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Parkinson’s Disease

12/16/2022

 
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Written by Caitlin Goodwin on Jan 21, 2021
​Last reviewed and updated by Caitlin Goodwin on Oct 18, 2022
Caitlin Goodwin, DNP, RN, CNM, is a Board Certified Nurse-Midwife, Registered Nurse, and freelance writer. She has over twelve years of experience in nursing practice.

Parkinson’s disease is a progressive nervous system disorder that affects movement. This neurodegenerative disorder affects cells in a specific area of the brain. According to the Centers for Disease Control and Prevention (CDC), the associated symptoms make Parkinson’s disease the 14th cause of death in the United States.

Parkinson’s disease causes stiffness or slowing of movement. It can start so gradually that it is often missed in the early stages. Empowering you and your family with information can help your family get an earlier diagnosis. This article will cover what to expect regarding Parkinson’s disease causes, symptoms, stages, diagnosis, and treatments.

CausesThe cause of Parkinson’s Disease is mostly unknown. Those with Parkinson’s have low dopamine concentrations in their brain. However, some factors may increase the risk of Parkinson’s.

Experts think that a combination of factors such as genetic mutations, lifestyle factors, and environmental effects cause the degenerative disorder. It is more likely to occur in men over the age of 60 years old. Chemicals like Trichloroethylene (TCEs) and Polychlorinated Biphenyls (PCBs) also increase the risk for Parkinson’s disease.

SymptomsThe symptoms of Parkinson’s disease vary depending on how far the disease has progressed. Signs and symptoms are gradual and often start with a slight hand tremor. As the person with Parkinson’s advances along the spectrum, the signs and symptoms of the disorder worsen.

Parkinson’s signs and symptoms include:
  • Tremor: Shaking often begins in your hand or fingers. Some rub their thumb and forefinger (pill-rolling tremor), while others experience hand shaking while at rest.
  • Bradykinesia: As it progresses, Parkinson’s disease slows movement. This means taking shorter steps, dragging feet while walking, or struggling to stand from sitting. For some, routine tasks now seem complicated and time-consuming.
  • Muscle stiffness: Any muscle in your body can become stiff, painful, and limit one’s range of motion.
  • Impaired balance: Parkinson’s disease may only affect posture initially. However, eventually, balance problems follow.
  • Loss of unconscious movements: Do you know the automatic actions you perform each day, like blinking, smiling, or swinging your arms while walking? Some with Parkinson’s experience a decreased ability to perform these.
  • Speech: Your speech may become monotone or soft-spoken. Some hesitate before talking, speak more quickly, slowly, or even slur.
  • Writing changes: Handwriting may become more complicated, while some find that it appears smaller than it used to.

As the disease progresses, the following may occur as a result of the above symptoms:
  • Loss of bladder control
  • Constipation
  • Dementia
  • Swallowing problems
  • Depression
  • Trouble sleeping
  • Cognitive problems
  • Fatigue
  • Pain

Stages of Parkinson’s DiseaseThere are five stages of Parkinson’s disease.
  • Stage 1: In this stage, the symptoms of Parkinson’s disease are mild, and diagnosis is unlikely.
  • Stage 2: The symptoms are more pronounced, but balance is not impaired.
  • Stage 3: While Parkinson’s disease is progressing, those remain independent in this stage.
  • Stage 4: Patients performing daily tasks become difficult during this stage. Patients can still stand unassisted but often struggle to walk.
  • Stage 5: This stage is the most advanced and requires around-the-clock care.

DiagnosisDiagnosing Parkinson’s disease may be challenging as the symptoms are mild at first. There is no specific test that diagnoses the illness. A neurologist, a doctor specializing in nervous system conditions, will evaluate your case. If it is early in the process, a follow-up appointment may confirm worsening symptoms.

The neurologist will ask questions like:
  • How long ago did you first experience symptoms?
  • Are there any associated symptoms?
  • Are these symptoms constant, or do they come and go?
  • Where do you experience the symptoms?
  • What makes the symptoms better?
  • What makes your symptoms worse?

They will base their diagnosis on your medical history, signs, symptoms, and a neurological and physical exam. The neuro exam will cover mental status, balance, motor function, and a sensory exam. This will cover items like:
  • Pushing and pulling against the provider’s hands with arms and legs
  • Moving from a seated position to standing and walking
  • Standing with closed eyes and being pushed to one side or the other.
  • Passive and active range of motion (ROM)
  • Discussing person, place, and time (who you are, where you are, and when it is)
  • Observation for speech and clarity
  • Assessing sensation with dull needles, tuning forks, alcohol swab, and cotton bulls

Your healthcare provider may order other tests, such as blood work or imaging like an MRI. However, instead of diagnosing Parkinson’s, these tests rule out other conditions that may be causing these symptoms. In rare cases, you may receive a dopamine transporter scan (DaTscan) to support the suspicion of Parkinson’s.

Treatments
There are many medical and surgical options for treatments for Parkinson’s, but no cure. Some medications will manage problems with walking, tremors, and movement by increasing dopamine. Dopamine cannot directly enter your brain.
People with Parkinson’s disease have medication options:
  • Carbidopa-levodopa is the most effective Parkinson’s disease medication. In fact, it is usually so effective that it is used as a diagnostic tool. If the symptoms improve significantly with the administration of this medication, it will confirm the diagnosis.
    • Levodopa is a natural chemical that your body converts to dopamine once it passes into your brain.
    • Carbidopa protects the levodopa from converting to dopamine before it passes into your brain and lessens side effects.
    • It can be taken orally, inhaled, or as a continuous gel through a feeding tube.
  • Dopamine agonists are not as effective as levodopa but last longer.
  • MAO B inhibitors prevent the breakdown of dopamine in the brain.
  • Catechol O-methyltransferase (COMT) inhibitors slightly prolong the effect of levodopa by blocking dopamine breakdown.
  • Anticholinergics were used for many years to control the tremor associated with Parkinson’s disease. However, the risks often outweigh the benefits with side effects like memory impairment, confusion, impaired urination, or constipation.
  • Amantadine alone provides short-term relief of mild, early-stage Parkinson’s symptoms. It can also be given during more advanced stages to control involuntary movements caused by carbidopa-levodopa.
  • A2A receptor antagonists are adenosine receptor antagonists that target areas in the brain that regulate the dopamine response to allow more dopamine to be released.
  • Pimavanserin is a drug that treats delusions and hallucinations associated with Parkinson’s disease.
There is also a surgical procedure called deep brain stimulation, in which the surgeon implants electrodes into your brain that connect to a generator in your chest. The generator near your collarbone sends impulses to your brain to reduce symptoms. There are risks like infection, stroke, or bleeding.

Deep brain stimulation (DBS) is best for those with advanced Parkinson’s disease who have unstable responses to their drug regimen. However, it will not cure Parkinson’s nor stop it from advancing.

Questions to Ask Healthcare Providers about Parkinson’s Disease
Getting a diagnosis of Parkinson’s disease can seem overwhelming. For others, it may be helpful to finally understand the changes you’re experiencing. However, having a support network and working with your medical team is important. You should ask questions after the diagnosis, such as:
  • What are my options for treatment?
  • Are there side effects to these treatments?
  • Are there any clinical trials or brand-new treatments?
  • What other specialists should I see?
  • What are the symptoms as Parkinson’s disease progresses?

Bottom line
While the cornerstone of Parkinson’s disease is worsening symptoms, there are ways to reduce them as the disease advances. The most crucial part of the treatment plan is a supportive network, coping tools, and safety measures. Coping tools include meditation, tai chi, yoga, or seeing a trusted therapist.
If balance becomes a problem, it is crucial to prepare the bathroom with grab bars and remove rugs. An occupational therapist can help with other strategies to promote safety.

Unfortunately, treatment cannot cure Parkinson’s disease, but you can manage the symptoms. Contact your healthcare provider or neurologist to start the conversation if you suspect that you or a loved one is symptomatic with Parkinson’s disease.

If you have questions about performing CPR for those with dementia, Pacific ACLS provides courses and a guide to first aid for people with dementia to give you a more in-depth look.

Works Cited
  1. Centers for Disease Control. LCWK5: Deaths, Percent of Total Deaths, and Death Rates for the 15 Leading Causes of Death: United States and Each State, 2017. Updated December 31, 2018. Accessed October 17, 2022.
  2. Parkinson’s Foundation. Environmental factors. Accessed October 17, 2022.
  3. Mayo Clinic. Parkinson’s disease. Updated July 8, 2022. Accessed October 17, 2022.
  4. Bastiaan RB, Okun MS, Klein C. Parkinson’s Disease. Lancet. 2021;397(10291):2284-2303.

Cryptogenic Stroke

11/2/2020

 
​The attached PowerPoint is from Dr. Cokgor.  She did a wonderful presentation on “Cryptogenic Stroke” last Wednesday. 

Cryptogenic Stroke definition is basically - An ischemic stroke occurring without being able to discover the cause/source. Crypto (hidden or secret) Genic (producing or forming) Meaning that what produced the stroke is unknown.

Dr. Cokgor has several points that she wants to stress to us as nurses caring for the Cryptogenic Stroke Patient - Remember we do not know the cause for the stroke so……
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  1. Monitor their telemetry closely- watch for signs of atrial fib or any other arrhythmia
  2. Look for signs of infection
  3. Take a good history and ask the patient about drugs and alcohol (they might tell you and not the doctor)
  4. Family history of strokes
  5. Recent Miscarriages  https://academic.oup.com/humrep/article/20/6/1729/748934  This is an excerpt from the article - CONCLUSIONS: Both idiopathic and antiphospholipid syndrome (APS)-associated recurrent miscarriage were associated with a similar long-term risk of thrombosis.

Coronavirus (COVID-19) information

3/25/2020

 
View short videos regarding COVID-19 
​vimeo.com/showcase/6852479
patientpoint_covid19_flyer.pdf
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Neurological Assessment of Stroke Patients - Feb 2020

2/24/2020

 

Concussion - Q & A

8/28/2018

 
Concussion - Q & A
See Marin IJ 8/25/18 article by Mark C. Volain - Marin schools focus on concussions as football participation declines

What does a concussion do to the brain?
A concussion occurs when the head hits or is hit by an object, or when the brain is jarred against the skull with sufficient force to cause temporary loss of function in the higher centers of the brain. The injured person may remain conscious or lose consciousness briefly and is disoriented for some minutes after the blow.

According to the Centers for Disease Control and Prevention, approximately 300,000 people sustain mild to moderate sports-related brain injuries each year. Most of them are young men between 16 and 25 years of age.

The risk of concussion from football is extremely high, especially at the high school level. Studies show that approximately one in five players suffer concussion or more serious brain injury during their brief high-school careers. The rate at the college level is approximately one in 20. Rates for hockey players are believed to be similar.

Concussion causes the brain to be jarred against the hard skull. This leads to inflammation, swelling and sometimes bleeding in the neurons and synapses in the brain. If untreated the brain pressure can rise and lead to fatal consequences. That’s why most common symptoms are confusion, headache, blurred vision, dizziness, cognitive problems, memory loss, mood swings and sleep disturbances. The injury to brain changes with the severity and recurrence of the impacts. Especially losing consciousness should be taken very seriously.

There have been a lot of studies recently linking head trauma like concussion to future issues like dementia and CTE. How have these studies impacted your practice, be it an increase is patients, less patients, more people looking for more info, people looking into preventative measures, etc.?
I have been seeing more high school and middle school students with soccer, basketball and football head traumas. The awareness of short and long term implications of head trauma are now well known by atheletes, parents and coaches. They all are looking for safer ways of playing sports. In adults, I see a lot of car accidents or bike accidents with head trauma or whiplash injuries to head and neck region. My patients with head injuries and postconcussion syndromes are exponentially increasing. The reason they all seek medical attention is the awareness and data on CTE and potential dementia.

What do you tell athletes who have suffered a head injury?
The atheletes who suffered a head injury should immediately stop playing their sport until they are evaluated by a professional. They should only go back to playing when all of their symptoms resolve. If they return earlier, their recovery will be delayed and they may be left with long term complications. On top if it, every additional head injury will cause further damage and delayed recovery. Therefore I recommend to be seen by a trained professional as soon as the injury occurs. Depending on the injury the atheletes may need brain scan, neuropsychological evaluation and treatment.

How do you feel about protocols that many schools have in place for dealing with head injuries and when they're able to return to both learning and competing athletically?
Many high schools and colleges now have initial impact or concussion evaluations before the students start playing their sports. I reviewed some and they are comprehensive. I feel strongly that this should be a country wide protocol in every school and concussion tests should be given annually to the students/athletes with no injuries and after every head injury. All atheletes, coaches and volunteering parents should take courses and get knowledgeable about the head injury protocols. The atheletes should only return to sports when they are fully recovered. The students should be allowed to home school and take their tests with accommodations till they fully recover.

Anything else you'd like to share in regards to athletics-based head injuries?
All athletes professional or school/college level should be given comprehensive courses regarding concussion. They should learn about signs and symptoms of concussion, post concussion syndrome and second impact syndrome. If they are aware of the symptoms then they will recognize them faster and take logical action themselves. It should be a mandatory training at schools to educate the students at every level. They should reach out to their primary care doctors with any questions if coaches or schools are not attentive to them.

Video: Causes, Signs and Treatment Options for Stroke

8/16/2018

 
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In this video, Dr. Cokgor discusses the causes, signs and treatment options for stroke.

Why is Sleep So Important?

8/1/2018

 
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​Click the image to watch the video
We’ve all had mornings when it was tough to function because of a poor night’s sleep. But when those poor nights of sleep happen repeatedly, it can create serious health problems for us. Why sleep is so critical to good health is the theme of my newsletter this month.  

The information in this blog post will help you understand why sleep matters and how you can get the most benefit from your shuteye.

Please take a look at the video below, and if you have any questions or you want to know more about sleep and your health, please don’t hesitate to contact my office.

New Help for Migraine Sufferers

7/4/2018

 
New Help for Migraine Sufferers
We are excited to share the new publication below. This study provides Class 1 evidence that for patients with migraine, gammaCore (non-invasive Vagus Nerve Stimulator) significantly increases the probability of having mild pain or being pain-free 2 hours post stimulation.
Follow the link below to review the published paper.
​
Contact the Neurology Clinic of Marin for an appointment! 
New Class 1 evidence for gammaCore (nVNS) published in Neurology
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Marin General Hospital receives American Heart Association/American Stroke Association’s Prestigious Get With The Guidelines®-Stroke Gold Plus Quality Achievement Award

5/23/2018

 
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Marin General Hospital has received the American Heart Association/American Stroke Association’s Get With The Guidelines®-Stroke Gold Plus Quality Achievement Award. The award recognizes the hospital’s commitment to ensuring stroke patients receive the most appropriate treatment according to nationally recognized, research-based guidelines based on the latest scientific evidence.

Marin General Hospital earned the award by meeting specific quality achievement measures for the diagnosis and treatment of stroke patients at a set level for a designated period. These measures include evaluation of the proper use of medications and other stroke treatments aligned with the most up-to-date, evidence-based guidelines with the goal of speeding recovery and reducing death and disability for stroke patients. Before discharge, patients should also receive education on managing their health, get a follow-up visit scheduled, as well as other care transition interventions.

​Dr. Ilkcan Cokgor has been the Stroke Director at Maring General Hospital and is proud to share this great news with you.

2017 Walk to End Alzheimer's Kick Off

7/6/2017

 
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Held annually in more than 600 communities nationwide, Walk to End Alzheimer’s is the world’s largest event to raise awareness and funds for Alzheimer’s care, support and research.

Please join us! We invite you to enjoy heavy appetizers, refreshments and inspiring speakers while learning more about how you can support your local ALZ office and your community by getting involved in this important cause! 

I am hosting a table and volunteering at the kick-off event on Thursday, August 10th 5:30 - 7 pm at The Embassy Suites San Rafael, 101 McInnis Parkway.

​https://www.alz.org/walk/

As seen on CBS American Health Front

6/1/2017

 
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KPIX-TV, CBS, Channel 5 - Saturday, June 3, 2017 @ 7:00-7:30pm
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“AMERICAN HEALTH FRONT!” has been produced by Medical Media Group since 2002. The program is dedicated to educating the public on healthcare technologies, providing our viewers with valuable information on the latest treatments and discoveries. Each half-hour program consists of news reports that introduce our audience to local health care specialists utilizing current techniques that are changing lives.

Recognized on the [415] Top Doctors 2017 List

5/26/2017

 
Recognized on the [415] Top Doctors 2017 List
Marin Magazine conducted a 2015 survey that has resulted in this [415] Top Doctors list — top physicians practicing in San Francisco and Marin counties who received multiple independent recommendations from their peers. The list was rechecked again this year. The survey process started with a list of more than 4,000 licensed doctors across all specialties in both counties. All doctors on this list were both candidates and eligible voters in the peer-to-peer voting poll. Doctors were allowed to cast an unlimited number of votes across all specialties — they could vote for as many doctors as they wanted regardless of specific area of expertise — but they could only vote for the same doctor once.

http://www.marinmagazine.com/People-Places/415-Top-Doctors/

DR. ILKCAN COKGOR HAS BEEN PRACTICING IN MARIN COUNTY for over 16 years as a general neurologist and neuro-oncologist. In addition to her private practice, she consults to Marin General, Novato Community and Kentfield Rehab hospitals. She has a large number of patients suffering from migraines, Alzheimer disease, dementia, movement disorders, stroke, and spine disorders. She works with multiple sclerosis patients, as well as clients suffering from fibromyalgia, chronic fatigue syndrome and brain tumors. She does EMG and nerve conduction studies for nerve and muscle disorders and offers Botox for dystonia, spasticity and migraines. She is a patient advocate and speaker for many neurological disorders and treats pediatric neurology patients with head and sports related injuries. For continuity of care, Dr. Cokgor covers her own patients if they are admitted to the hospital. Her practice is open everyday and she has an efficient, bilingual staff to help patients fast and comprehensively. She accepts every kind of insurance.
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Stroke Director for Marin General

5/22/2017

 
Stroke Director for Marin General
Marin General Hospital is one of the main stroke centers in Marin county. We have a very aging population with stroke risk factors. We are diamond certified for our care of patients admitted to MGH. We take care of acute stroke patients by giving them TPA, admitting them for the full work up by doing MRI, echo and risk management. Then we refer them to rehab hospitals and follow up after their discharges till their fulll recovery. We have a close relationship with paramedic services, stroke awareness centers and provide all the information to our patients before they get discharged.

​Dr. Cokgor became the stroke director in MGH as of May 2017. She oversees ER, hospitalists, Neurologists, physical, occupational therapy and speech therapy services. She is responsible for the timeliness and the availability of offering every cutting edge therapy to our patients. When needed we transfer patients to university hospitals for thrombus retraction. We educate patients' families about care and symptoms. We have very trained nurses, doctors and therapists in MGH to provide all the needs for stroke patients and families.

Concussion and Related Syndromes

4/17/2017

 
Concussion and Related Syndromes
Concussion is a direct impact by a blow or whiplash to the head, face and the neck. It can be a blow to the body that transmits to head too. In mild cases, symptoms resolve within 10 days. CT or MRI of brain are usually normal. If an injury is serious, the patients improve slowly over time. Torsional forces can delay the recovery.

Post concussion syndrome symptoms are headaches, dizziness, imbalance, memory problems and mood swings. The pathophysiology involves many disrupted pathways in the brain either causing nerves to be functionally compromised or die at severe cases.

Second impact syndrome means a second head injury between 24 hours and 10 days after the first one. It can cause massive brain swelling leading to death or severe disability. It is common in young patients and boxers.

​Traumatic brain injury (TBI) is a consequence of concussion and can occur after bicycle accidents, skateboard accidents, MVAs, falls and sport injuries. Patients with repeated TBIs are at risk of chronic traumatic encephalopathy ( CTE). There are 4 stages of CTE. First stage includes headaches, inattention and concentration problems. Second stage includes impulsive behavior, depression and short term memory loss. Third stage includes executive dysfunction with severe cognitive decline. Fourth stage includes dementia. MRI of brain shows atrophy by then.

Treatment of concussion is to stop any activity for 10 days and see a neurologist. Patients need a full exam, rest and sleep. Imaging may or may not be necessary. The patients should then start some limited exercise like walking, cycling or swimming. If they have recurrence of their symptoms they should stop immediately. There is no diagnostic blood test available yet to diagnose these patients. The patients, coaches and families should have a understanding of these syndromes before pushing athletes back to the fields.

Chronic Tension Headaches (CTH)

10/28/2016

 
Chronic Tension Headaches (CTH)
Tension headaches are the most common type of headaches. Chronic Tension Headaches (CTH) mean constant tension headaches more than 15 days per month for at least 3 months. The CTH last hours to days and are constant. They can be episodic or chronic. They involve both sides of the head and they are pressing or tightening kind of pain that change in intensity from mild to severe. Unlike migraines, they are not accompanied by other symptoms such as nausea and light sensitivity. CTH mostly affect working people with jobs in front of a computer and students who carry heavy backpacks.

The cause of CTH is unknown but both peripheral and central pain mechanisms play a role. The peripheral sensitization causes local tissue damage, producing pain and causing substances to be released. Prolonged peripheral sensitization leads to central sensitization which means that the pain radiates all around the original tissue. The main symptoms of CTH are tenderness and dull pain over frontal, neck muscles and chewing muscles. It hurts when a patient moves the neck up and down or sideways. It causes stiff neck muscles and postural abnormalities.

​The diagnosis includes eliminating other neck and brain causes contributing to pain syndrome first. Treatment is muscle relaxors, anti-inflammatory medications like Advil or Motrin and physical therapy. Physical therapist can evaluate the muscles, pain and pressure over the neck muscles. She can give isometric manual exercises, massage trigger points and mobilize joints. The best treatment is combination of physical therapy and massage. Botox is another option if all modalities fail.

Welcome to our New Website

6/29/2016

 
Welcome to our New Website
Dear patients, friends, and colleagues,

This is my first ever blog and I am excited to share news with you on a regular basis on my new website. To start with I want to emphasize what I actually specialize on. I do both outpatient and inpatient Neurology which require different skills. Hospital patients get admitted mostly due to a stroke, head injury, brain infections and spinal cord problems. If patient develops severe pain in the neck or back or severe headache they get admitted for work up and treatment. If they develop sudden onset of weakness, numbness, speech difficulty and balance problems they get admitted to rule out a stroke.

I treat every kind of neurological disorder in my clinic. I am a general neurologist with a long experience on migraines, dementia, multiple sclerosis and back and neck pain. I see young and old patients with concussion, brain injuries and bleeds. I am subspecialized in neuro-oncology which means I treat brain and spinal cord tumors but luckily these tumors are rare. I offer Botox injections for neck spasms, back torsion, migraines, TMJ problems and grinding. I also treat stroke related spasticity patients with Botox. I do EEG to work up seizure patients. I do EMG and nerve conduction studies for nerve and muscle disorders. Long experience with migraines, demantia , movement disorders like Parkinson's disease. 

As you see I cover almost every part of Neurology. As I am very up to date with advances in Neurology and get qualified every year for new technology and medications I feel confident to help every kind of neurology patient. I will go into details and update you about the new discoveries and treatment options for different neurological disorders in my blog as time goes on.

​Please feel free to contact me through my contact web form with your questions, feedback and your own experiences. My staff and I hope to give you the best, comprehensive care possible in Marin county.

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​Ilkcan Cokgor, M.D.

If you have a life threatening emergency at any time of day, call 9-1-1 or go to the Emergency Room. ​If you need to reach us, call our office during business hours. After business hours you can leave a voice mail and we will return your call during the next business day. 

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San Anselmo CA 94960
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