Medical journal club template ppt,chinese medicine shop malaysia facebook,how do you treat cancer of the uterus lining - New On 2016


Customer Relationship Management (CRM) systems and CRM software can help you increase sales by streamlining communications with your potential and current customers. A critical feature of any CRM system is to track communications with customers, plan follow-up contacts, update the lead status, and after gaining a customer, schedule future communication that will help you keep them as a customer.
The CRM template provides a starting point for people looking for an Excel-based CRM solution.
In it's current form, this template is just a table formatted to allow sorting, filtering, and display of important customer information - a fancier version of the Contact List Template. The most complex part of the spreadsheet has to do with the conditional formatting used to highlight the dates in the Last Contact and Next Contact columns. I personally do not use CRM software, so future updates and versions of this template will be based on the feedback and requests that I get from users.
Sorting and Filtering: This template is designed around Excel's built-in Sorting and Filtering features.
Demographics - For any contact, you'll want to record their name, company, job title or position, email, phone #, etc. Estimated Sale - For active customers, this might be the average monthly or annual sales figure - something to help you easily see the value of keeping that customer.
Next Contact - Planning follow-up communication is important, so use this column to record the date for the next contact and use the Next Action column to enter a code that describes what your follow-up action will be. Notes - There are many ways that you can record notes about communications with your leads.
Sales Log - If you want to create monthly or quarterly or annual sales reports, you'll need a way to record individual sales. In a delicious turn of terrible-for-us events, a website created by McDonald’s to help its employees create a monthly budget may have just become the prime example of how difficult it is to live off a minimum wage paycheck. The fast food giant teamed with Visa to create a sample budget that shows the realities of earning $7.25 an hour — the national minimum wage.
Some of that can be made up from the fictitious $20 health insurance that no worker will ever find. With recent bills before Congress that look to raise the minimum wage above $10 an hour, the issue has become part of the national conversation on inequality. Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. The junior doc pops along and the patient tells her that she feels as though there is a lump in her throat and there is discomfort when breathing. Symptoms have been developing over the last 4 hours but the feeling of difficulty with breathing has been developing quickly over the last hour.
Menstrual cycles are irregular and she has been previously investigated for possible endometriosis, evidence of which was found on laparoscopy the previous year.
Current medication: NSAID for analgesia prn (recent use) uses salbutamol intermittently when chest feels tight as is presumed mild asthma. Working on the assumption that this is allergy related, the Junior Doc has given antihistamine (Chlorphenamine 4mg oral) about 2 hours ago as well as 200mg IV Hydrocortisone. Since there has been no improvement, she comes to ask if she should give adrenaline in view of the feeling of discomfort with breathing. It has also been associated with URTI and often a lip swelling closely predates a cold sore eruption. A feeling of swelling in the back of the pharynx and discomfort with breathing is the reason for attendance today. In this patient, antihistamines have not had an effect and if adrenaline was given would we expect any improvement? Attacks can effect the skin, the face and lips, the larynx and pharynx, the gastrointestinal or genito-urinary tracts.
Facial and pharyngeal attacks are at best disfiguring, preventing the sufferer from working for several days, but they are potentially lethal with 30% of affected families describing airway obstruction deaths in affected family members, often associated with simple URTI.
Triggers that are recognized are; direct trauma, such as dental work, intubation, and peripheral injuries, infections, exposure to oestrogens (HRT and Oral Contraceptives), Non steroidal analgesics and ACE inhibitors. In vivo this might be a viral or bacterial surface coat, or various altered proteins such as amyloid or Bence Jones protein as well as articular cartilage, endotoxins and heparin amongst other physiological auto-activation triggers. Type 1, making up 85% of such cases, with a pathologically low level of C1 esterase inhibitor protein, and Type 2 (15%) where the protein concentration is near normal but it lacks function. Other known causes of “normal inhibitor” angioedema are those patients on ACE inhibitors (ACEI), where up to 2% can suffer from angioedema. The traditional treatments we, in the ED, routinely use when airway appears compromised by swelling are adrenaline, antihistamines and steroids. Tranexamic acid has been used for decades as prophylaxis for HAE with some reduction in attack frequency and consequently is used in the acute event although studies suggest a slow response to treatment with 20+ hours before resolution. Since the end organ trigger for angioedema appears to be bradykinin in at least three patient types of angioedema, it would seem logical to consider attempting blocking the Bradykinin receptor.
Known HAE cases need replacement of C1 esterase inhibitor, which now exists in purified form. There is also a new Bradykinin blocker which acts at the end organ directly and can be given as a subcutaneous injection. It is very probable that most angioedema attacks will prove to be due abnormally elevated bradykinin levels and so as an emergency treatment a selective blocker is a logical choice for these cases as well, although that would be currently out of license and so would need to be discussed as such with the patient. Lastly, but most importantly. Although this case is hypothetical it is based on very real events and on events very close to the Volans family. 2010 International consensus algorithm for the diagnosis, therapy and management of hereditary angioedema Bowen et al. Acute angioedema: recognition and management in the emergency department Thiagarajan Jaiganesh, Martin Wiese, John Hollingsworth, Chris Hughan, Mohamed Kamara, Philip Wood and Claire Bethune. Emerging concepts in the diagnosis and treatment of patients with undifferentiated angioedema Jonathan A Bernstein and Joseph Moellman Int J Emerg Med. Factor XII mutations, estrogen-dependent inherited angioedema, and related conditions Binkley.
Therapeutic efficacy of icatibant in angioedema induced by angiotensin-converting enzyme inhibitors: a case series.
My experience with angioedema over the years, almost exclusively due to ACE, is that airway problems are rare.
This case series describes using FFP but I didn’t find it particularly convincing from an efficacy perspective.
In the paper from the European Journal they make a similar point about the ACE associated ones I.e. I think that’s why there is differentiation in the diagnostic pathway between the two groups. A wonderful overview Simon of a poorly appreciated condition that most of us have seen and dealt with at some point. I still frequently see many doctors give the knee-jerk H1 receptor blockers and steroids for non-histamine mediated angioedmea. Although I am not a fan of using the above stated medications in what I clinically suspect to be a non-histamine mediated angioedema (like you I am convinced bradykinin is usually the common final pathway and main guilty culprit for most of the symptoms) I am still cautious in completely dismissing the use of such medications when discussing this with my colleagues just to reinforce the point that patients with HAE (types I, II and III) or any cause of acquired angioedema could of course still suffer from histamine mediated allergic reactions, so I give leeway to physician judgement.
Bradykinin receptor blocker use for ACE inhibitor induced angioedema may be off-licence but I agree it makes sense based on the putative patho-physiology.

I am collecting our AE cases, since they seem quite common just now, so will try to present a case series. I know of a fatal case where angioedema occurred, probably Bradykinin related as nonresponsive to adrenaline, antihistamines. We have a family with HAE and its useful to see the rapid response to Berinert, factor concentrate as well as icatibant. The researchers came to these findings, published in the medical journal Pediatrics, after analyzing three national databases that contained injury information reported to various healthcare settings, including emergency departments, inpatient and outpatient medical providers, and certified high school athletic trainers. Alarmingly, researchers estimated that between 511,590 and 1,240,972 SRRCs went untreated in children under 18 each year.
The study comes as concerns over concussions and their long-term effects on the brain have increasingly gained attention, especially as related to chronic traumatic encephalopathy (CTE).
Concussions, which are a mild form of traumatic brain injury, can be the result of any direct blow to the head.
He pointed concussive impacts can cause bruising of the brain or can cause the nerve cells to twist or stretch, causing injury.
According to Flanagan, the most generally accepted treatment early on is physical and cognitive rest, which includes limiting time spent watching TV or reading. While high school athletes have easy access to people trained in recognizing concussive symptoms, many children may be injured during free play or during recreational sports. He also noted that there is a disparity in the amount of money and resources provided to children not participating in an organized sport versus those who are, especially as medical providers are increasingly promoting more physical activity for all children and adolescents. Access to the brachial artery is gained at the cubital fossa just proximal to its division.
Online CRM software can help you integrate revenue tracking, sales, and email into an all-in-one system. I'm a fan of conditional formatting, but if you don't like it or want to change the colors, see Excel's help system (F1) for how to clear or change conditional formats.
Information that may be nice to know what not necessary to refer to on a day-to-day basis could be saved in the optional ContactDetails worksheet (which is just the contact list added to this workbook). For potential customers, this could be your estimate of the customer's potential monthly or annual sales. The highlighting will make the cell green if the contact was recent, pink if it has been a long time since that last contact, or yellow for somewhere in between. The budget (pictured) is making its way around the web and is deceptive — at best — because it factors in a second job on top of working full-time at McDonald’s. Twenty-seven American dollars worth of spending money to help pull the economy out of this recession, which in McDonald’s dream world has nothing to do with large corporations paying their workers next to nothing. Add in other factors — such as $600 rent that may be a steal depending on the city or an employee with, gasp, childcare expenses — and McDonald’s makes an incredibly strong argument that the minimum wage should be raised and then tied to inflation. Support for a change is broad though far right ideologues have suggested ridding the workforce of the minimum wage all together.
He currently contributes to WePartyPatriots, Addicting Info, Secret Party Room, and Football Nation. Andy Volans is consultant in Emergency Medicine in the seaside town of Scarborough, Yorkshire.
You assign the case to one of the junior docs to see in the majors end whilst you are busy in resus.
She is on the oral contraceptive to try and suppress the Endometriosis and regularize the periods. It is after all a common cause of swelling in the ED, but the normal treatments are not working so at this stage we need to stop and think again.
Allergy conditions are triggered by exposure to environmental allergens and involve interaction with Immunoglobulins, either free in the plasma or attached to cells, resulting in the release of histamine from mast cells. Probably not as this syndrome is almost certainly mediated via the transmitter, Bradykinin.
Angioedema is a deep dermal, submucosal or subcutaneous swelling associated with vascular leakage. A recent publication describes an algorithm supporting the diagnosis and treatment of acute attacks of angioedema presenting to the ED. A typical and common example of bradykinin activity is the congestion of the upper airway present during an URTI.
Based on this work, a treatment regimen was developed, using Fresh Frozen Plasma to replace the C1inhib that has now been refined to deliver the isolated plasma derived inhibitor (Cinyrise) or a synthetic inhibitor (Berinert).
It is most commonly seen in women but not is not exclusively so, it seems to be oestrogen driven and is seen to run in families. Given the incidence of ACE inhibitors in the community, this group will make up a significant number of cases that will present to the ED. Review of the patho-physiology above suggests that steroids and antihistamines are unlikely to be effective. The suggestion is that Tranexamic acid works on the secondary prostaglandin activation or somewhere in the Thrombin pathway. It has become apparent that where oestrogens increase the amount and activity of factor XII, androgens reduce both the oestrogen level and consequently the stimulation to the factor XII, and also may have a direct suppression effect on Factor XII.
Currently there is a BK2 receptor blocker (Icatibant) in the formulary, which has a license for use in Hereditary Angioedema.
It’s fantastic to share the story and photographs to help others learn about the condition and to support other patients with the condition.
Obviously the soft tissue swelling can be a bit scary in the ED when you’re seeing someone with a swollen mucosa and contemplating the A of ABC. Haven’t looked through references above but a descriptive case series detailing course and outcomes would be a useful addition to the literature. Airway compromise due to angiotensin-converting enzyme inhibitor-induced angioedema: clinical experience at a large community teaching hospital. I did a BestBet on the specific topic (unpublished) of ACE inhibitor induced angiooedmea and came to the conclusion that there was no strong evidence either way for the use or non-use of steroids and anti-histamines in the treatment (this was simply through the lack of any good quality studies specifically addressing the question).
Hopefully someone somewhere will run and publish a DBRCT to answer the question definitively. We see the acute attack but haven’t been told of the new treatments, and when they should be used. They can also be caused by any impact to the body that is strong enough to shake the brain inside the skull. Steven Flanagan, chair of Rehabilitation Medicine at NYU Langone Medical Center and an expert in traumatic brain injuries including concussions, said more attention needs to be paid to concussive injuries and identifying teens or other children with these injuries early.
Whenever a concussion is suspected, the athlete should be taken out of play until they are evaluated and cleared by a healthcare provider.
It’s important to remember that a concussion is not always accompanied by a loss of consciousness.
These include nausea, vomiting, worsening headache, trouble staying awake, or if symptoms don’t clear up after a few days.
If you don't need that type of integration and are just looking for a simple (and free) way to keep track of leads, then you can try using an Excel template.

You can use a Notes column with Wrap Text turned on (though for long notes, that will make the table messy).
You could then add a Pivot Table to summarize the data, or create your own Excel dashboard to display important summary data. Of course, this is not how such an exercise was originally intended, but the rational American can see the writing before them and make this argument without much trepidation.
A lovely part of the world with sea, hills, forests, beaches…pretty much everything really.
The clinical differentiation of Histamine based allergy and Bradykinin mediated Angioedema is based on the lack of an identifiable allergic trigger, the burning nature of the pain, the slow progression, with a period of acceleration, the lateralization of the swelling when it first develops and the lack of response to adrenaline and antihistamine and has been described in a recent paper in the European Journal of Emergency Medicine There is a nice algorithm in that paper that we cannot reproduce here for copyright reasons.
Depending upon the region affected, the swelling may be described as burning or having a deep itch and often described being painful. Patients with a known diagnosis tend to understand their peripheral swellings and so will only present to the Emergency Department when they are suffering an attack that is different, more painful or is life threatening.
Many such patients end up having surgery where there is little found to explain the clinical findings.
Bradykinin is generated on the surface membrane of most endothelial cells by the interaction of Kallikrein and high molecular weight Kininogen that circulate bound together in the plasma. These traditional HAE types only make up about 1-2% of all cases of Angioedema that present clinically. Clinically it’s presentation is indistinguishable from traditional HAE other than having a normal C1 inhib level and activity.
The activity of Angiotensin Converting Enzyme is known to vary between individuals by as much as 60%.
Adrenaline might be expected to be helpful, however experience suggests that the effect is quite small in practice. The side effects of danozol and stanozolol limit their acceptability as prophylaxis in most patients.
However, do remember that both Berinet and cinryse come in at ?1500 per treatment, Berinet needs 3 vials for a 70kg person at ?500 per vial plus is IV so Icatibant is arguably comparable. Cicardi M, Bork K, Caballero T, Craig T, Li HH, Longhurst H, Reshef A, Zuraw B on behalf of HAWK (Hereditary Angioedema International Working Group). However that does not appear to be the case with the non-ACE associated ones if the family mortality described by Andy is to be believed.
I have had some hairy experiences in Resus with a few cases and have learned a thing or two watching my wife’s disorder being mistreated by a number of colleagues. Symptoms that may occur at the time of injury include feeling dazed or confused, blurred vision, or amnesia for the time of the injury. You can also use the optional ContactLog worksheet, to record notes about each individual communication. If there is generalized release then the patient can suffer hypotension due to vessel dilatation and leakage, as well as bronchospasm and local swelling that can affect the airway. This interaction is initiated by an activated factor XII (which is common to both the clotting and complement cascades). Activated Factor XII activates Factor XI in coagulation cascade, resulting in Thrombin formation. The vast majority of cases have normal levels and activities of plasma inhibitor when measured during attacks, and so other precipitating causes need to be sought. So far about 20% of these cases have been found to have an abnormal structural form of factor XII but how this abnormality alters its function is as yet unclear. This might suggest that a patient with a low activity ACE might be more susceptible to ACE Inhibitor associated angioedema when challenged by stimulation to their complement system.
And indeed I have found it very effective in patients with non hereditary angioedema though it is an off licence use of the drug. Although extremely rare, this can lead to massive brain swelling that can lead to severe brain damage, according to Flanagan. Additional symptoms later on may include difficulty paying attention, becoming more irritable, or sleepiness. It may not be everything you want it to be, but it might give you a head start on customizing your own solution or help you decide whether a spreadsheet-based solution is right for you.
These symptoms can and usually are reversed by the use of adrenaline and antihistamines. Similarly, steroids will suppress the Immunoglobulin production and reduce the chances of recurrent allergic response. Many of these patients may attend gynaecology clinics with repetitive cyclical pain and may also present with unilateral labial swelling. Activated Factor XII converts pre-kallikrein into Kallikrein, which produces bradykinin from Kininogen. Activated Factor XII is also cleaved by Kallikrein to produce another active form that activates the first step of the Classical Complement cascade (C1 esterase). Allergy related swelling of the upper airway, mediated by histamine, is indeed seen and must not be ignored, and in the early phases of resuscitation should be treated until a more accurate diagnosis can be made. What does appear to be true is that factor XII acts as a more efficient amplifier of bradykinin production and possibly this version of XII is less susceptible to inhibitory factors.
Other known causes are autoimmune diseases and haematological malignancies such as lymphoma. Case reports exist showing rapid resolution of attacks of ACEI induced Angioedema using FFP suggesting that replacing both the inhibitor and unblocked plasma ACE removes the bradykinin. It is not surprising that many of these patients become labeled, as “irritable bowel” or “dysmenorrhea” and many are not diagnosed as having angioedema for an average of 10 years after their first presentation to a doctor. Kallikrein also activates Complement factors 3 and 5 directly, further driving the classical complement system. In general, it has a short time scale, an identifiable probable trigger and is responsive to antihistamine and adrenaline treatment.
It has been recently shown that factor XII is directly activated by contact with unfolded proteins such as Bence Jones and Amyloid suggesting a reason why these diseases may predispose to expression of excess bradykinin production. The two concentrated C1 esterase inhibitors (nanofiltered, human derived, Cinryse or synthetic, Berinert) are now available and have been shown to be very fast and effective in reversing symptoms.
Factor XII activation is part of the “Contact Activation” response of the Complement Cascade. Recent studies suggest that these pathways can be triggered selectively although how this occurs is currently unknown.
Interestingly, we have seen cases of patients on oestrogen therapy for conditions such as prostate cancer present with angioedema and this may be a mechanism for such attacks. The activated Kininogen cleaves Kallikrein to produce the 9-peptide transmitter Bradykinin. It also triggers the prostaglandin cascades associated with inflammation and attracting leucocytes to the area. These activities are moderated by a number of suppressing factors: The Kininogen and Carboxypeptidase activity and factor XII activation is suppressed by C1 esterase inhibitor (C1inhib) that circulates in the plasma, and as previously described, bradykinin is broken down to non active moieties by ACE which is in close proximity to the BK2 receptor.

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