, so just in terms of clinical outcomes and efficacy?  Dr Geldmacher: Sure. So, for Medicare to reimburse on these treatments, people need to be enrolled in a registry program - and there are several of these, CMS runs one of their own. But the requirement for that is, every six months, to do cognitive and functional outcomes through the first two years. Cognitive outcomes are up to the clinician, but things like the mini mental state exam, the MoCA, are appropriate. In our own program, we use something we developed locally called the Alabama Brief Cognitive Screener. As for the cognitive outcomes and then for functional, we use an instrument called the General Activities of Daily Living Scale, but there are many other ADL scales that could be used as well. CMS does not mandate specific tests. Since the progression of the disease is variable to begin with, we don't really know how to interpret these results in reference to whether the drug is working, but I can tell a patient or a family member, your scores are stable, or, you have a decline of three points in this test. That's typical for this duration of illness. But there isn't a good way to know whether the drug is working in this person at this time, at least with our current levels of data.  Dr Monteith: So, I think we have to talk about health equity, and it sounds like Medicare is reimbursing for some of us. We look at different socioeconomic backgrounds, educational backgrounds, race, ethnicity. Not everyone is aware of these treatments. So, how do we get more patients to become aware of these treatments? And how do we get them to more people to help people? Dr Geldmacher: Yeah, I mean, that's- it's a major, major issue of inequity in our population. We've done some work at UAB looking at the flow of members of minority communities into memory clinics. So, we know that the overall population of, and I'll choose, for an example, blacks and African Americans, that they are represented a much higher rate in our overall UAB treatment population than they are in our memory clinic population. So, they're not even getting to us in the specialty clinic at the same rates as other segments of our population. We also know that blacks and African Americans in our population are not receiving PET scans as often as the overall treatment population. So yes, there are real, real problems with access. There are cultural issues behind this as well. And in many communities, a change in cognition, a loss of memory is an expected part of the aging process rather than recognized as a disease. So, people who come to us from minority communities are often further along in the course of cognitive and functional decline and beyond the point where they might qualify for the disease-modifying therapies, where early AD is the sort of defining boundary. So, I think more awareness and more screening in primary care settings, perhaps more community outreach to let people know that changes in memory that affect daily function are not normal as part of the aging process and should be evaluated for intervention. So, there's lots of places in our healthcare community where we could foster better outreach, better knowledge to get more folks access to the medicines. And this is before we even get to cost. Dr Monteith: Yeah, yeah. And obviously, there's some stigma as well.  Dr Geldmacher: That's right.  Dr Monteith: Really recognizing what the issues are and diving and asking those questions and funding research that asks those questions, as you mentioned, is really important. And then you have also a nice area where, you know, looking on the impact of treatments on caregiver-related outcomes, and of course ultimately want to keep patients out of nursing homes and prevent death. And so, can you talk a little bit about that? And, you know, mainly the caregiver burden.  Dr Geldmacher: So, my research in that area goes back a long way now. But I learned early in the course of therapy that many times the outcome that the family is noticing for symptomatic therapies is not a change in the patient's memory per se, but that there is less work involved in the caregiving. Less time is spent in direct caregiving roles. The patient may shadow less and because they have better independent cognition. I remember one family member once told me, the medicine you started is a godsend because now I can go to the bathroom by myself and he's not pounding on the door saying where are you, where are you. He's able to recall long enough that I'm in the bathroom that I have that moment of privacy. That was very meaningful to me to hear that. So. Dr Monteith: Cool. So why don't you just help us wrap this up and just give us, like, three main takeaway points that we should be getting out of your article? Dr Geldmacher: The three points that I would emphasize from my article is that the symptomatic therapies provide meaningful benefits and measurable, consistent, meaningful benefits. The second is that those benefits extend beyond things like cognitive test scores and into things like caregiver well-being and maintenance of independence in the home environment. And the third is that the disease-modifying therapies are an exciting opportunity to modify the pathology, but we still are learning about their cost effectiveness and their long-term benefit both to individuals and to society. But the only way we're going to learn that is by using them. And that was the experience that we gained from the symptomatic therapies that took use in the community for years before we really began to understand their true value. Dr Monteith: Thank you. That was excellent. And I put you on the spot, too.  Dr Geldmacher: No problem.  Dr Monteith: Again, today I've been interviewing Dr David Geldmacher, whose article on treatment of Alzheimer's disease appears in the most recent issue of Continuum on Dementia. Be sure to check out Continuum audio episodes from this and other issues. And thank you to our listeners for joining today. Dr Monteith: This is Dr Teshamae Monteith, associate editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in depth and clinically relevant information important for neurology practitioners. Use this link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at contentpub.com/AudioCME. Thank you for listening to Continuum Audio.

Episode No. 688 features artist Sayre Gomez and curator Anna Katz.  Gomez is included in two of the season's major contemporary group shows: "The Living End: Painting and Other Technologies, 1970-2000," at the Museum of Contemporary Art Chicago, and "Ordinary People: Photorealism and the Work of Art since 1968" at the Museum of Contemporary Art, Los Angeles.   Gomez is a Los Angeles-based painter whose work uses hyperrealism to address current events and representation and visuality in US society.   Katz is the curator of "Ordinary People," which is at MOCA through May 4. The exhibition's fine catalogue was published by the museum and DelMonico Books. Amazon and Bookshop offer it for about $65.  "The Living End" was curated by Jamillah James, who discussed her exhibition on Episode No. 683. It is on view through March 16. The exhibition catalogue is available from the MCA for under $20. Instagram: Sayre Gomez, Anna Katz, Tyler Green.

Que en las cárceles se consuma drogas no es noticia. Se consume de todo, se venden los cuerpos de hombres y mujeres y ni ahora ni nunca antes se ha hecho un esfuerzo por ordenar mínimamente esa situación. Lo ha impedido la corrupción. El último incidente vinculado a la corrupción y los negocios que sobre todo benefician a policías y militares en el sistema carcelario fue el desmantelamiento de un almacén de bebidas en el penal de la victoria. Ese almacén desmantelado en noviembre pasado estaba nada mas y nada menos que en el baño del coronel José Rodríguez Valenzuela que a la sazón era el jefe de seguridad del penal. En la misma Victoria en el 2022 fue desmantelado un sistema de fibra óptica para la distribución de señales de internet cuya instalación requería de personal técnico competente. El cable de fibra llegaba por la vía subterránea o sea que se cavó una zanja kilométrica para ello sin que nadie lo viera. Sin embargo la denuncia de Guanchy Compres de que tres reclusos han sido hospitalizados, uno de ellos en cuidados intensivos, como resultado de un concurso de consumo de drogas en el interior de una carcel rompe todos los records. Una se pregunta cuanta droga ingresa a ese penal de manera que se posibilite hace un concurso de consumo. Cuántos privados de libertad, como se dice ahora, participaron en él y cómo todo eso ocurre en un recinto carcelario sin que las autoridades del penal se enteren. Insisto que una sabe que en la cárceles se trafica todo pero por sentido común hay que suponer que los únicos reos que participaron en el concurso no fueron los que llegaron a los niveles de intoxicación. Comprés ha pedido el traslado de todo el personal que trabaja en la cárcel de la Isleta y una se pregunta para qué. Esa práctica  de los traslados de policías muda el problema para otra parte. No sé a quién le toca investigar ni a quién le toca sancionar pero alguien debe hacerlo.

En este episodio, exploramos la inspiradora travesía de Hugo Pérez, CEO de Terrestra, desde sus humildes comienzos en Moca hasta liderar proyectos de construcción en el Caribe. Hugo comparte valiosas lecciones sobre resiliencia, visión y cómo transformar desafíos en oportunidades. Reflexionamos sobre la importancia de reconocer oportunidades, construir con propósito y mantenerse enfocado en metas significativas. Si buscas motivación para superar límites, este episodio está lleno de aprendizajes que cambiarán tu perspectiva. #DalePlay y #LearnWhileInvesting

Although Alzheimer disease (AD) is the most common neurodegenerative cause of dementia, other etiologies can mimic the typical amnestic-predominant syndrome and medial temporal brain involvement. Neurologists should recognize potential mimics of AD for clinical decision-making and patient counseling. In this episode, Kait Nevel, MD, speaks with Vijay K. Ramanan, MD, PhD, an author of the article “LATE, Hippocampal Sclerosis, and Primary Age-related Tauopathy,” in the Continuum December 2024 Dementia issue. Dr. Nevel is a Continuum® Audio interviewer and a neurologist and neuro-oncologist at Indiana University School of Medicine in Indianapolis, Indiana. Dr. Ramanan is a consultant and assistant professor of neurology in the Division of Behavioral Neurology at Mayo Clinic College of Medicine and Science in Rochester, Minnesota. Additional Resources Read the article: LATE, Hippocampal Sclerosis, and Primary Age-related Tauopathy Subscribe to Continuum: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: IUneurodocmom Guest: @vijaykramanan Full episode transcript available here Dr Jones: This is Dr Lyle Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, which features conversations with Continuum 's guest editors and authors who are the leading experts in their fields. Subscribers to the Continuum Journal can read the full article or listen to verbatim recordings of the article and have access to exclusive interviews not featured on the podcast. Please visit the link in the episode notes for more information on the article, subscribing to the journal, and how to get CME. Dr Nevel: This is Dr Kait Nevel. Today I'm interviewing Dr Vijay Ramanan about his article he wrote with Dr Jonathan Graff-Radford on LATE hippocampal sclerosis and primary age-related tauopathy, which appears in the December 2024 Continuum issue on dementia. Welcome to the podcast. Vijay, can you please introduce yourself to the audience? Dr Ramanan: Thanks so much, Kait. I'm delighted to be here. So, I am a cognitive neurologist and neuroscientist at the Mayo Clinic in Rochester, Minnesota. I have roles in practice, education and research, but amongst those I see patients with cognitive disorders in the clinic. I help direct our Alzheimer's disease treatment clinic and also do research, including clinical trial involvement and some observational research on genetics and biomarkers related to Alzheimer's and similar disorders. Dr Nevel: Great, thanks for that. So, I'd like to start off by talking about why is LATE hippocampal sclerosis, why is this important for the neurologist practicing in clinic to know about these things? Dr Ramanan: That's a great question. So, if we take a step back, we know that degenerative diseases of the brain are really, really common, and they get more and more common as we get older. I think all neurologists, and in fact most clinicians and large swaths of the general public, are well aware of Alzheimer's disease, which is the most common degenerative cause of cognitive impairment in the population. But there are non-Alzheimer's degenerative diseases which can produce cognitive difficulties as well. And it's important to be aware of those disorders, of their specific presentations and their implications, in part because it's always a healthy thing when we can be as precise and confident about diagnosis and expectation with our patients as possible. I'll look to the analogy of a patient presenting with a myelopathy. As neurologists, we would all find it critical to clarify, is that myelopathy the result of a compressive spondylotic change? The result of an inflammatory disorder, of a neoplastic disorder, of an infectious disorder? It's critical to guide the patient and choose appropriate management options based on the cause of their syndrome. It would potentially harm the patient if you treated an infectious myelopathy with steroids or other immune-suppressant drugs. So, a similar principle holds in cognitive neurology. I accept with humility that we can never be 100% crystal clear certain about things in medicine, just because when you think you got it all figured out there's a curveball. But I want to get as close to that 100% as possible. And recognizing that disorders like LATE or PART can mimic the symptoms, sometimes even the imaging features of Alzheimer's disease. I think it's critical to have heightened awareness of those disorders, how they look, to be able to apply appropriate counseling and management options to patients. I think this becomes particularly critical as we move into an era of disease-specific, and sometimes disease-modifying, therapies, where applying a choice of a treatment option could have significant consequences to a patient if the thing you're treating isn't the thing that the drug is trying to accomplish. So, having awareness and spreading awareness about some of these non-AD causes of cognitive difficulty, I think, is a big mission in the field.  Dr Nevel: Yeah, that makes total sense. And kind of leaning into this, you know, trying to differentiate between these different causes of late-life amnestic cognitive impairment. You know, I'll point out to the listeners today to please read your article, but in addition to reading your article, I'd like to note that there's a really nice table in your article, Table 6-1, where you kind of go through the different causes of amnestic cognitive impairment and the different features that better fit with diagnosis X, Y, or Z, because I think it's a really nice table to reference and really easy to look at and reference back to. But on that note, what is your typical approach when you're seeing a patient in clinic, have a new referral for an older patient presenting with a predominantly progressive amnestic-type features? Dr Ramanan: Excellent question. And this is one that I think has relevance not just in a subspecialty memory clinic, but to all the clinicians who help to diagnose and manage cognitive disorders, including in primary care and general neurology and others. One principle that I think it's helpful to keep in our minds is that in cognitive neurology, no one data point takes precedence over all the others. We have a variety of information that we can gather from history, from exam, from imaging, from fluid biomarkers. And really the fun, the challenge, the reward is in piercing together that information. It's almost like being a lawyer and compiling the evidence, having possibilities on your list and raising and lowering those possibilities to get as close to the truth as you can. So, for patients with a cognitive syndrome, I think the first plank is in defining that syndrome. As you mentioned, if I'm seeing someone with a progressive amnestic-predominant syndrome, I first want to make sure, are we talking about the same thing, the patient, the care partner, and I?  Can often be helpful to ask them for some examples of what they see, because sometimes what patients may report as memory troubles may in fact reflect cognitive difficult in other parts of our mental functioning. For example, executive functioning or naming of objects. And so helpful to clarify that in the history to get a sense of the intensity and the pace of change over time, and then to pair that with a good general neurologic exam and some type of standardized assessment of their cognitive functioning. At the Mayo Clinic, where partial to the short test of mental status. There are other ways to accomplish that, such as with an MMSE or a MoCA. If I understand that the syndrome is a progressive amnestic disorder, Alzheimer's disease is the most common cause of that presentation in older adults, it deserves to be on my differential diagnosis. But there might be some other features in the story that could raise or lower those mimics on my list. So, in patients who are, say, older than the age of seventy five, disorders like LATE or PART start to rise higher on the likelihood for me, in particular if I know that their clinical course has been more slow brewing, gradually evolving. And again, most degenerative disorders we expect to evolve not over days or weeks, but over many months to many years. But in comparison with Alzheimer's disease, patients with LATE or with PART would be expected to have a little more slow change where maybe year over year they or their care partners really aren't noticing big declines. Their daily function is relatively spare. There might not be as much involvement into other non-memory cognitive domains. So, these are some of the pieces of the story that can help to perhaps isolate those other non-AD disorders on the list as being more likely and then integrating, as a next level, diagnostic testing, which helps you to rule in and rule out or support those different causes. So, for example, with LATE there can be often out of proportion to the clinical picture, out of proportion to what you see on the rest of their imaging or other profiles, very predominant hippocampal and medial temporal volume loss. And so that can be a clue in the right setting that you may not be dealing with Alzheimer's disease or pure Alzheimer's disease, but that this other entity is there. So, in the big picture, I would say being systematic, recognizing that multiple data points being put together helps you get to that confident cause or etiology of the syndrome. And in particular, taking a step back and thinking about big picture factors like age and course to help you order those elements of the differential, whether AD or otherwise. Dr Nevel: Great, thanks. In your article, you talk about different imaging modalities that can be used, as you mentioned, you know, just another piece of the puzzle, if you will, to try and put together what may be going on with the patient, and recognizing that some of these imaging techniques are imaging is special imaging, not available in a lot of places.  You know, and maybe other diagnostic type tests that could be helpful in differentiating between these different disorders may not be available, you know, for the general neurologist practicing in the community. So, what do you suggest to the general neurologist maybe practicing somewhere where they don't have access to some of these ancillary tests that could assist with a diagnosis?  Dr Ramanan: Critical question. And here I think there's not likely to be one single answer. As with most things, awareness and recognition is a good place to start. So, some of those clues that I mentioned earlier about the clinical course, about the age, the- we're talking about clinical setting there. So, comfort with and understanding that the clinical setting can help you to be more confident about, for example, LATE or PART being present in contrast to AD. That's important information. It deserves to be part of the discussion. It doesn't necessarily need other tests to have value on its own. A second piece is that tests help, in some cases, to rule in and rule out causes for cognitive difficulty. As part of a standard cognitive evaluation, we would all be interested in getting some blood tests to look for thyroid dysfunction or vitamin deficiencies. Some type of structural head imaging to rule out big strokes, tumors, bleeds. Head CT can accomplish some of that perspective. It's ideal if a brain MRI can be obtained, but again, keeping in mind, what's the primary goal of that assessment? It's to assess structure. Occasionally you can get even deeper clues into a syndrome from the MRI. For example, that very profound hippocampal or medial temporal atrophy. So, increasing awareness amongst clinicians throughout our communities to be able to recognize that change and put it in the context of what they see in other brain regions that can be affected by Alzheimer's or related disorders. For example, the parietal regions can be helpful. And recall that MRI can also be helpful in assessing for chronic cerebrovascular disease changes. This is another mimic that shows up in that table that you mentioned. And so multiple purposes can be satisfied by single tests. Now, you're absolutely right that there are additional test modalities that, perhaps in a subspecialty clinic at an academic medical center, we're very used to relying on and finding great value on; for example, glucose PET scans or sometimes fluid biomarkers from the blood or from the spinal fluid. And these are not always as widely available throughout our communities. Part of the challenge for all of us as a field is therefore to take the expertise that we have gathered in more subspecialty settings and tertiary care settings and translate and disseminate that out into our communities where we need to take care of patients. That's part of the challenge. The other challenge is in continued tool and technological development. There's a lot of optimism in our field that the availability of blood-based biomarkers relevant for Alzheimer's disease may play a part in helping to address some of the disparities in resource and access to care. You can imagine that doing a blood test to give you some high-quality information, there are going to be less barriers to doing that in many settings compared to thinking about a lumbar puncture or a PET scan, both in terms of cost to the patient as well as infrastructure to the clinicians and the care team. So I'm optimistic about a lot of those changes. In the meantime, I think there are, through both clinical evaluation and some basic testing including structural head imaging, there are clues that can help navigate these possibilities. Dr Nevel: So, let's say you have your patient in clinic, you've done your evaluation, maybe gotten some ancillary testing, and you highly suspect either LATE or PART. How do you counsel those patients and their families? How do you manage those patients moving forward who you really suspect don't have, you know, some sort of co-pathology? Dr Ramanan: So, it's- I think it's helpful to remember when patients are coming to see us, either they or the people around them have noticed an issue. And very likely it's an issue that's been brewing for a little while. I think it can be very valuable, very helpful for patients to have answers. What's the cause for the issue? Once you have answers, even if sometimes those answers are not the most welcome things or the things that you'd be looking forward to, answers give you an opportunity to grab hold of what's going on, to define a game plan. So, understanding there is a degenerative disease there, it sheds light on why that individual had had memory symptoms over the years. And it gives them a general expectation that over time on an individualized basis, but generally expecting gradually over many months to many years, there may be some worsening in some of those symptoms helps them to plan and helps them to make the adaptations that are a-ok and great to make to just help you to do the things you want to do. As much as I can, I try to put the focus here closer to how we would view things like high blood pressure or high cholesterol. Those are also chronic issues that tend to be more common as we get older, tend to get more troublesome as we get older. The goal is, know what you're dealing with and take the combination of lifestyle modifications, adaptations in your day-to-day and maybe medications to keep them as mild and as slow-changing as possible. With something like LATE, we don't have specific medication therapies to help support cognitive functioning at this time. There's a lot of hope that with additional research we will have those therapies. But even so, I think it's an important moment to emphasize some of those good healthy lifestyle habits. Staying mentally, socially and physically active, getting a good night's sleep, eating a healthy, balanced diet, keeping good control of vascular risk factors, all of that is critical to keeping the brain healthy, keeping the degenerative disease as mild and slow-brewing as possible. And understanding what some of the symptoms to expect could be. So, with LATE the syndrome tends to be very memory-predominant. There may be some trouble with maybe naming of objects or perhaps recall of emotionally salient historical knowledge, world events, but you're not expecting, at least over the short to medium term, huge intervening on other cognitive functioning. And so that can be helpful for patients to understand. So, the hope is once you know what what you're dealing with, you understand that the disease can look different from person to person. Having a general map of what to expect and what you can do to keep it in check, I think, is the goal. Dr Nevel: I agree with you 100% that it really can be helpful even if we can't, quote unquote, fix it, that for people, family, the patient have a name for what they have and kind of have some sort of idea of what to expect in the future. And they may come in thinking that they have Alzheimer's or something like that. And then, so, to get that information that this is going to be a little different, we expect this to go a little bit differently then it would if you had a diagnosis of Alzheimer's, I can see how that would be really helpful for people.  Dr Ramanan: I completely agree. And here's another challenge for us in the field when most patients have heard about Alzheimer's disease and many have perhaps even heard of dementia with Lewy bodies or frontotemporal dementia, but may not have heard of things like LATE. And they're not always easy to go online or find books that talk about these things. Having a name for it and being able to pair that with patient-friendly information is really critical. I see our appointments where we're sharing those diagnosis and making initial game plans as an initial foray into that process.  Dr Nevel: Yeah, absolutely. What is the greatest inequity or disparity that you see in taking care of patients with progressive amnestic cognitive impairment? Dr Ramanan: Yeah, great question. I think two big things come to mind. The first, you hinted at very well earlier that there are disparities in access to care, access to diagnostic testing, access to specialists and expertise throughout our communities. If we want diagnostics and therapeutics to be broadly applicable, they do need to be broadly available. And that's a big challenge for us as a field to work to address those disparities. There's not going to be one single cause or contributor to those iniquities, but as a field, I'm heartened to see thought and investment into trying to better address those. Another big weakness, and this is not just limited to cognitive neurology, it's a challenge throughout neurology, is that too many of our research studies are lacking in diversity. And that impacts our biological and pathophysiological understanding of these disorders. It also impacts our counseling and management. Again, if we want a new drug treatment to be broadly applicable throughout all of the patients that we take care of, we need to have data which guides how we apply those treatments. And so again, I'm heartened. This is a big challenge. It's a long standing challenge. It will take deep and long standing committed efforts to reverse. But I'm heartened that there are efforts in the field to broaden clinical trial enrollment, broaden observational research enrollment, and again, broaden access to tools and expertise. As a neurologist, I got into this field because I want to help people, use my expertise and my training to help people. These are steps that we can take to make sure that that help is broadly applicable throughout everybody in our communities. Dr Nevel: Yeah, absolutely. So, kind of segueing from you mentioning research and how we can better include patients in research. What do you think the next breakthrough is going to be? What do you think the next big thing is going to be in these disorders? What do we still need to learn? Dr Ramanan: There's a lot. I think for LATE and PART, the development of specific biomarkers would be top of the agenda. Now, biomarkers are by their nature imperfect. Even with Alzheimer's disease, where in comparison, we know quite a lot. We have a variety of imaging and fluid biomarkers that we can use to support or rule out a diagnosis. There are nuances in how you interpret those biomarkers. Patients can have signs of amyloid plaques in their brain and have completely normal cognition. They may be at risk for developing cognitive trouble due to Alzheimer's disease in the future, but it's one piece of the puzzle. Patients can have the changes of Alzheimer's disease amyloid plaques and tau tangles in the brain. We can confirm that through biomarkers. But at the end of the day, their cognitive syndrome might be driven by something else. Maybe it's Lewy body disease, maybe it's LATE, maybe it's a combination of factors. So, integrating and interpreting those biomarkers is challenging. But I do think, again, from the standpoint of giving patients answers with a diagnosis, having those biomarkers is really critical to just kind of closing the loop. It will also be critical to have those biomarkers as we're assessing for treatment response. So, for example, patients who may have coexistent Alzheimer's disease and LATE, I don't think we know the answer fully as to how likely they are to benefit from, say, newer antiamyloid monoclonal antibodies for Alzheimer's disease in the setting of that second pathology. So, wouldn't it be great if, similar to an oncologic setting where you engage in a treatment and then you're tracking two or three or four plasma measures and you're tracking tumor size with imaging, if we had this multimodal ability to track neurodegenerative pathology through biomarkers? I think that'll be a critical next step. And so, filling out that for non-Alzheimer's diseases, including LATE and PART, I think is item number one on the agenda. Dr Nevel: Wonderful, thank you so much. I really appreciate you taking the time to chat with me today about your article. I really enjoyed our conversation, certainly learned a lot. Dr Ramanan: Thank you so much, Kait. Love talking with you. And again, it was an honor to write this article. I hope it's helpful to many out in the field who take care of patients with cognitive issues.  Dr Nevel: Yeah, I think it will be. So again, today I'm interviewing Dr Vijay Ramanan about his article that he wrote with Dr Jonathan Graff-Radford on LATE hippocampal sclerosis and primary age-related tauopathy, which appears in the most recent issue of Continuum on dementia. Be sure to check out Continuum audio episodes from this and other issues. And thank you, Vijay, and thank you to our listeners for joining us today. Dr Monteith: This is Dr Teshamae Monteith, associate editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use this link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/AudioCME. Thank you for listening to Continuum Audio.

Episode No. 685 features artist Vincent Valdez and curators Theresa Harlan and Drew Johnson. The Contemporary Arts Museum Houston is presenting "Vincent Valdez: Just a Dream..." the first major survey of Valdez's career. The exhibition, which features Valdez's work across media, reveals Valdez's construction of US national memory. It was co-curated by Patricia Restrepo and Denise Markonish. It's on view at CAMH through March 23, 2025, when it will travel to the Massachusetts Museum of Contemporary Art. A catalogue is forthcoming. Also, Valdez is included in "Ordinary People: Photorealism and the Work of Art since 1968" at the Museum of Contemporary Art, Los Angeles. The exhibition surveys post-war photorealism up to the present. It was curated by Anna Katz with Paula Kroll and is on view through May 4, 2025. MOCA and DelMonico Books published an excellent catalogue. Amazon and Bookshop offer it for $65. Harlan and Johnson are the curators of "Born of the Bear Dance: Dugan Aguilar's Photographs of Native California" at the Oakland Museum of California. It's on view through June 22, 2025. The exhibition surveys Aguilar's presentation of Native life and land, mostly between 1982 and 2018. The exhibition is OMCA's first presentation of Aguilar's work after the Aguilar's family gift of his archive to the museum in 2022. The show does not have a catalogue, but many of the works in the show are featured within Harlan's 2015 Aguilar monograph for Heyday Books, "She Sang Me a Good Luck Song."

A pragmatic and organized approach is needed to recognize patients with symptomatic Alzheimer Disease in clinical practice, stage the level of impairment, confirm the clinical diagnosis, and apply this information to advance therapeutic decision making. In this episode, Aaron Berkowitz, MD, PhD, FAAN, speaks with Gregory S. Day, MD, MSc, MSCI, FAAN, author of the article “Diagnosing Alzheimer Disease,” in the Continuum December 2024 Dementia issue. Dr. Berkowitz is a Continuum® Audio interviewer associate chief medical information officer at the Cleveland Clinic in Cleveland, Ohio. Dr. Day is an associate professor in the Department of Neurology at Mayo Clinic Florida in Jacksonville, Florida. Additional Resources Read the article: Diagnosing Alzheimer Disease Subscribe to Continuum: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @AaronLBerkowitz Guest: @GDay_Neuro Full episode transcript available here Dr Jones: This is Doctor Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, which features conversations with Continuum's guest editors and authors, who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article and have access to exclusive interviews not featured on the podcast. Please visit the link in the episode notes for more information on the article, subscribing to the journal, and how to get CME. Dr Berkowitz: This is Dr Aaron Berkowitz, and today I have the pleasure of interviewing Dr Gregory Day about his article on Alzheimer disease, which appears in the December 2024 Continuum issue on dementia. Welcome to the podcast, Dr Day. Would you mind introducing yourself to our audience?  Dr Day: Thanks very much, Aaron. I'm Gregg Day. I'm a behavioral neurologist at Mayo Clinic in Jacksonville, Florida, which means that my primary clinical focus is in the assessment of patients presenting typically with memory concerns and dementia in particular. Dr Berkowitz: Fantastic. Well, as we were talking about before the interview, I've heard your voice many times over the Neurology podcast and Continuum podcast. I've always learned a lot from you in this rapidly changing field over the past couple of years, and very excited to have the opportunity to talk to you today and pick your brain a little bit on this very common issue of evaluating patients presenting with memory loss who may have concerns that they have dementia and specifically Alzheimer disease. So, in your article, you provide a comprehensive and practical approach to a patient presenting for evaluation for possible dementia and the question of whether they have Alzheimer disease. The article is really packed with clinical pearls, practical advice. I encourage all of our listeners to read it. In our interview today, I'd like to talk through a theoretical clinical encounter and evaluation so that I and our listeners can learn from your approach to a patient like this. Let's say we have a theoretical patient in their seventies who comes in for evaluation of memory loss and they and/or their family are concerned that this could be Alzheimer disease. How do you approach the history in a patient like that? Dr Day: It's a great way to approach this problem. And if you're reading the article, know that I wrote it really with this question in mind. What would I be doing, what do we typically do, when we're seeing patients coming with new complaints that concern the patient and typically also concern those that know the best? So be that a family member, close friend, adult child. And in your scenario here, this seventy year old individual, we're going to use all the information that we have on hand. First off, really key, if we can, we want to start that visit with someone else in the room. I often say when talking to individuals who come alone that there's a little bit of irony in somebody coming to a memory assessment alone to tell me all the things they forgot. Some patients get the joke, others not so much, but bringing someone with them really enhances the quality of the interview. Very important for us to get reliable information and a collateral source is going to provide that in most scenarios. The other thing that I'm going to start with, I'm going to make sure that I have appropriate time to address this question. We've all had that experience. We're wrapping up a clinical interview, maybe one that's already ran a little bit late and there's that one more thing that's mentioned on the way out the door: I'm really concerned about my memory or I'm concerned about mom 's memory. That's not the opportunity to begin a memory assessment. That's the opportunity to schedule a dedicated visit. So, assuming that we've got someone else in the room with us, we've got our patient of interest, I'm going to approach the history really at the beginning. Seems like an easy thing to say, but so often patients in the room and their caregivers, they've been waiting for this appointment for weeks or months. They want to get it out all out on the table. They're worried we're going to rush them through and not take time to piece it together. And so, they're going to tell you what's going on right now. But the secret to a memory assessment, and particularly getting and arriving at an accurate diagnosis that reflects on and thinks about cause of memory problems, is actually knowing how symptoms began. And so, the usual opening statement for me is going to be: Tell me why you're here, and tell me about the first time or the first symptoms that indicated there was an ongoing problem. And so, going back to the beginning can be very helpful. This article is focused on Alzheimer disease and our clinical approach to the diagnosis of Alzheimer disease. And so, what I'm going to expect in a patient who has a typical presentation of Alzheimer disease is that there may be some disagreement between the patient and the spouse or other partners sitting in the room with me about when symptoms began. If you've got two partners sitting in the room, maybe an adult child and a spouse, there may be disagreement between them. What that tells me is at the onset, those first symptoms, they're hard to pin down. Symptoms typically emerge gradually in patients with symptomatic Alzheimer disease. They may be missed early on, or attributed or contributed to other things going on in the patient's time of life, phase of life. It's okay to let them sort of duke it out a little bit to determine, but really what I'm figuring out here is, are we talking about something that's happened across weeks, months or more likely years? And then I'm going to want to listen to, how did symptoms evolve? What's been the change over time? With Alzheimer disease and most neurodegenerative diseases, we expect gradual onset and gradual progression, things becoming more apparent. And at some point, everyone in the room is going to agree that, well, as of this state, there clearly was a problem. And then we can get into talking about specific symptoms and really begin to pick that apart the way that we traditionally do in any standard neurological assessment. Dr Berkowitz: Fantastic. And so, what are some of the things you're listening for in that history that would clue you in to thinking this patient may indeed be someone who could have Alzheimer's disease and going to require a workup for that diagnosis? Dr Day: It's pretty common when I have new trainees that come to clinic, they just head into the exam room and they sort of try to approach it the way that we would any patient in the emergency department or any other clinical scenario. The challenge with that is that, you know, we're taught to let the patient speak and we're going to let the patient speak - open-ended questions are great - but there's only so many questions you need to sort out if someone has a memory problem. And memory is really only one part, one component, of a thorough cognitive evaluation. And so, I'm going to help by asking specific questions about memory. I'm going to make sure that there is memory challenges there. And whenever possible, I'm going to solicit some examples to back that up, add credibility and sort of structure to the deficits. I'm also going to choose examples that help me to understand how does this concern, or this complaint, how does that actually affect the patient in their day-to-day life? Is it simply something that they're aware of but yet hasn't manifested in a way that their partner knows about? Is it to a level where their partner's actually had to take over their responsibility? It's causing some difficulties, disability even, associated with that. That's going to be important for me as I try to understand that. So, I'll ask questions when it comes to memory, not just, you know, do you forget things, but do you manage your own medications? You remember to take those in the morning? Do you need reminders from your partner? What about appointments; health appointments, social appointments? Are you managing that on your own? Sometimes we need a little bit of imagination here. Partnerships, and particularly those who have been together for a long time, it's natural that different people are going to assume different responsibilities. And so, might have to say, Imagine that you went away for the weekend. Would you worry about your partner remembering to take their medications over that time frame? That can help to really solidify how much of an impact are these challenges having on a day-to-day basis. I may ask questions about events, something that they maybe did a couple of weeks ago. Is the patient likely to remember that event? Are they going to forget details? Maybe the most important of all, with each of these, when there's a yes or an affirmation of a problem, we want to be clear that this represents a change from before. We all have forgetfulness. Happens on a day-to-day basis, and we all pay attention to different details, but what we're concerned about and typically the reasons patients want to come and see us as neurologists is because they've noticed a change. And so, I'm going to focus in on the things that represent a change from before. After I've discussed memory, I think it's really important to talk about the other domains. So, how is judgment affected? Decision-making?  In a practical way, we often see that borne out in financial management, paying the bills. Not just paying them on time and consistently, but making wise choices when it comes to decisions that need to be made. You're out at a restaurant. Can you pay the bill? Can you calculate a tip? Can you do that as quickly and as efficiently as before? Are we starting to see a breakdown in decision-making abilities there? We can sometimes lump in changes in behavior along with judgment as well. The patient that you know, maybe isn't making wise choices, they've picked up the phone and given their social security number out to someone that was calling, seeming to be well-meaning. Or maybe they've made donations to a few more institutions than they would have otherwise? Again, out of- out of order. Again, something that could be atypical for any individual. Looking for behavioral changes along with that as well. And then I'm going to talk about orientation. What's their ability to recognize days of the week, date of the month? Do they get lost? Is there concerns about wayfinding? Thinking about that, which is really a complex integration of some memory, visuospatial processing, judgment, problem solving, as we look to navigate our complex world and find our way from point A to B. And then I like to know, you know, what are they doing outside of the home? What are they doing in the community? How are they maintaining their engagement? Do they go to the store? Do they drive? An important topic that we may need to think about later on in this patient 's assessment. And inside the home? What responsibilities do they maintain there? Are the changes in decision making, memory problems, are they manifesting in any lost abilities inside the home? Cooking being a potentially high-risk activity, but also using typical appliances and interacting with technology, in a way that we are all increasingly, increasingly doing and increasingly reliant on. And last but not least, you know, maybe the one that everyone wants to think about, well, I can still manage all of my own personal care. Well, good news that many of our patients who have early symptoms can manage their own personal care. Their activities of daily living are not the big problem. But we do want to ask about that specifically. And it's not just about getting in the shower, getting clean, getting out, getting your teeth brushed. Do you need reminders to do that? Do you hop in the shower twice because you forgot that you'd already been in there once during the day? And so, asking some more of those probing questions there can give us a little bit more depth to the interview and really does sort of round out the overall comprehensive history taking in a patient with a memory or cognitive concern. Dr Berkowitz: Fantastic. That was a comprehensive master class on how to both sort of ask the general questions, have you noticed problems in fill in the blank memory, judgment, behavior, orientation, navigation and to sort of drill down on what might be specific examples if they're not offered by the patient or partner to try to say, well, in this domain, tell me how this is going or have you noticed any changes because the everyone's starting from a different level cognitively based on many factors. Right? So, to get a sense of really what the change is in any of these functions and how those have impacted the patient's daily life. So, let's say based on the history, the comprehensive history you've just discussed with us, you do find a number of concerning features in the history that do raise concern for dementia, specifically Alzheimer's disease. How do you approach the examination? We have the MoCA, the mini-mental. We have all of these tools that we use. How do you decide the best way to evaluate based on your history to try to get some objective measure to go along with the more subjective aspects of the history that you've ascertained? Dr Day: And you're honing in on a really good point here, that the history is one part of the interview or the assessment. We really want to build a story and potentially and hopefully a consistent story. If there are memory complaints, cognitive complaints from history, from reliable- that are supported by reliable collateral sources, we're going to expect to see deficits on tests that measure those same things. And so, I think that question about what neuropsychological measures or particular bedside tests can we integrate in our assessment is a good one. But I'll say that it's not the end-all-be-all. And so, if you've got a spouse, someone that lives with an individual for twenty or thirty years, and they're telling you that they notice a change in daily activity and it's impairing their day to day function, or where there's been some change or some concern at work, that's going to worry me more than a low score on a cognitive test with a spouse saying they haven't noticed any day-to-day impact. And so, we're going to take everything sort of in concert and take it all together. And it's part of our job as clinicians to try to process that information. But often we're going to see corroborating history that comes from a bedside test. He named a few that our listeners are probably pretty familiar with. I think they're the most common ones that are used. The Mini-Mental State Exam, been in practice for a long time. All the points add up to thirty and seems to give a pretty good sample of various different cognitive functions. The Montreal Cognitive Assessment, another favorite; a little bit more challenging of a test, I think, if we're if we're looking at how people tend to perform on it. And like the MMSE, points add up to thirty and gives a pretty good sample. There are others that are out there as well, some that are available without copyright and easy for use in clinical practice. The Saint Louis Mental Status Exam comes to mind. All these tests that we're willing to consider kind of share that same attribute. They can be done relatively quickly. They should sample various different aspects of function. There should be some component for language reading, spoken, spoken word, naming items, something that's going to involve some kind of executive function or decision making, problem solving. Usually a memory task where you're going to remember a set of words and be asked to recall that again later. So, learn it, encode it, and recall it later on. And then a few other features, I mean, some of them, these tests, most of these tests use some sort of drawing tasks so that we can see visuospatial perception and orientation questions about date, time, location, sort of the standard format. Any of these tests can be used aptly in your practice. You're going to use the one that you're most comfortable with, that you can administer in a reasonable amount of time and that seems to fit with your patient population. And that's the nuance behind these tests. There are many factors that we have to take into account when we're picking one and when we're interpreting the test results. These tests all generally assume that patients have some level of traditional sociocultural education that is westernized for the most part. And so, not great tests for people that aren't well into integrated into the community, maybe newcomers to the United States, those that have English as a second, third, or fourth language, as many of our patients do. Statements like no ifs, ands, or buts may not be familiar to them and may not be as easy to repeat, recall and remember. And so, we want to weigh these considerations. We may need to make some adjustments to the score, but ideally, we're going to use these tests and they're going to show us what we expect and we're going to try to interpret that together with the history that we've already ascertained. When I obtain that history and I'm thinking about memory loss, I'm going to look at the specific domain scores. And so, if I'm using the mini mental state examination thirty point test, but three questions that relate to relate to recall. Apple, penny, table. And so, depending on how our patients do on that test, they could have an overall pretty good score. Twenty seven. Oh, that looks good. You're in the normal range according to many different status. But if I look at that and there's zero out of three on recall, they could not remember those three items, that may support the emergence of a memory problem. That may corroborate that same thing on the MoCA, which uses five-item recall, and other tests in those same parameters. I mentioned some other caveat cities testing. Are patients who are presenting with prominent language deficits important part of cognition. They can't get the words out. They can't frame their sentences. They may really struggle with these tests because a lot of them do require you to both understand verbal instructions and convey verbal instructions. People with prominent visual problems, either visual problems that come because of their neurodegenerative disease and so part of cognition, visual perceptual problems, or people who simply have low vision. Are there difficulties for that? These tests require many people to read and execute motor commands, to draw things, to follow lines and connect dots, all very difficult in that setting. And so, we have to be cautious about how we're interpreting test results in patients who may have some atypical features or may arrive with sort of preexisting conditions that limit our ability to interpret and apply the test to clinical practice.  Dr Berkowitz: Really fantastic overview of these tests, how to use them, how to interpret them. It's not all about the number. As you said, it depends if all the points are lost in one particular domain, that can be salient and then considering, as you said, the patient 's background, their level of education, where English falls in their first language, second, third or fourth, as you said, and then some of the aspects of the MoCA, right, are not always as culturally sensitive since it's a test designed in a particular context. So, let's say your history and exam are now concerning to you, that the patient does indeed have dementia. Tell us a little bit about the next steps in the laboratory neuroimaging evaluation of such a patient?  Dr Day: I've got a history of memory and thinking problems. I've got some corroborating evidence from bedside cognitive testing, a normal neurological exam. This is where we think about, well, what other tests do we need to send our patients for? Blood testing really can be pretty cursory for most patients with a typical presentation who have typical risk factors, and that can include a thyroid study and vitamin B12. So, measuring those in the blood to make sure that there's no other contributions from potential metabolic factors that can worsen, exacerbate cognitive function. And pretty easy to do for the most part, if patients have other things in their history, maybe they come from a high-risk community, maybe they engage in high risk behaviors, I may think about adding on other tests that associate with cognitive decline. We'll think about the role of syphilis, HIV, other infections. But generally, that's when it's driven by history, not a rule of thumb for me in my typical practice. But beyond the blood tests, neuroimaging, some form of structural brain imaging is important. A CT scan will get you by. So, if you have a patient that can't get in the scanner for one reason or another or won't get in the scanner, or you don't have easy access to an MRI, a CT scan can help us in ruling out the biggest things that we're looking for. That's strokes, hemorrhages, and brain masses. So other things that obviously would take us down a very different path, very different diagnosis and very different treatment approach. An MRI, though, is going to be preferred, not only because it gives us a much higher-resolution view, but also because it helps us to see sort of regional areas of atrophy. It's a sensitive scan to look for small vessel disease, tiny strokes, tiny bleeds, microhemorrhages that again might point towards meteorology for us. Of course, it's better at finding those small masses, whether they be metastasis or primary masses, that could give us something else to consider in our diagnostic evaluation. I get an odd question often from patients, well, can you see Alzheimer's disease on an MRI? And the true answer to that is no, you can't. Can we see the signs of Alzheimer's disease? Sure, in some patients, but really what we see on an MRI is a reflection of neurodegeneration. And so, we see evidence of tissue loss and typically in areas that are most often involved early on in Alzheimer's disease. The hippocampus, the entorhinal areas around the hippocampus, we may see atrophy there. We may see biparietal atrophy, and of course, as the disease progresses, we're going to see atrophy distributed throughout other areas of the brain. But if you're looking for atrophy, you've got to have a pretty good idea what's normal for age and what you expect in that patient population. So, I do encourage clinicians who are assessing patients routinely, look at your own images, look at the images for patients with and without cognitive impairment. So we develop a pretty good sense for what can be normal for age, and of course work with our colleagues in radiology who do this for a living and generally do an excellent job at it as well.  Dr Berkowitz: Perfect. So, you're going to look for the so-called reversible causes of dementia with serum labs, structural imaging to either rule out or evaluate for potential structural causes that are not related to a neurodegenerative condition or patterns of regional atrophy suggestive of a neurodegenerative condition, and maybe that will point us in an initial direction. But the field is rapidly expanding with access to FDG-PET, amyloid PET, CSF biomarkers, genetic testing for APOE 4, probably soon to be serum biomarkers. So, patients may ask about this or a general neurologist referring to your clinic may ask, who should get these tests? When should we think about these tests? How do you think about when to send patients for advanced imaging, CSF biomarkers, genetic testing for APOE 4? Dr Day: It's not that patients may ask about this. Patients will ask about this. And you've probably experienced that in your own world as well. They're going to ask about any of these different biomarkers. Certainly, whatever they've recently read or has been covered on television is going to be common fodder for consideration in the clinic environment. It's important to know what tests you can get, what reliable tests that you can get, and to know the differences between some of these tests when making a recommendation or weighing the pros and cons of doing additional testing. I think common practice principles apply here. Let's order tests that are going to change our next steps in some way. And so, if we have a patient, particularly a patient like the one that we've been talking about: seventy something year old, presenting with memory complaints, they're concerned, the family is concerned. We've got that history, physical exam, and now we may need to really hone in on the etiology. Well, I say may need because for that patient it may be enough to know, yeah, I agree, there's a problem here. And I can say it's an amnestic, predominant, gradual-onset progressive cognitive decline. This is probably Alzheimer disease based on your age. And maybe that's all they want to hear. Maybe they're not ready to pursue additional testing or don't see the value or need for additional testing because it's not going to change their perspective on treatment. In that case, it's okay to apply an often underrated test, which is the test of time. Recognizing this is a patient I can follow. I can see them in six months or twelve months, depending on what your clinic schedule allows. If this is Alzheimer disease, I'm going to expect further gradual progression that may affirm the diagnosis. We can think about symptomatic therapies for a patient like that, perhaps Donepezil as an early, early medication that may help with symptoms somewhat and we can leave it at that for the time being. But there's many scenarios where that patient or the family member says, look, I really need to know. We really want this answer. And as you pointed out, there are good tests and increasingly good tests that we have access to.  Dr Berkowitz: Well, that's a very helpful overview of the landscape of more precise diagnostic testing for Alzheimer disease specifically and how you think about which tests to order and when based on your pretest probability and the patient 's candidacy for some of these new potential therapies. To close here, as you said, treatment is discussed in another podcast. There's another article in this issue. So, we won't get into that today. But let's say you have gotten to the end of the diagnostic journey here. You are now convinced the patient does have Alzheimer's disease. How do you present that diagnosis to the patient and their family? Dr Day: I think here we're going to recognize that different styles align with different patients and families, and certainly different clinicians are going to have different approaches. I do tend to take a pretty direct approach. By the time that patients are coming to see me, they've probably already seen another neurologist or at least another physician who's maybe started some of the testing, maybe even built the foundation towards this diagnosis and shared some indications. Certainly, when they look up my profile before they come to see me, they know what I specialize in and so, they may even have done their own research, which has ups and downs in terms of the questions that I'll be faced with at that point in time. The way I like to start is first acknowledging the symptoms. And the symptoms that the patients have shared with me, recognizing if those symptoms are impacting daily life, how they impacted daily life, and usually using that information to synthesize or qualify the diagnosis. Is there cognitive impairment, yes or no? And at what level is that cognitive impairment? Is this mild cognitive impairment? Is this mild dementia? Is it maybe more moderate or severe dementia? So, using those terms directly with patients and explaining the meaning of them. But I then transition in relatively quickly to the important point of not leaving it at the syndrome, but actually thinking about the cause. Because it is cause that patients come to talk about. And if they don't say that directly, they say it in their next question, which is what are we going to do about it and how are we going to treat this? And so, I will use the information I have available at that time to suggest that based on your age, based on the history, the normal physical examination, the performance and the bedside testing that we've done. And hey, that's pretty normal structural imaging or imaging that only shows a little bit of atrophy in a few areas. I think that this condition is most consistent with symptomatic Alzheimer's disease, mild cognitive impairment due to Alzheimer's disease, or mild dementia due to Alzheimer's disease. And then I'll discuss the next options in terms of testing and try to get a feel of what our patients are thinking about when it comes to treatment. Do they want to be on the cutting edge with brand-new therapies that offer potential benefits but counterbalance by pretty substantial risks that warrant individualized discussions? Are they interested in symptomatic therapies? Would that be appropriate for them? And I can usually round out the discussion with advice that works for everyone. And that's where we talk about the importance of brain health. What are the other things that I should be doing, you should be doing, and our patients and their partners should be doing as well to maintain our brain in its best possible state as we hope that we all continue to age and look towards the future where we maintain our cognition as best as possible? And that is still the goal. Even when we're talking to patients who have neurodegenerative diseases that are working against our efforts, we still want to do what we can to treat other problems, to evaluate for other problems that may be contributing to decline and may be amenable to our management as well.  Dr Berkowitz: Well, thank you so much for taking the time to speak with us today. I've learned a lot from your very nuanced and thoughtful approach to taking the history, performing the examination, making sense of cognitive tests and how they fit into the larger picture of the history and examination, and thinking about which patients might be candidates for more advanced imaging as we try to make a precise diagnosis in patients who may be candidates and interested in some of the potential novel therapies, which we both alluded to a few times, but are deferring to another podcast that we'll delve more deeply into that topic in this series. So, thank you so much again, Dr Day. Again, I've been interviewing Dr Gregory Day from the Mayo Clinic, whose article on Alzheimer's disease appears in the most recent issue of Continuum on Dementia. Be sure to check out Continuum Audio episodes from this and other issues. And thank you so much to our listeners for joining today. Dr Monteith: This is Dr Teshamae Monteith, associate editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use this link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/AudioCME. Thank you for listening to Continuum Audio.

Amy King hosts your Thursday Wake Up Call. ABC News White House correspondent Karen Travers joins the show to discuss Biden and Trump meeting yesterday. ABC News investigative reporter Peter Charalambous talks about the private prison industry seeing lucrative opportunity in Trump's mass deportation plan. The show closes with ABC News correspondent Jim Ryan speaking on lawmakers taking another run at UFO phenomena.

The U.S. Presidential election ends, and all sorts of new questions arise. Ours? Just how influential is PolyMarket, the crypto-based app that brought election betting to the general public? Max and Colborn talk PolyMarket's origins, its seed investments, its political inclinations, and most importantly, its effect (if any) on the elections it revolves around. What does PolyMarket's rise tell us about the electorate? Can betting on election be ethical? This, social media's forcible politicization, the future for crypto in a second Trump term, and much more. 

We revisit our home networking setups including using MoCa (network over coax), Chris searching for a unicorn, and relying on an Apple TV for home automation.       Support us on Patreon and get an ad-free RSS feed with early episodes sometimes           See our contact page for ways to... Read More

#LADodgers #NYMets #NLCS Más De Una Milla 14/10/2024 Los Dodgers “paran en seco” a los Mets en el inicio de la Serie de Campeonato de la Liga Nacional | Las Explosivas de Moca se imponen a las Cangrejeras y envían un mensaje claro en la semifinal del BSNF | Havanna Cabrero gana el Puerto Rico Pro Surf Circuit en Isabela | Krystal Rosado, Jan Paul Rivera y prospectos boricuas obtuvieron victorias en cartelera de boxeo en Caguas | Jonathan “Bomba” González no logra obtener un título mundial en una segunda división | Delegación puertorriqueña termina con 63 medallas en los Juegos Latinoamericanos de las Olimpiadas Especiales | Nueve atletas y propulsores del deporte puertorriqueño fueron exaltados al Salón de la Fama del Deporte ¡Sintoniza y Comparte! #VamoArriba #AlmuerzoDeportivo #tiempodedeportes #BonitaDeportes #DeporteEsMásQueJuego #Anótalo #periodismoinvestigativo #periodismodigital

ONE STORY A DAY / Una historia para cada Día es una iniciativa para celebrar el Mes de la Herencia Hispana 2024 de la Hispanic Chamber Cincinnati USA y Latina Today Podcast series. Ana es oriunda de Moca, República Dominicana y a los 18 años llegó a New York con su familia. Su pasión por trabajar con la comunidad hispana comenzó en Nueva York y ha continuado desde que se mudó para Cincinnati hace más de 19 años. Ana habla de sus desafíos personales, su experiencia como inmigrante navegando una nueva cultura, un nuevo idioma y un sistema educativo completamente diferente a su país natal.

Más De Una Milla 08/10/2024 No suenan nombres de puertorriqueños para dirigir la Selección Nacional Masculina de Baloncesto | Las Cangrejeras de Santurce y las Explosivas de Moca tendrán una revancha en las semifinales del BSNF | Todas las series divisionales en Grandes Ligas están empatadas | Faltan 38 días para la revancha más esperada en el boxeo: Serrano Vs Taylor II ¡Sintoniza y Comparte! #VamoArriba #AlmuerzoDeportivo #tiempodedeportes #BonitaDeportes #DeporteEsMásQueJuego #Anótalo #periodismoinvestigativo #periodismodigital

Autumn McCann sits down with CEO Michael Nash and CFO Brock Thomas of the Men of Color Alliance, Incorporated (MOCA) to discuss the significant impact their organization has on supporting men in both the Rowan University community and across New Jersey. In this engaging conversation, they explore MOCA's mission to build men of purpose and excellence through self-empowerment, and the positive influence the organization has had on the lives of many.

Amanda Yates Garcia (she/her) is a writer, witch, and the Oracle of Los Angeles. Her work has been featured in The New York Times, The LA Times, The SF Chronicle, The London Times, CNN, BRAVO, as well as a viral appearance on FOX. She has led rituals, classes and workshops on magic and witchcraft at UCLA, UC Irvine, MOCA, The Hammer Museum, LACMA, The Getty and many other venues. Amanda hosts monthly moon rituals online, and the popular Between the Worlds podcast, which looks at the Western Mystery traditions through a mythopoetic lens. Her book, Initiated: Memoir of a Witch, received a starred review from Kirkus and Publisher's Weekly and has been translated into six languages. To find out more about her work become a member of her Mystery Cult on Substack. Episode Highlights Welcome to our third cross-pollination episode, where we share space with other queer podcasters and creators. Amanda is the host of "Between the Worlds" podcast. We are so grateful to have Amanda Yates Garcia share some time with us. Join us for a queerly witchy saunter and exploration of the medicine of enough.  Amanda gets us started and casts a delicious, magic circle, and then we dive in and explore. We get curious about our “enough's” and spend some time both in the light and shadowy aspects, while being between the worlds.  We get cozy naming our “enough's” which takes us into our queer + witchy stories, potently connecting some dots.  We close by sending a care spell out to our collective past and future selves.  Web links Find Amanda online at OracleOfLosAngeles.com You can also connect with her on Instagram @oracleofla Listen to Between the Worlds podcast here Join the private Queer Spirit Community to continue the conversation and connect with other listeners.  Join us for FREE meditation + chanting + breath work circles online.   And follow us on Instagram!  Join our mailing list  to get news and podcast updates sent directly to you.

¡Qué palo... es noticia! 24/09/2024 El fraude electoral con los votos encamados se verificó en la elección del 2016 cuando una jueza del Tribunal de Primera Instancia celebró dos vistas y recibió prueba de médicos convocados por Servidores Públicos del PNP para que certificaran los mismos sin que conocieran a los pacientes. Incluso había pacientes de Alzheimer. | Los alcaldes y el asfalto, un binomio ilegal que no termina determina la contralora en el caso de un informe del municipio de Moca. | Bad Bunny le ahorra tiempo al Contralor Electoral, parece decirle "fui yo y qué", el que pagó por billboards que identifican al PNP como corrupto y de la mano de LUMA. ¡Sintoniza, comenta y comparte! #periodismodeinvestigación #periodismoindependiente #puertorico #waltervelez #badbunny #pichytorreszamora

#MónicaPuig #WildCard #NewYorkMets Más De Una Milla 23/09/2024 Los Mets de Nueva York se asoman a la postemporada, mientras esperan que Francisco Lindor se reincorpore esta semana | Los Tigres de Detroit siguen ganando y desplazan a los Mellizos en la carrera por el comodín de la Liga Americana | Las Lobas de Arecibo extienden su invicto en el Béisbol Doble A femenino | Las Explosivas de Moca terminan con el invicto de las Cangrejeras en el BSNF | Mónica Puig Marchán completa el Campeonato Mundial Ironman en Francia ¡Sintoniza y Comparte! #VamoArriba #AlmuerzoDeportivo #tiempodedeportes #BonitaDeportes #DeporteEsMásQueJuego #Anótalo #periodismoinvestigativo #periodismodigital

#ShoheiOhtani #Club50/50 #EdgardoVillegas Más De Una Milla 20/09/2024 Shohei Ohtani logra una histórica hazaña con un histórico juego anoche. Es un jugador generacional | El jugados más valioso del Mundial U23 de béisbol, Edgardo Villegas, reconoce los beneficios de haber jugado a nivel internacional en categorías menores | Victoria de las Explosivas de Moca en el BSNF | Los Caribes de San Sebastián se consolidan como los líderes de la Liga de Voleibol Superior Masculino ¡Sintoniza y Comparte! #VamoArriba #AlmuerzoDeportivo #tiempodedeportes #BonitaDeportes #DeporteEsMásQueJuego #Anótalo #periodismoinvestigativo #periodismodigital

#CaneloVsBerlanga #FranciscoLindor #MundialBéisbolU23 Puerto Rico es el único equipo invicto en el Mundial de Béisbol U23 que se celebra en China | Francisco Lindor le arruina el “No-Hitter” a Toronto con fuerza bruta | El Pulpo Rivera está luciendo bien en la ofensiva con Baltimore | Segunda victoria en línea para Moca mientras que Manatí pierde de nuevo en el Baloncesto Superior nacional femenino | Canelo Alvarez aventaja a Edgar Berlanga en muchas areas de cara al combate que sostendrán el sábado ¡Sintoniza y Comparte! #VamoArriba #AlmuerzoDeportivo #tiempodedeportes #BonitaDeportes #DeporteEsMásQueJuego #Anótalo #periodismoinvestigativo #periodismodigital

On this week's episode of Hands-On Tech, Mikah Sargent discusses ways to improve your home internet and offers some products to help! Host: Mikah Sargent Get episodes ad-free with Club TWiT at https://twit.tv/clubtwit Sponsor: betterhelp.com/ATG

On this week's episode of Hands-On Tech, Mikah Sargent discusses ways to improve your home internet and offers some products to help! Host: Mikah Sargent Get episodes ad-free with Club TWiT at https://twit.tv/clubtwit Sponsor: betterhelp.com/ATG

On this week's episode of Hands-On Tech, Mikah Sargent discusses ways to improve your home internet and offers some products to help! Host: Mikah Sargent Get episodes ad-free with Club TWiT at https://twit.tv/clubtwit Sponsor: betterhelp.com/ATG

Are you feeling overwhelmed by the constant need to prove your medical expertise?In this week's episode, Dr. Lia talks about the challenges and anxieties surrounding board certification for pediatricians, particularly focusing on the evolution of the MOCA peds program. She shares personal experiences with various certification methods, from proctored exams to open-book tests, highlighting the stress and self-doubt that often accompany these processes. The importance of continuous learning in the medical field is also mentioned, recommending resources like pediatric board review materials and various CME opportunities. You'll hear Dr. Lia will also touch on the prevalence of imposter syndrome among medical professionals, reassuring listeners that it's normal to not know everything and encouraging them to ask for help when needed. Ultimately, she advocates for a balanced approach to professional development, acknowledging both the necessity of expertise and the reality of human limitations in medical practice. [2:54 -05:07] The Evolution of Board Certification MethodsProctored exams: Anxiety-inducing and challenging to concentrateOpen-book tests: Time-consuming but aligned with real-world practiceReturn to proctored exams: Disliked by many professionalsMOCA Peds: A modern, quarterly assessment approach[5:08 - 07:14] Navigating MOCA peds and Continuous Learning Utilize pediatric board review materials for preparationApproach questions as real-life cases, not trick questionsTake advantage of the 5-minute time limit per questionEmbrace continuous learning through various CME opportunities[07:15 - 12:30] Expanding Mental Health Knowledge in PediatricsSeek out mental health sessions at national conferencesAttend specialized mental health conferences for pediatriciansConsider long-term training programs like the REACH InstituteUtilize resources from AAP and ACAP for ongoing education Resources mentioned on the showMOCA-PBR www.pediatricsboardreview.com Neuroscience Education Institute https://www.neiglobal.com/REACH https://thereachinstitute.org/nncpap.orgaap.orgaacap.orgAAP National Conference https://aapexperience.org/Other episodes mentioned on the show:https://pediatricmeltdown.com/episodes116. Physician Wellness Coaching: Proven Benefit! 98. Anxiety? Inattention? Depression?: Prescribe Nature! Dr. Stacy Beller Stryker 76. Pediatric Practices: Find Your BalanceBuilding Better Workflows PodcastBuilding Better...

¡¡¡ ESCRÍBENOS!!!En este episodio te hablo de un crimen de odio ocurrido en Moca, Puerto Rico en el 2013. Un crimen macabro que cobró la vida de un prestigioso y muy querido estilista y maquillista puertorriqueño. Fuentes de información y documentos adicionales disponibles en Patreon.En Fashion Reason, no solo encuentras ropa, encuentras calidad y diseño. ¿Buscas marcas exclusivas? Ellos tienen lo último de Michael Kors, Coach, Nike, Adidas, Puma entre otras marcas. Cada pieza es seleccionada para que siempre luzcas a la moda y con clase. Además, te ofrecen envío gratis y un 15% de descuento en tu primera compra al utilizar el código CrimepodPR15. Visíta fashionreason.com y transforma tu closet hoy mismo. Puedes llamar a Fernando Fernández Investigador Privado y Forense con más de 17 años de experiencia a nivel local e internacional al 787-276-5619 o visítalo en: Fernando Fernandez PIEste episodio también es traído a ustedes por Jabonera Don Gato. Los jabones Don Gato son hechos a mano, sin químicos dañinos ni detergentes. Elaborados con aceites naturales, esenciales y aromáticos, seguros para la piel. Pruébalos y siente la diferencia. Visítalos en jaboneradongato.com y utiliza el código "Crimepod" para obtener un 10% de descuento en tu compra.Este episodio es traído a ustedes por Libros787.com. Ordena tus libros favoritos escritos por autores puertorriqueños desde la comodidad de tu casa. Utiliza el código promocional: CRIMEPODPR para que recibas envío gratuito en tu primera compra. Envíos a todas partes de Puerto Rico y Estados Unidos. Support the Show.