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Crystal Palace were today set to complete the signing of Emmanuel Adebayor.
The 31-year-old has been a free agent since leaving Tottenham last September and Alan Pardew has turned to the striker in the hope that he will cure Palace's lack of goals.
The Togo international is determined to reignite his career and could make his Palace debut against Stoke in the FA Cup on Saturday.
Adebayor has not appeared in the Premier League since May and, while he has been keeping fit with the help of a personal trainer, it remains to be seen how quickly he will be able to make an impact. Pardew needs him to get up to speed quickly as Palace look to revive their push for a European spot.
Player Ratings: Crystal Palace vs Tottenham
Player Ratings: Crystal Palace vs Tottenham
1/23 Who impressed at Selhurst Park?
Standard Sport assesses the individual performances from the clash between Crystal Palace and Tottenham. Scroll through the gallery for our full ratings.
2/23 Wayne Hennessey: 6
The Welshman had clearly put events at the Etihad to the back of his mind. Solid throughout and made a couple of good saves.
3/23 Joel Ward: 5
The right back was inconsistent. He appeared composed on occasion but all at sea during others.
2015 Getty Images
4/23 Scott Dann: 6
The defender was unfortunate not to level the scores when his header cannoned back off the bar but could not prevent Palace slipping to defeat late on.
2015 Getty Images
5/23 Damien Delaney: 5
A captain's performance. The centre back helped to stifle Kane - aside from the goal - and marshalled all those around him superbly.
2015 Getty Images
6/23 Pape Souare: 6
Provided an attacking outlet on the left but was also undone on several occasions by Trippier's clever runs forward.
2015 Getty Images
7/23 Joe Ledley: 6
Solid if not spectacular presence in the centre of the park from the Welshman.
8/23 Yohan Cabaye: 6
Threatened to be bypassed by Spurs' direct midfield early on, but recovered to produce an encouraging display. His passing repertoire and ability to sprinkle a bit of magic is vital to Palace.
2016 Getty Images
9/23 Wilfried Zaha: 7
Had Rose on toast for the majority of the game. His trickery was magnificent but his vision and decision making less so. The winger's cross led to Vertonghen's own goal and he was a constant menace.
2016 Getty Images
10/23 James McArthur: 5
The Palace midfielder endured a quiet afternoon and was eventually withdrawn after he began to tire.
11/23 Jason Puncheon: 5
Below par. Guilty of several moments of indecisiveness and struggled to get a run at the Spurs defence like Zaha did at will on the opposite flank.
12/23 Connor Wickham: 5
Put himself about but rarely had a sight of goal. Needs to do more if he is to retain Pardew's faith and remain Palace's number one striker. He is only by default at present.
2016 Getty Images
13/23 Hugo Lloris: 6
Usually a man who oozes calm, Lloris was guilty of a number of nervous moments but also produced several superb reflex saves.
2015 Getty Images
14/23 Kieran Trippier: 6
Finally looks confident in a Spurs shirt after several months of appearing to be out of place. Kyle Walker is no longer assured of a spot on the right. Booked.
2015 Getty Images
15/23 Toby Alderweireld: 6
Threatened to add to his goal tally when on the front foot, and passed impeccably, but was not at his best in his own third of the pitch.
2015 Getty Images
16/23 Jan Vertonghen: 6
The Belgian steered the ball into his own net for the opening goal but rarely put a foot wrong otherwise. Withdrawn due to injury.
2015 Getty Images
17/23 Danny Rose: 5
The full-back had a tough time against Wilfried Zaha and struggled to cope with his countryman's pace. Unfortunate to see a fierce volley saved.
2016 Getty Images
18/23 Eric Dier: 5
The midfielder endured a quiet afternoon and was substituted by Pochettino in an effort to get more attack-minded players on the pitch.
Nacer Chadli: 7
Thrown on in an attempt to help change the game and did so after he provided the assist for Kane's goal and wrapped things up with a cracking effort of his own.
2016 Getty Images
19/23 Moussa Dembele: 7
The Belgian's powerful presence swatted Palace aside early on, but they eventually got to grips with his presence. Bridged the gap between defence and attack time and again.
20/23 Christian Eriksen: 6
The Danish drifted across the front line dangerously but could not unlock the Palace defence himself. Looking like the player he was last season again.
2015 Getty Images
21/23 Heung-min Son: 6
Deserved his start after impressing against Leicester but may not have done enough to retain his place.
22/23 Dele Alli: 8
The midfielder capped another impressive display with a beautiful goal that you will never tire of seeing on a highlight reel.
2016 Getty Images
23/23 Harry Kane: 7
Stifled by Delaney and Dann for long periods but - deservedly - got his name on the team sheet courtesy of a well placed header.
2015 Getty Images
Palace have slipped into the bottom half of the table after six games without a win and their strikers have contributed only one League goal this season. The side have managed only 24 goals in 23 League games this term and only Swansea, West Brom and Aston Villa have scored fewer.
Adebayor left Tottenham when his deal was terminated by mutual agreement but they have still been paying his £100,000-a-week wages.
Harry Redknapp, who brought Adebayor to Spurs in 2011, said in his Standard Sport column this month that signing the striker was a "no‑brainer" but there are lingering doubts about his attitude.
He becomes one of the top earners at Palace but Pardew and chairman Steve Parish believe the former Arsenal and Manchester City striker is worth the risk.
Pardew said recently he has no concerns about handling Adebayor.
"Whenever he has played against me he has been totally committed and he is a dangerous world player," said the manager.
"You have only got to look at his clubs. For whatever reason there has been a fall-out at Spurs but he remains a player that can have great impact and would improve us. And I have had difficult players before, non more difficult than Hatem Ben Arfa at Newcastle. If I can deal with him, I can deal with Adebayor for sure..."
Adebayor also attracted interest from Watford and wanted to stay in England despite receiving more lucrative offers from the Middle East, China and Turkey.
He has his sights set on becoming the Premier League's leading African goalscorer.
Adebayor has scored 96 times in 230 League games in England, leaving him eight shy of the mark set by former Chelsea and Ivory Coast striker Didier Drogba.
When does the transfer window close across Europe? Scroll over the map below to find out
- More about:
- Crystal Palace FC
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Report summaryThe Logbaba gas field is located in the Douala Basin in the eastern suburbs of Cameroon's largest city, Douala. The field was discovered by Elf Serepca in 1954. Victoria Oil & Gas became operator of the Logbaba licence when it acquired Bramlin in 2008. Two successful appraisal wells were drilled between 2009 and 2011. A production facility was commissioned in 2011 and commercial production started in 2012. The field is being developed via two production wells tied back to minimal ...
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subset: commoncrawl


text:
Happy Friday
It's Friday my favorite day...what's yours???
Tis the day relished by most
Which will result on Monday
With plenty of stories to boast
Celebration, alcohol, dancing
for some, extra sleep
Yet other's engage in festivals
carnivals, Rodeo's, farming and
chasing sheep
Lakeside party goers and camping
maybe a campfire story
Most of them frightening tales
some more gory
What ever your fancy
I wish it your way
Just wishing everyone listening
A happy Friday!!


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Haeya Boutique Hotel
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Haeya Boutique Hotel
About the Hotel
Property Location
With a stay at Haeya Boutique Hotel in Ulsan, you'll be convenient to Geunlo Bokji Hoegwannae Bowlingjang and Dongchun Gymnasium. This hotel is within close proximity of Seonggwang Bowling Center and Star Bowlingjang.
Make yourself at home in one of the 57 air-conditioned rooms featuring refrigerators and flat-screen televisions. Computers, complimentary wireless Internet access, and cable programming provide entertainment. Private bathrooms with separate bathtubs and showers feature jetted bathtubs and complimentary toiletries. Conveniences include phones and complimentary bottled water, and housekeeping is provided daily.
Make use of convenient amenities, which include complimentary wireless Internet access and barbecue grills.
Enjoy a satisfying meal at a restaurant serving guests of Haeya Boutique Hotel.
Business, Other Amenities
Free self parking is available onsite.
Hotel Facilities
- Free breakfast
- Free WiFi
- Laundry facilities
- Free self parking
- Barbecue grill(s)
- Restaurant
- Total number of rooms - 57
Room Facilities
- Hair dryer
- Refrigerator
- Jetted bathtub
- Free bottled water
- Private bathroom
- Flat-panel TV
- In-room computer
- Free WiFi
- Cable TV service
- Air conditioning
- Phone
- Free toiletries
- Separate bathtub and shower
- Daily housekeeping
Hotel Policy
National Rating
For the benefit of our customers, we have provided a rating based on our rating system.


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Sleep Inn & Suites
No prices found through our partners. Please contact the business directly or check some of our recommended alternatives.
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- Suites
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TripAdvisor Reviews Sleep Inn & Suites Shamrock
Travel Blogs from Shamrock
Continuing on rt 66
Rt 66 is facinating.
It's incredible to see just how big an impact the newer I40 has been to the local towns.
Even though, in many cases, the highway is literally a stones through from the old rt 66, the impact is severe. In many of the towns, there is very little left but old shells of buildings, ...
Cars in Real Life!
Check out the cool pictures. This building, truck and overweight but handsome guy were the basis of a movie. (Okay the overweight but handsome guy is not the basis of any movie except maybe " Nista, when are you due?" or "How to eat across Route 66 and gain a pound or two a ...
West 40 RV Park
Beautiful morning in Claremont like Randy said. It was made even better by taking a great shower and washing my hair in the KOA grounds; small luxuries. Had breakfast while watching beautiful horses warm up around the race track right next to the KOA campsite. We packed up and were on the road for 10 am. We finally seem to be getting the hang of things. We drove to Bedlam BBQ, a site Randy found by using yelp. We drove into OK City and ...
Day 9. The Lone Star state
About 280 miles today and now in Texas staying in a town called Shamrock and hotel called The Blarney Inn. Been out for food and there was a sign on the door 'No Firearms'. A guy came in wearing jeans and shirt with a cap which said 'Sheriff' but did not leave his gun outside - he was the local sheriff
We have been on parts of 66 today where we stopped ...
My Heart was Bursting with Happiness
... rain at home with just a few exceptions so waking up to a rainy morning is quite a treat for us.
We planned to go to church service at 10:30 so after eating breakfast we packed and loaded up the car. We were early and traffic was extremely light so we decided to go the the Grand Village and do a little shopping. This was a very pretty area with flowers, a fountain and beautiful architecture. The ...


text:
Warranty: 3 Year Warranty
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The official marketing text of ASUS Extreme N6600/TD 256MB PCI-E GDDR as supplied by the manufacturerASUS Extreme N6600 Series equip with newest ASUS-specific award-winning features and nVidia®'s GeForce 6600 Graphics Processing Unit(GPU), which owns both ultimate excellent cinematic resolution and fierce graphics computing power. Incorporating various state-of-the-art technologies such as NVIDIA® UltraShadow™ II technology, NVIDIA® CineFX™ 3.0 engine, NVIDIA® Intellisample™ 3.0 technology, ASUS GameFace™ Live, ASUS VideoSecurity and ASUS OnScreenDisplay and rich-spectrum of unique ASUS innovations. ASUS Extreme N6600 Series is positioned on the performance products and the most complete solution for the 3D and video application market.
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text: THE JOURNAL OF ACADEMIC 82 EMERGENCY MEDICINE Review Approach to Patients with Syncope in Emergeny Department - An Evidence-Based Review Orçun Çiftci1, Cemil Kavalcı2, Polat Durukan3 Department of Cardiology, Başkent University Faculty of Medicine, Ankara, Turkey Department of Emergency, Başkent University Faculty of Medicine, Ankara, Turkey 3 Department of Emergency, Erciyes University Faculty of Medicine, Kayseri, Turkey 1 2 Abstract Syncope is an important health problem, constituting 1%-5% of all emergency service admissions and up to 6% of all hospitalizations. Substantial experience with patient history and physical examination and time are required to diagnose syncope in patients presenting with transient loss of consciousness. In addition, only up to 50% of patients with syncope can be diagnosed with a final diagnosis, despite all efforts. Thus, management of syncope in emergency departments has shifted from reaching a final diagnosis and treatment to short-, moderate-, or long-term risk stratification systems, allowing decisions for outpatient management, including specialized branch care, or admission for further work-up. This review discusses the definition of syncope-related transient loss of consciousness, differential diagnosis of syncope, diagnostic methods and algorithms, and the main risk stratification studies. It also incorporates the recommendations of the American College of Emergency Physicians (ACEP) 2007 policy statement regarding patients with syncope. (JAEM 2014; 13: 82-91) Key words: Emergency, syncope, transient loss of consciousness Introduction Syncope is a rapid-onset, short-duration, transient loss of consciousness (T-LOC) with spontaneous recovery due to global cerebral hypoperfusion (1). Although the final endpoint is global cerebral hypoperfusion and rapid loss of posture, syncope has a diverse pathophysiological and etiological spectrum with respect to triggers and mechanism of occurrence. Therefore, it is challenging to make a differential diagnosis, detect life-threatening conditions, and make important therapeutic decisions. Syncope constitutes 1%-5% of yearly emergency department visits and 6% of hospital admissions (2, 3). This review aimed to discuss the differential diagnosis and risk stratification of syncope with a review of the relevant literature and make recommendations about making decisions on consultation, emergency intervention, hospital admission, or discharge in light of information obtained from the patient history and laboratory data in patients presenting to the emergency department with suspected loss of consciousness. Syncope as a Symptom Syncope is not a disease per se but rather a symptom that may arise during the course or as a result of a number of diseases. The self-limiting nature of syncope and full recovery after syncopal attacks indicate that syncope-related mortality and morbidity are not from the syncope itself but rather from the resulting trauma or the severity of underlying disease. Thus, the importance of syncope lies in being a warning sign or a cause of trauma rather than a true disease state. It is of prognostic significance that emergency physicians urgently begin diagnostic tests and start to treat relatively rare life-threatening conditions (e.g., arrhythmias, aortic dissection, pulmonary embolism, acute coronary syndromes). Unfortunately, initial evaluation of patients in the emergency department is usually unrevealing. The most common and important limitations of emergency department evaluation are lack or inconsistent statements of witnesses regarding the syncopal event, post-syncopal fatigue or panic experienced by patients, leading to inability to give a reliable history, and limitation of history taking due to undulations in the consciousness level of patients traumatized by a syncopal episode. Etiology of syncope: There are 3 main forms of syncope: reflex (neurocardiogenic), orthostatic, and cardiovascular. Reflex syncope is grouped as vasovagal, situational, carotid sinus syncope, and atypical forms. Syncope due to orthostatic syncope is due to primary or sec- Correspondence to: Cemil Kavalcı, Department of Emergency, Faculty of Medicine, Başkent University, Ankara, Turkey Phone: +90 312 212 68 68 e.mail: [email protected] Received: 05.03.2013 Accepted: 29.05.2013 Available Online Date: 17.07.2013 ©Copyright 2014 by Emergency Physicians Association of Turkey - Available online at www.akademikaciltip.com DOI:10.5152/jaem.2013.040 JAEM 2014; 13: 82-91 ondary autonomic failure, drug effects, or volume loss (due to bleeding, dehydration, vomiting, or diarrhea). Cardiovascular syncope is generally secondary to cardiac causes and includes arrhythmic forms (bradycardia or tachycardia), structural cardiovascular disorders, or cardiorespiratory diseases (pulmonary embolism or pulmonary hypertension) (Table 1) (1). In a considerable portion of patients, the syncope etiology can not be found. Such cases are said to have "unexplained syncope." Previous studies have shown that the etiology of syncope can be clarified in at best 20%-50% of patients, while 15%-30% of them remain undiagnosed despite extensive investigations (2, 4, 5). Thus, the decision of emergency physicians as to which patients require further diagnostic workup or monitorization is very important. The role of emergency physicians in the management of syncope has recently evolved from a diagnostic standpoint to a cooperative role with other departments in the form of risk stratification or decisions with respect to hospitalization (6). In the Framingham Heart Study, 822 of a total of 7814 patients experienced syncope between 1971 and 1998. The rate of first reported syncope was 6.2 per 1000 patients. The syncope forms with identifiable etiology were neurocardiogenic syncope (21.2%), cardiogenic syncope (9.5%), and orthostatic syncope (9.4%). On the other Çiftci et al. Syncope in the Emergency Department 83 hand, the largest group was unexplained syncope, which had a rate of 36.6%. According to this analysis, rate of death from any cause or cardiovascular reason was high. Patients with syncope of unknown origin were also at increased risk of mortality of any cause. In contrast, vasovagal syncope had a markedly benign course. Recurrence rates (overall 21.6%) have been found to be higher in patients with previous syncopal attacks or cardiac syncope (7). Non-traumatic Transient Loss of Consciousness Transient loss of consciousness (T-LOC) encompasses conditions with reversible, complete loss of consciousness, including syncope. As viewed from this aspect, all syncope cases fall into the T-LOC definition, but not all T-LOC cases can be included by the term syncope. T-LOC is a sine qua non for a diagnosis of syncope, and its absence should make one consider the possibility of cataplexy, falls, and psychiatric (psychogenic pseudosyncope) and neurologic (TIA of carotid origin) causes and move away from a syncope diagnosis. Therefore, it is imperative to obtain a thorough history from the patient or, if possible, from the witnesses of the episode to find out whether loss of consciousness was actually present. A transient, rapid-onset, short-duration loss of consciousness with full recovery makes the diagnosis of T-LOC (Figure 1). Table 1. Syncope classification and major etiological factors Reflex (neurally mediated) syncope Vasovagal - Emotional stress-induced: fear, pain, instrumentation, blood phobia, orthostatic stress-induced: prolonged standing or sitting Situational - Coughing, sneezing, gastrointestinal stimulation (swallowing, defecation, visceral pain), micturition (post-micturition), post-exercise, post-prandial, others (e.g., laughter, blowing into a brass instrument, weightlifting) Carotid sinus syncope Atypical forms (no specific trigger and/or atypical presentation) Syncope due to orthostatic hypotension Primary autonomic insufficiency Pure autonomic insufficiency, multiple system atrophy, Parkinson+autonomic insufficiency, Lewy body dementia Secondary autonomic insufficiency - Diabetes mellitus, Amyloidosis, Uremia, Spinal cord injuries Drug-induced orthostatic hypotension - Alcohol, Vasodilators, Diuretics, Phenothiazines, Antidepressants Volume loss - Bleeding, diarrhea, vomiting Cardiac Syncope (Cardiovascular) Primary etiology is arrhythmia Bradycardia Sinus node dysfunction, atrioventricular conduction defect, dysfunction of implantable devices (PM, ICD, etc) Tachycardia - Supraventricular, ventricular Structural Heart Disease Valvular disease (native or prosthetic), myocardial disease ( hypertrophic cardiomyopathy, restrictive myocardial disease, dilated cardiomyopathy, pericardial disease (tamponade, constrictive pericarditis) congenital coronary anomalies, cardiac mass, pulmonary embolism and hypertension, aortic dissection (Modified from reference No. 1) 84 Çiftci et al. Syncope in the Emergency Department JAEM 2014; 13: 82-91 Figure 1. Algorithm for assessment of patients according to the presence and characteristics of loss of consciousness Seizure vs. Syncope Epileptic seizures are the most important conditions that require distinction from a syncopal episode. Emergency physicians often straddle making one of these diagnoses, leading to extended emergency department waiting times. Indeed, it is sometimes challenging to differentiate syncope from seizure activity. Some studies have attempted to devise various algorithms and scoring systems with the use of some historical variables as well as clinical clues for the differentiation of syncope and seizure. Crampton et al. reported that some elements in the patient history can be used in the differentiation of syncope from seizure. These include presence of previous presyncope or syncope attacks; prolonged sitting or standing as the initiating mechanism; rapid assumption of upright posture; dehydration; prodromal symptoms, such as nausea, palpitation, dyspnea, warmth sensation, dizziness, blurred vision, and sounds coming from a distance; paleness and sudden collapse during attacks; and recalling the onset of loss of consciousness during recovery (Table 2) (8). Sheldon et al. (9) developed a scoring system for syncope versus seizure distinction based on elements of the patient history (Table 3). They assigned certain point scores to various historical variables. According to this scoring system, a total point score ≥1 was in favor of seizure, and <1 was in favor of syncope. The authors reported that the sensitivity and specificity of the scoring system were both 94%. In a review by McKeon et al. (10), it was reported that some features of the patient history may be beneficial for a distinction between syncope and seizure. According to this, dizziness, sweating, prolonged standing, certain precipitants and chest pain, palpitation, low heart rate, and low blood pressure point to a syncope episode, whereas deja vu and jamais vu, aphasia, olfactory aura, tongue biting, post-event delirium, and focal neurological signs are indicative of a seizure attack. Witness accounts pointing to a pale, sweating subject with low pulse and blood pressure indicate a syncopal origin, while presence of aphasia, delirium, head turning to the side, automatism, convulsion, and postictal delirium are more consistent with seizure activity. Perhaps convulsive syncope is the condition that is most commonly confused with a seizure attack. This syncope variety is characterized by convulsions or tonic-clonic movements similar to those in epileptic seizure. A useful diagnostic clue in such patients is that Çiftci et al. Syncope in the Emergency Department JAEM 2014; 13: 82-91 85 Table 2. Features of patient history in differentiation of syncope from seizure activity In favor of syncope In favor of seizure activity Past history Previous presyncope*/syncope Previous seizure attacks, cortical abnormalities Prolonged standing or sitting*, sudden assumption of erect posture, dehydration, vertigo, sweating, situational triggers (micturition, defecation, etc) chest pain, palpitation, low heart rate, low blood pressure Stress*, sleep deprivation, drug withdrawal (alcohol, benzodiazepines), photic triggers, deja vu or jamais vu, aphasia, olfactory aura, epigastric sensation, tongue biting, post-event delirium, focal neurological signs Prodrome nausea*, dyspnea*, palpitation*, warmth sensation*, dizziness, blurred vision With partial onset symptoms, points to a temporal, frontal, parietal or occipital focus Attack Pallor, collapse, low pulse or blood pressure Tongue biting*, head deviation*, bizarre posture*, urinary incontinence*, cyanosis*, automatism, aphasia, delirium, convulsion Recovery Confusion*, postictal delirium, headache*, event not recalled* Loss of consciousness recalled* *Previously determined discriminators of syncope vs seizure attack (Modified from reference No. 8) Table 3. Scoring for syncope vs seizure differentiation Point Waking up with tongue biting? 2 Deja vu or Jamais vu? 1 Emotional stress 1 Head turning 1 Unresponsive, uncommon posture, extremity movements, or amnesia? (any) 1 Post-event confusion 1 Dizziness attacks -2 Pre-event sweating -2 Loss of consciousness with prolonged standing or sitting -2 ≥1 point indicates high seizure likelihood, <1 point indicates high syncope likelihood (Modified from reference No. 9) myoclonus or convulsion occurs after pallor, sweating, and collapse, whereas this order is reversed in seizure attacks. A patient history notable for structural heart disease (coronary artery disease, heart failure, left ventricular hypertrophy), diabetes, and presence of multiple risk factors for coronary artery disease may specifically direct clinicians to cardiac syncope. Investigation of Syncope Etiology in the Emergency Department The etiology of syncope may not readily be found in the emergency department. Solid evidence may be apparent in the patient history at the initial stage of the patient evaluation in some patients, while the diagnosis is only possible after an extensive workup, including complete blood count, biochemistry, ECG, cardiac biomarkers, chest x-ray, and thoracic tomography in others. Initial Assessment After determining that the transient loss of consciousness is due to a syncopal attack, an initial assessment should be rapidly done. This assessment includes evaluation of vital signs as well as taking a patient history and performing a thorough physical examination and ECG. The initial evaluation should specifically aim to reveal resting or orthostatic tachycardia or orthostatic hypotension. Points not to miss in the physical examination include evaluation of pulse characteristics (e.g., filiform pulse, pulsus paradoxus, pulsus alternans, pulsus bigeminus, pulsus bisferiens, pulsus parvus et tardus, or pulse deficit), neck veins, place of maximal apical impulse, additional heart sounds (S3S4), certain auscultatory findings of aortic stenosis, hypertrophic cardiomyopathy, left atrial myxoma, or pericardial effusion/tamponade. The diagnostic findings in the initial examination are listed in Table 4 (1). Vasovagal, situational, and orthostatic syncope; arrhythmic syncope; and syncope related to cardiac ischemia or some other cardiovascular disorders can be diagnosed with diagnostic clues obtained from history taking, physical examination, and ECG. Vasovagal syncope is the most common type after unexplained syncope. Some components of the patient history may lead to vasovagal syncope in the emergency department. A relatively young patient age, lack of previous history of cardiovascular diseases, rare syncopal episodes with relatively long inter-episode intervals, and the index episode being the very first syncope episode are all indicative of a benign etiology. In addition, the presence of typical stressors (prolonged standing or sitting in the unchanged position; waiting without changing posture in crowded, moist, poorly ventilated, hot environments; exposure to unwanted sounds, images, smells, or blood), and having warmth sensation, rapid pulse, nausea, and dizziness prior to syncopal episode are supportive of a vasovagal origin. Situational syncope is characterized by very typical, recurrent syncopal attacks always elicited by the same activity (vagally mediated maneuvers, such as blowing a musical instrument, defecation, micturition, sneezing, or swallowing); orthostatic syncope is related to advanced patient age, diabetes, neurological, renal, or hepatic diseases; disorders characterized by autonomic dysfunction; use of drugs, including diuretics, alpha blockers, dihydropyridine derivatives, or first doses of ACE inhibitors or ARBs; and reduced circulatory volume associated with diarrhea, blood loss, vomiting, excessive sweating, dehydration, or fluid loss to the third space. Orthostatic hypotension is diagnosed by a reduction of systolic blood pressure by 20 mm Hg and a reduction of diastolic blood pressure by 10 mm Hg 2 minutes after active standing. Presence of arrhythmia (absence of a prodrome, syncope during exercise or supine position, a low ejection fraction or presence of clinical heart failure, or family history of sudden cardiac death or syncope) or typical features of ischemic episodes (typical angina pectoris or angina equivalents) along with typical ischemic ECG changes secures arrhythmic or ischemic syncope. On the other hand, angiotensin-converting enzyme I/D polymorphism episode associated Çiftci et al. Syncope in the Emergency Department 86 JAEM 2014; 13: 82-91 Table 4. Diagnostic findings and related diagnoses at first assessment Diagnosis Syncope triggered by emotional orthostatic stress and associated with typical prodrome vasovagal syncope Syncope occurs during or immediately after specific triggers such as micturition, defecation, and swallowing Situational syncope Syncope takes place with standing up and orthostatic hypotension is documented Orthostatic syncope Any of the following: Arrhythmic syncope - Persistent sinus bradycardia < 40 bpm, sinusal pause ≥3 seconds, or recurrent sinoatrial block - Mobitz Type 2 or 3. degree AV block - Alternating right and left bundle branch block - VT or fast SVT - Short or long QT interval with episodes of polymorphic VT - PM/ICD dysfunction with cardiac pause Syncope with typical signs and symptoms of cardiac ischemia and ECG findings of acute ischemia with or without enzyme positivity Cardiac ischemiaassociated syncope Syncope occurs with atrial myxoma, severe aortic stenosis, pulmonary hypertension, pulmonary embolism, and aortic dissection Cardiovascular syncope (Modified from reference No. 1) Table 5. ACEP Risk stratification Class A Defines patient management principles that are generally accepted and show highly clinical precision Class B Defines patient management principles with moderate clinical precision Class C Defines evidence that is precursory, imprecise, or controversial (Modified from reference No. 6) with emotional or orthostatic stress preceded by a typical prodrome makes the diagnosis of vasovagal syncope. Tests directed at the suspected etiology should be rapidly performed in cases having no clear diagnosis after the initial evaluation but that are suspected to have a specific etiology, including acute coronary syndromes, pulmonary thromboembolism, aortic dissection, pulmonary hypertension, left atrial myxoma, pericardial tamponade, hypertrophic cardiomyopathy, or aortic stenosis. These conditions may not show typical findings in the ECG, history, and physical examination in the initial evaluation. These possible diagnoses should be confirmed with use of cardiac biomarkers (BNP, troponins, CK-MB), chest x-ray, serial ECGs, echocardiography, thoracic CT, ventilation-perfusion scintigraphy, and coronary angiography whenever suspected (Figure 2). Risk Stratification in Unexplained Syncope Only some (20%-50%) patients presenting to the emergency department with syncope can be diagnosed with a specific etiology after the initial evaluation (2, 4, 5). Despite an extensive workup, approximately 30% of cases with syncope remain unexplained. The current role of emergency physicians in the evaluation of syncope has shifted from the point of making an exact diagnosis to the point of risk stratification (6). The following are three critical questions an emergency physician should ask (6): 1. Which elements of the history and physical examination help in risk stratification? 2. Which diagnostic tests are helpful in risk stratification? 3. Which patients with unexplained syncope should be hospitalized? History and physical examination play an important role in risk stratification of a patient with syncope. Risk stratification based on patient history and physical examination, as suggested by the 2007 ACEP consensus guidelines for syncope, is summarized in Table 5. In the guideline mentioned above, a Class A recommendation was made for a search of typical signs and symptoms of heart failure with the history and physical examination to determine patients at higher risk of adverse events; a Class B recommendation was made for giving consideration to advanced age, structural heart disease, or coronary heart disease with respect to future risk of adverse events, and a Class B recommendation was also made for determining young persons who do not have exercise-induced syncope, any history of cardiovascular disease, or any family history of sudden cardiac death. The primary objective of risk stratification in the emergency department is to predict short-term (days to weeks) and long-term (months to years) risk and to prevent adverse events, with death being in the first place, in high-risk patients. In the San Francisco syncope rule (3), which was originally devised to pick up low-risk patients, 5 parameters were identified that can be remembered as the CHESS mnemonic. According to this syncope rule, the presence of any of the following criteria puts a patient into the high-risk category: a history of heart failure, hematocrit <30, abnormal ECG, dyspnea, and triage blood pressure less than 90 mm Hg. The score had a sensitivity of 96% (95% CI 92%-100%) and a specificity of 62% (95% CI 58%-66%). A validation study of the scoring system, dated 2006, revealed a sensitivity of 98% (95% CI 89% to 100%) and a specificity of 56% (95% CI 52% to 60%), confirming that the scoring system functioned well (11). However, an external validation of that scoring system, which was performed by Birnbaum et al. (12) in 2008, did worse with a sen- Çiftci et al. Syncope in the Emergency Department JAEM 2014; 13: 82-91 87 Syncope Consultation for admittion Discharge Figure 2. An algorithm for diagnostic assessment of syncope in emergency department sitivity of 74% (95% CI 61% to 84%), specificity of 57% (95% CI 53% to 61%), negative likelihood ratio of 0.5 (95% CI 0.3 to 0.7), and a positive likelihood ratio of 1.7 (95% CI 1.4 to 2.0). However, a correspondence (13) written by the authors of the original study for criticism of the study by Birnbaum et al. stressed that a lower rate of syncope presentation (0.5% versus 1.2% to 1.5%) and a higher admission rate (86% versus 55%) in the study by Birnbaum et al. compared to previous studies were indicative of a selection bias. They also added that the authors misapplied the criteria for abnormal ECG and that the study ECGs were not reviewed by the primary physicians but rather by a separate physician in a retrospective manner, leading to possibly variable and inconsistent ECG interpretation. In reply to this criticism, Birnbaum et al. (14) replied that 88% of ECGs were reviewed by an emergency physician, and senior physicians reviewed ECGs for the purpose of standardization. They put forward geographic and ethnic differences of the study region for their study's different syncope and admission rates from the previous literature. In 2011, Saccilotto RT et al. published a meta-analysis of 12 studies containing 5316 patients. They reported a combined sensitivity of 87% (95% CI 79% to 93%) and a combined specificity of 52% (95% CI 43% to 62%) for the San Francisco syncope rule (15). Gabayan et al. (16) made a retrospective analysis of short-term (7-day) adverse cardiac events (cardiac death or hospitalization) in 39,943 admissions for syncope in 35,330 patients and reported that 3% of patients experienced adverse events, the positive predictors of which were age ≥60 years, male gender, congestive heart failure, ischemic heart disease, cardiac arrhythmias, and valvular diseases. In contrast, the following criteria were nega- tive predictors for adverse events: history of a previous pacemaker or implantable cardioverter-defibrillator (ICD) implantation or a previous revascularization, both protecting against lethal arrhythmias or coronary ischemia; history of dementia, making the patient history unreliable for distinguishing syncope from fatigue, seizure, or drop attacks; or history of cerebrovascular disease, making a neurological etiology more likely than a cardiological etiology. In the latter study, it was stressed that the cardiac event rate was higher during the first 7 days and especially within the first 3 days. The authors, therefore, suggested that patients who are discharged from the emergency department after the initial tests fail to point to a specific etiology should be followed on an outpatient basis for the first 7 days. However, the patients analyzed in that study were younger than similar studies (mean age 60.1 years) and had a better health status, leading to lower event rates as compared to other trials (2.5% vs 8%-11%). Moreover, prediction of short-term events was negatively affected by reviewing comorbidity data from available records and a lack of assessment of ancillary instruments, such as symptoms or physical examination findings. Another short-term risk stratification tool, the Boston Syncope Rule, introduced 8 criteria about the signs and symptoms for prediction of 30-day risk of adverse events or death (17). These include signs and symptoms of acute coronary syndromes, signs of conduction system disease, a positive cardiac history, valvular disease as determined with a history or physical examination, sudden death in the family, persistent abnormal signs in the emergency department, volume depletion (persistent dehydration, gastrointestinal bleeding, or 88 Çiftci et al. Syncope in the Emergency Department Hct <30), and a central nervous system event. The Boston rule could predict syncope with a sensitivity of 97%, a specificity of 62%, and an NPV of 99%. Implementation of the rule reduced the rate of hospitalization by 48% in the original study. A recent study from our country compared the value of several syncope rules, including EGSYS, OESIL, and the San Francisco syncope rule, in predicting short-term serious events and additionally developed a new syncope rule, called the "Anatolian Syncope Rule" (18). In a total of 231 patients, dyspnea, orthostatic hypotension, a precipitating factor causing syncope, age >58 years, congestive heart failure, and ECG abnormalities (defined by the acronym DO-PACE) were predictive of short-term adverse events in the univariate analysis. According to that study, the newly developed "Anatolian Syncope Rule" had a sensitivity of 100% (0.66-1.0) for mortality compared to the OESIL score having a sensitivity of 90% (0.54-0.99), EGSYS score having a sensitivity of 80% (0.44-0.97), and San Francisco syncope rule having a sensitivity of 100% (0.66-1.0). The rules had a specificity of 78% (0.72-0.83), 76% (0.70-0.82), 80% (0.74-0.85), and 70% (0.630.76), respectively. The scoring systems had sensitivities of 97% (0.851.00), 70% (0.52- 0.82), 56% (0.40- 0.72), and 87% (0.72 - 0.95), respectively. Their specificities for any adverse event were 72% (0.64- 0.78), 82% (0.76 - 0.87), 84% (0.78 - 0.89), and 78% (0.71 - 0.83), respectively. The authors stated that the newly developed scoring system was considerably sensitive in predicting short-term serious events and was non-inferior to the previous scoring systems. Nevertheless, as the authors admitted, their study was a single-center study, and its results may not have reflected the entire Turkish patient population. The real-world performance of that scoring system will be clarified by prospective validation studies. The ROSE (Risk stratification Of Syncope in the Emergency department) (19) risk stratification score includes risk predictors designated with the mnemonic BRACES. B stands for BNP ≥300 pg/mL, or bradycardia <50 bpm), R stands for occult blood in stool (in rectal examination/laboratory tests), A stands for anemia (Hb<9 mg/dL), C stands for chest pain preceding or concurrent with syncope, E stands for Q wave on the ECG (except for D3), and S stands for saturation <94% (in room air). Presence of at least one of these criteria puts patients at increased risk for serious adverse events (acute myocardial infarction, life-threatening arrhythmias, need for implantation of a pacemaker or implantable cardioverter-defibrillator, pulmonary embolism, stroke, and bleeding or surgical intervention) at 1 month. The sensitivity, specificity, and NPV of the rule were 87%, 65.5%, and 98%, respectively. Of them, the criterion that was most commonly associated with cardiac events was a BNP level greater than 300 pg/ml. EGSYS (20), OESIL (1), and the risk scoring system developed by Martin et al. (22) have been used for long-term risk stratification. While OESIL and the scoring system of Martin et al. predict rates of serious events at 1 year, the EGSYS score predicts 2-year risk. The EGSYS score has been reported to possess a two-aspect predictive value. One of them is prediction of long-term mortality, and the other is prediction of cardiac syncope. According to this scoring system, palpitation preceding syncope is assigned 4 points, heart disease and/or abnormal ECG is assigned 3 points, syncope during exercise is assigned 3 points, syncope in supine position is assigned 2 points, presence of a precipitating or predisposing factor is assigned -1 point, and presence of a prodrome with nausea and vomiting before the episode is assigned -1 point. A score ≥3 was reported to predict cardiac syncope with a sensitivity of 92% and a specificity of 69%, and patients with JAEM 2014; 13: 82-91 point(s) were reported to portend higher mortality in both the original and validation studies. The OESIL risk score examined the role of the following criteria in the prediction of serious events at 1 year: abnormal ECG, history of cardiovascular disease, age >65 years, and lack of prodrome. The original study determined risk factors for mortality at 1 year in 270 patients and validated the results in another 328 patients (13). Each of the criteria (abnormal ECG, history of cardiovascular disease, age > 65 years, and lack of prodrome) was assigned 1 point. The mortality rates for 0, 1, and 2 points were 0%, 0.6%, and 14%, respectively. Patients with a score of 0-1 were accepted as low-risk, and those with a score equal to or greater than 2 were considered high-risk. There have been some inconsistencies between the original OESIL risk study and the subsequent validation studies. Martin et al. (14) attempted to devise a risk classification system for arrhythmias and mortality at 1 year in 252 patients. They also validated the system in a 374-patient cohort. The risk factors were ECG abnormalities, history of ventricular arrhythmias, history of congestive heart failure, and age > 45 years. The validation study reported a mortality rate of 0% at 1 year for patients with no risk factors and 27% for 3 or 4 risk factors. Advanced age, abnormal ECG, lack of prodrome, and a positive history of cardiovascular disease, especially ventricular arrhythmias being in the first place, appear to have predictive power for 1-year risk in both the OESIL risk score and the risk score of Martin et al. However, long-term risk stratification has a limited role in emergency departments, where short-term risk has a greater role in patient management. Long-term risk stratification is rather used by other departments, particularly cardiology. A meta-analysis published in 2011 (23) analyzed studies investigating patients presenting to emergency departments between 1990 and 2010. The mean age of a total of 43,314 study participants studied by 11 trials was 63 years (range 60-64 years). The hospital admission rate was 44%. The mortality rate was low, albeit significantly increased (4.4%; 95% CI: 3.1-5.1). One-third of deaths were attributed to cardiovascular causes. One-third of the patients were undiagnosed; in the group where a diagnosis could be reached, the most common diagnoses were vasovagal, orthostatic, and situational syncope, which altogether were responsible for 29% of all episodes (95% CI: 12-47). The syncope etiology was a cardiac condition in 10.4% of cases (95% CI: 7.8-16), with bradyarrhythmias (4.8%; 95% CI: 2.2-6.4) and tachyarrhythmias (2.6%; 95% CI: 1.1-3.1) being the most common etiologic factors. The most powerful predictors of adverse cardiac events were palpitation before syncope, exercise-induced syncope, history of heart failure or ischemic heart disease, and active bleeding or a history of bleeding. A review of predictors of adverse events (death or hospital admission) separately for each of these 11 studies revealed that all studies reported heart failure, ischemic heart disease, and abnormal ECG; 6 studies reported age; 3 studies reported abnormal blood pressure (<90 mm Hg or >160 mm Hg); 3 studies reported male sex; and 2 studies reported signs of bleeding. A systematic review and meta-analysis of the methodological quality and prognostic accuracy of clinical decision rules examined a total of 18 studies including 10,994 patients aged 50-79 years, of whom 55% were women. Five of these studies were derivation studies, 9 were validation studies, and 4 were derivation/validation studies. A total of 13 studies were 30-day studies, 1 was a 6-month study, and 2 were 1-year studies. One study did not specify any follow-up duration. Three to forty-one percent of the patients were hospitalized, and 13% had adverse events, a quarter of which could be di- Çiftci et al. Syncope in the Emergency Department JAEM 2014; 13: 82-91 89 Figure 3. In case of undefined syncope patient management according risk classification agnosed in the emergency department. That review suggested that the San Francisco syncope rule and OESIL risk score were validated in more than one setting (level 2 evidence) and therefore may be considered to be implemented in clinical practice (24). Risk stratification before investigating the syncope etiology will miss serious diagnoses, such as an acute coronary syndrome, dysrhythmia, ectopic pregnancy, or subarachnoid bleeding. For example, a middle-aged man with chest pain and subsequent syncope will be labeled as low-risk unless an abnormality is detected in his vital signs and admission ECG. Therefore, one should search for identifiable causes of syncope first, reserving risk stratification to be performed for unexplained syncope after the initial evaluation. Another important point for clinicians to remember is that none of the available scoring systems for risk stratification is ideal. Therefore, a risk score should never preclude a clinician's common sense, no matter how comprehensive it is (25). Position of ACEP and ESC Guidelines for Risk Stratification There are several guidelines for risk stratification and management of patients presenting with syncope. Among these, the American College of Emergency Physicians (ACEP) guideline, dated 2007, and the European Society of Cardiology guideline, dated 2009, will be discussed here. Although the ESC guideline is not primarily intended for use by emergency physicians, it conveys important information related to the initial evaluation and urgent management of syncope. The ACEP guideline (6) published in 2007 recommends use of signs and symptoms of heart failure as assessed with past history and physical examination to determine patients at higher risk (Level A recommendation). Level B recommendations consider structural heart disease or coronary artery disease as risk factors for adverse events. Level B recommendations also suggest considering young patients with no cardiovascular disease or comorbidities as low-risk. The same guideline mentioned that 12-lead ECG is helpful in risk stratification and recommended performing advanced tests, such as echocardiography or cranial CT, according to specific findings or results of the physical examination and ordering laboratory tests in the appropriate clinical context. It was specified that cardiac electrical monitorization may be useful in patients with strongly suspected arrhythmic syncope. Electrical monitorization beyond 24 hours does not add much to 24-hour monitoring. Despite referring to a report suggesting that rhythm monitoring for up to 72 hours might be beneficial in case of age >65 years, male gender, history of heart disease, or a non-sinus rhythm in the first ECG, the guideline states that patients in whom an arrhythmia is detected in the second and third 24hour period remain asymptomatic (26). The ESC guideline for management of syncope (1) that was published in 2009 recommends that an initial evaluation be made for risk stratification in patients with transient loss of consciousness suspected to have syncope. It also recommends rapid treatment of patients in whom a clear diagnosis can be made. As also admitted by the guideline, however, a definitive diagnosis can not be made in a considerable portion of cases, and risk stratification should inevitably be made. The ESC guideline recommends classifying patients as high- or low-risk and admitting and rapidly assessing high-risk pa- 90 Çiftci et al. Syncope in the Emergency Department JAEM 2014; 13: 82-91 Table 6. Quick hospitalization and requiring extensive research, which increases the risk of short-term high-risk criteria Severe structural disease or coronary artery disease Heart failure Low EF Prior MI Clinic suggesting arrhythmic syncope or EKG characteristics Syncope in the supine position/Exercise During syncope, palpitations Family history of sudden cardiac death Discontinuous VT Bifascicular block (LBBB, RBBB+LAHB/LPHB) or QRS>120 ms along with other interventricular conduction abnormalities Without negative chronotropic medication or history of long-term physical exercise, inefficient sinus bradycardia or sinoatrial block Preeksit of the QRS complex Short or long QT interval ST elevation of V1-V3 with RBBB (Brugada patern) Negative T waves in right precordial leads, epsilon waves and ventricular late potentials (AVRD finding suggesting) Serious co-morbidities Serious anemia Electrolytes abnormalities EF: ejection fraction, MI: myocard infarction, LBBB: left bundle branch block, RBBB: right bundle branch block, LAHB: left anterior hemifascicular block, LPHB: left posterior hemifascicular block, ARVD: arrhythmogenic right ventricular displazisis tients with at least one high-risk criterion that increases short-term risk and requires rapid admission and extensive workup, including echocardiography, stress tests, angiography, electrophysiologic procedures, and tests for neurally mediated syncope. Further evaluation of low-risk cases varies by whether there is one or recurrent syncopal episodes (Figure 3). Conditions specified by the ESC guideline that put patients into the high-risk category are listed in Table 6. Decisions about Treatment and Hospitalization Treatment of syncope patients with a definitive diagnosis includes treatment of underlying disorder(s) and trauma-associated injuries. In this context, a specific therapy in the emergency department or hospital admission is not needed in vasovagal syncope or situational syncope where the triggering event is no longer present and the patient has already fully recovered. On the other hand, fluids or blood products should be administered as needed in orthostatic syncope, and the offending drug should be stopped or a specific antidote be administered in drug-induced syncope. Specific treatment options are available in emergency departments when arrhythmic syncope is suspected. In bradyarrhythmic syncope, atropine or temporary transcutaneous or transvenous pacemaker therapy may permanently or transiently abolish the underlying cause. Syncope of tachyarrhythmic origin is managed by treating supraventricular or ventricular arrhythmias by antiarrhythmic drugs (class 1, 2, 3, and 4) or, when the patient is unstable or unresponsive to medications, cardioversion or defibrillation. Lastly, conditions, such as pulmonary embolism, pulmonary hypertension, aortic dissection, or acute cardiac ischemia, should be treated in collaboration with the relevant departments. In patients with no clear diagnosis who could not be given specific or nonspecific therapy, the decision should be made about the setting (outpatient/inpatient) in which the tests and therapeutic interventions will be delivered. The main aim of the risk scores mentioned above is to pick up patients to be admitted to the hospital versus those to be followed on an outpatient basis. Patients labeled by the risk scores as high-risk should be hospitalized. However, there are some other high-risk criteria not found in available risk scores; patients with such criteria should also be admitted to the hospital. In addition, patients considered high-risk by a physician should be admitted to the hospital independently of the results of the risk scoring. The ACEP guideline recommends hospitalization of patients with heart failure or structural heart disease as well as patients with highrisk features as detected by risk stratification schemes. High-risk patients typically have at least 1 of the following: 1. Advanced age 2. Abnormal ECG 3. Hct <30% 4. History of heart failure, coronary artery disease, or structural heart disease. Conclusion Syncope constitutes a considerable part of emergency service admissions. It is associated with medicolegal and ethical difficulties. Diagnosing transient loss of consciousness and distinguishing it from central nervous system events, especially from seizure, are the first steps towards a correct diagnosis. Unfortunately, the majority of patients continues to have unexplained syncope after completing the initial evaluation composed of a history, physical examination, and ECG. Emergency physicians should perform risk stratification before sending such patients home. Despite being far from ideal, available risk stratification tools now provide emergency physicians with tan- Çiftci et al. Syncope in the Emergency Department JAEM 2014; 13: 82-91 gible risk stratification tools that were not present until the last decade. Nevertheless, no risk stratification tool can replace physician judgment and common sense. Physicians can avoid adverse events with good clinical practice. Informed Consent: Informed consent was waived due to the nature of the research. 5. 6. 7. Peer-review: Externally peer-reviewed. Author Contributions: Concept - O.Ç., C.K.; Design O.Ç.; Supervision - P.D.; Resource - O.Ç.; Materials - C.K.; Data Collection&/or Processing C.K.; Analysis/ Interpretation - O.Ç, C.K.; Literature Search - C.K, P.D.; Writing - O.Ç.; Critical Reviews - P.D. Conflict of interest: No conflict on interest was declared by the authors. 8. 9. 10. 11. Financial Disclosure: The authors declared that this study has received no financial support. 12. References 1. 2. 3. 4. Task Force for the Diagnosis and Management of Syncope; European Society of Cardiology (ESC); European Heart Rhythm Association (EHRA); Heart Failure Association (HFA); Heart Rhythm Society (HRS). Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm JB, et al. Guidelines for the diagnosis and management of syncope. Eur Heart J 2009; 30: 263171. Blanc JJ, L'Her C, Touiza A, Garo B, L'Her E, Mansourati J. Prospective evaluation and outcome of patients admitted for syncope over a 1 year period. Eur Heart J 2002; 23: 815-20. [CrossRef] Quinn JV, Stiell IG, McDermott DA, Sellers KL, Kohn MA, Wells GA. Derivation of the San Francisco syncope rule to predict patients with shortterm serious outcomes. Ann Emerg Med 2004; 43: 224-32. [CrossRef] Crane SD. Risk stratification of patients with syncope in an accident and emergency department. Emerg Med J 2002; 19: 23-7. [CrossRef] 13. 14. 15. 16. 91 Kapoor WN, Karpf M, Maher Y, Miller RA, Levey GS. Syncope of unknown origin. JAMA 1982; 247: 2687-91. [CrossRef] Huff JS, Decker WW, Quinn JV, Perron AD, Napoli AM, Peeters S, Jagoda AS. American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with syncope. Ann Emerg Med 2007; 49: 431-44. [CrossRef] Soteriades ES, Evans JC, Larson MG, Chen MH, Chen L, Benjamin EJ, Levy D. Incidence and prognosis of syncope. N Engl J Med 2002; 347: 878-85. [CrossRef] Crampton DE, Berkovic SF. The borderland of epilepsy: clinical and molecular features of phenomena that mimic epileptic seizures. Lancet Neurol 2009; 8: 370-81. [CrossRef] Sheldon Resuscitation, Rose S, Ritchie D, Connolly SJ, Koshman ML, Lee MA, et al. Historical criteria that distinguish syncope from seizures. J Am Coll Cardiol 2002; 40: 142-8. [CrossRef] McKeon A, Vaughan C, Delanty N. Seizure versus syncope. Lancet Neurol 2006; 5: 171-80. [CrossRef] M.J. Reed, D.E. Newby, A.J. Coull, R.J. Prescott, K.G. Jacques, A.J. Gray The ROSE (Risk stratification Of Syncope in the Emergency department) study J Am Coll Cardiol 2010; 55: 713-21. [CrossRef] Brignole M, Disertoni M, Menozzi C, Raviele A, Alboni P, Pitzalis MV et al. Evaluation of Guidelines in Syncope Study (EGSYS) group. Management of syncope referred urgently to general hospitals with and without syncope units. Europace 2003; 5: 293-8. [CrossRef] Colivicchi F, Ammirati F, Melina D, Guido V, Imperoli G, Santini M et al. OESIL (Osservatorio Epidemiologico sulla Sincope nel Lazio) Study Investigators. Development and prospective validation of risk stratification system for patients with syncope in the emergency department: the OESIL risk score. Eur Heart J 2003; 24: 811-9. [CrossRef] Martin TP, Hanusa BH, Kapoor WN. Risk stratification of patients with syncope. Ann Emerg Med 1997; 29: 459-66. [CrossRef] Miller CD, Hoekstra JW. Prospective validation of the San Francisco Syncope Rule: will it change practice? Ann Emerg Med 2006; 47: 455-6. [CrossRef] Bass EB, Curtiss EI, Arena VC, Hanusa BH, Cecchetti A, Karpf M, Kapoor WN. The duration of Holter mnitoring in patients with syncope. Is 24 hours enough? Arch Intern Med 1990; 150: 1073-8. [CrossRef]


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Hi Bex
Thanks for your reply. I agree I don`t think there is a way of getting that sleep back. I have got the week off from the Monday so my plan is to get back into the day routine and fit a small amount of training in to keep loose. I find it really difficult training whilst working nights but I think I will just have to plan it in and stick to it. I'll probably go before work because I'm always way too tired after work. What do you do?
Thanks for your comments. Its good advice. I'm tempted to overdo it but I think you're right that I should rest more. I think I'll take your advice and do a long run on the day of the first night and then do some gentle cross training and short runs during the week.
I hope all your training is going well. Good luck on the day!


text:
KATE Moss flashes a toothy grin after attending a George Michael gig in London
last night.
The music-loving supermodel looked happy as she left the Royal Albert Hall
with her mum Linda Rosina.
Sporting a deep tan from her recent
break in Ibiza, Kate looked sexy in an all-black leather combo.
Her attractive mother also dressed in dark attire.
After performing at the gig, George announced he was cancelling forthcoming
tour dates in Australia to seek help for "major anxiety".
In a statment, the ex-Wham star wrote: "I have today announced the
cancellation of the shows in Australia which breaks my heart.
"By way of explanation all I can say at this time is that since last
year's illness I have tried in vain to work my way through the trauma that
the doctors who saved my life warned me I would experience.
"They recommended complete rest and the type of post traumatic
counselling which is available in cases like mine but I'm afraid I believed
(wrongly) that making music and getting out there to perform for the
audiences that bring me such joy would be therapy enough in itself.
"Unfortunately I seriously underestimated how difficult this year would
be… I was wrong to think I could work my way through the major anxiety
that has plagued me since I left Austria last December."


text:
Indie Pop Meets Midrash With 'Girls in Trouble'
The Museum of Jewish Heritage — A Living Memorial to the Holocaust recently announced the line-up for their annual New York's Best Emerging Jewish Artists Showcase next month, and Alicia Jo Rabins's new art pop band, Girls in Trouble, is among the performers.
The group, which started playing shows in October and made it to South by Southwest this year, performs songs based on tragic stories of forgotten women of the bible. Rumor has it that Rabins (a violinist extraordinaire and member the klezmer punk group Golem) was looking to avoid writing a thesis for her masters in theology, so she composed a song cycle instead. That project eventually grew into the band.
Clear, lilting vocals, haunting harmonies, driving strings and rolling rhythms are what I heard on the group's MySpace page. Girls in Trouble could certainly be described as indie-meets-midrash, but I didn't feel like the sounds of the shtetl were being forced down my throat (which is definitely the case with many of the self-identified Jewish bands on the scene these days). I'm looking forward to hearing more from them.
The Showcase is scheduled for June 17.
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text:
-I have no title-
In a world where we are told
to be proud of who we are
why are children still told to change
if they do not fit in with their 'roles'
when a teenage boy loves fashion
his father deems him 'not a man'
and tries to tell him to fight, man up
and pushes the teens dreams down.
The little girl who wants to play
as a scientist or astronaut
is, instead, patted on the head,
and sent of to play 'kitchen'
the little boy who wants to play
with dolls and shoes and dresses
is handed a toy car and 'taught to race'
and then taken to play football.
When a teenage girl loves mechanics
Her mother thinks she'd 'not quite right'
and tries to drag her clothes shopping
and insults her make-up free face.
The boy is laughed at when he cries
and the girl is called ugly
all because they want to be
more than what society thinks they should be.
People pride themselves on being different
accepting, kind and loving.
But when faced with someone with different dreams
they seems to hurt instead of help.
So if a child has a dream
or a talent that they love
don't put them down for it being strange
instead, remind them to be proud.


text:
According to police, Rahul Prajapati, who was pursuing his doctorate in chemistry, was found dead in his room in BHU's Aiyer hostel. He hailed from the Shahganj area of Jaunpur district in Uttar Pradesh. After Prajapati failed to emerge from his room till late in the morning, his fellow inmates at the hostel informed senior authorities who then forced open the door to his room only to find his body on the bed.
Police said that prima facie, the case appeared to be one of suicide, although they added that the matter could be properly ascertained only after a post-mortem.


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12" at widest x 10″H (not including handle)
Handle loop 7″ drop
This leather:
is a very lightweight, extremely soft cowhide in oyster (a cool beige color). Has a small scale pebble texture and a matte finish.
This item is HANDMADE with LOVE inNYC. You will receive an email when your order has been shipped.
Please contact me if you need an item sooner.
-All materials purchased from USA vendors.
©2014 Gift Shop Brooklyn
Style Photography – Justyna Fijalska
Model – Annie Choi & Victoria Zeldin
Meet the owner of AnnieBukhmanLearn more about the shop and process
Frequently asked questions about AnnieBukhman
RIO Leather Purse in Oyster. Light Beige Leather Bag. Ivory Leather Purse. Leather Evening Bag.
- Handmade item
- Materials: leather, linen lining
- Made to order
- Ships worldwide from United States
- Feedback: 1991 reviews
- Favorited by: 936 people
- Listed on Aug 25, 2015
- 936 favorites


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ED Magedson – Founder
Ripoff Report
Cricket WirelessSan Marcos, Texas U.S.A.
Does your business have a bad reputation?
Fix it the right way.
Corporate Advocacy Program™
This report was posted on Ripoff Report on 06/29/2009 01:44 PM and is a permanent record located here: http://www.ripoffreport.com/reports/cricket-wireless/san-marcos-texas-78666/cricket-wireless-they-have-been-nothing-but-rude-san-marcos-texas-466046. The posting time indicated is Arizona local time. Arizona does not observe daylight savings so the post time may be Mountain or Pacific depending on the time of year.
Ripoff Report has an exclusive license to this report. It may not be copied without the written permission of Ripoff Report. READ: Foreign websites steal our content
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AUDIO: Brandon James on Gators' success
Fightin Gators Top Stories
Gators Staff Watching Top TalentFlorida is once again busy on the recruiting trail on Tuesday as several in-state targets are playing in their spring games. Who are they watching?
Fightin Gators12:01 PM
Ranking the Units: The Running Backs (#3)As we work through the various position units on the Florida football team, we come to the running back position. Throughout history there have been big time running backs, dating…
Fightin Gators9:03 AM
Gators Jump into the Mix for GarnerA pair of SEC powers are now two feet in with scholarship offers for 2018 Florida-based cornerback, Stanley Garner.
Scout Football7:18 AM
Top DE Ojulari Continues to Evaluate OptionsAzeez Ojulari has seen plenty of interest this spring. The Scout's No. 12 defensive end has seen plenty of schools come by his school this spring, and he is now focused on learning…
Fightin Gators7:13 AM


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|Reviews for Hot? Damn hot
| dolphinrain chapter 6 . 2/7/2013
Cute story.
| TheNaggingCube chapter 6 . 6/14/2009
I enjoyed the story. The ending was a bit to abrupt for the pace and depth of the rest of the story.
| Wenwalke chapter 6 . 6/14/2009
I enjoyed your story. You did end it alittle abruptly, but it still worked. Thanks
| Thesaurusgirl chapter 6 . 6/12/2009
I did enjoy the story very much. Not a bad ending. Thanks for the explanation of how Colby learned to sign. It was not what I expected, which was nice.
| ArodLoverus2001 chapter 6 . 6/12/2009
aw poor colby.
| SgtGroganSG chapter 6 . 6/12/2009
you are very well know with ASL. I'm pretty well know with it aswell, and the way you wrote it I immediatly knew what you ment.
I loved the storY... Poor Colby :D It so wasn't... *Rubs finger on th left side of her nose* Boring ;)
Hope to read more Colby whumping FF from you
| TheNaggingCube chapter 5 . 6/12/2009
Hey this chapter worked just fine. Reasonable continuation of the story.
One tiny nit they are outside it is not a floor but the ground :-D
| ArodLoverus2001 chapter 4 . 6/9/2009
can't wait for more. plz update soon
| TheNaggingCube chapter 4 . 6/8/2009
I like it. I've enjoyed all your Colby fics so far.
Can't wait for more back story.
| Thesaurusgirl chapter 3 . 6/8/2009
Love what I've read so far. Keep it coming! I would love to know where Colby learned to sign. Hope you are planning to expand on that in coming chapters.
| sarasidle3 chapter 2 . 6/8/2009
hey i want more plz plz plz plz plz continue i really want to know if Colby and Megan will be ok.
| teetotally chapter 2 . 6/8/2009
wicked stuff, update quick. I'm dying to find out what you're gonna put the poor boy through (not enough Colby stories out there, and I love a good whump one :)
sure the poor sick lamb is gonna be a hereo again... :)
| ArodLoverus2001 chapter 1 . 6/7/2009
interesting. can't wait for more.


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Web Design West Caldwell New Jersey 07006
Web Design West Caldwell NJ
Your website is usually the first impression you make to potential customers. You want a website that will represent your company within seconds of people seeing it. Our talented web designers in West Caldwell NJ will bring your website to life, crafting an effective solution that will allow your business to grow.


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8B Ann Street, Noosaville
Townhouse, Noosaville
Rated 5 out of 5 stars 3 reviews
From $256 per night {{quote.pricing.message}} Total {{quote.pricing.price | format:'currency':'short'}} for
Min 3 - 7 nights stay
This stunning 2 level duplex in one of the most desirable locations in Noosaville, just right for your next Noosa getaway
With it's own very private plunge pool, secure access, ducted air conditioning and 3 bedrooms, 2 bathrooms and 2nd TV room, this property will suit the most fastidious holiday maker looking for quality, location and comfort.
And being onlytwo blocks away from Noosa River and Gympie Terrace, you will be close to all the fabulous restaurants that Noosaville is famous for as well as the fishing and boating on the very safe Noosa River.
But you will still be only a short distance from iconic Hastings St, Noosa Main Beach and Noosa National Park - a 5 minute drive or 20 minute leisurely stroll.
You will not be disappointed.
3 bedrooms
Sleeps 61 king, 1 queen, 2 singles
2 bathrooms 1 withbath plus powder room
Balcony off Master bedroom with outdoor setting
Linen & Towels are Provided
Hair Dryer
Ultra modern kitchen with dishwasher, microwave and stone bench tops
Living area opening onto the al fresco area
3 x TV's, 2 x DVD players
Air conditioning throughout as well as ceiling fans in every room
Bedrooms upstairs and living downstairs
Beautiful polished timber floors downstairs and carpet in bedrooms upstairs
Outdoor covered alfresco dining area with BBQ and sun lounges
Short walk to Noosa river and the restaurants of Gympie Tce
Over 2 levels in a block of just 2
Security access for your safety
Phone local calls only Plus WiFi
Single lockup garage
3 Night Minimum Stay Off Peak
7 Night Minimum Stays - Mid/High/Peak Seasons
1 Car Spaces
Noosaville, private pool, duplex
Rating snapshot
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Have a question?
Feel free to send a message to the owner/manager if you have any specific needs, or if you require additional information before you can commit to a booking request.
Select request booking to access the quote calculator and to check availability.
Enter your check in and check out dates to see availability and a total price.
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When it comes down to: There is a bad guy with a gun, everyone wishes a good guy with a gun will save them!
If the bad guy is going to shoot you, you wish you had a gun to defend yourself or someone to shoot the bad guy before he shoots you!
When the Police are not there, and some nut case is running around killing people, and they are pointing a gun at you...and its supposed to be a Gun Free Zone, you wish someone would shoot the bad guy.
"When seconds count, the police are only minutes away!!"


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Traditionally, new homes have typically cost 15 to 20 per cent more than older resale properties. During the buying frenzy between 2004 and summer 2007, this differential was up to 40 per cent in new-build hotspots such as Docklands, and as much as 100 per cent at top-end developments in Knightsbridge.
When the crash came, developers in the mainstream market were forced to slash prices to survive, sometimes to below the value of second-hand properties. This made new homes an attractive option for first-time buyers, and they remain so. This is the message being trumpeted by house-builders during September 2010 - New Homes Month - a campaign aimed at boosting sales.
Property analyst Hometrack confirms that new homes remain good value. Builders are under pressure to sell, which means buying opportunities for people with a deposit and mortgage funds in place.
Moreover, housing associations are now major developers in their own right and have a mission to make new homes as affordable as possible, through shared ownership and other low-cost initiatives.
Research by the National Housing Federation, which represents the affordable housing sector, says prices are likely to jump by more than 20 per cent during the next five years. Getting on the ladder now may prove to be a smart move.
New homes come with certain advantages: modern interiors and flexible room layouts, energy efficiency and reduced running costs. Also, some developers offer design choices plus incentives not available in the second-hand market.
Last week, 16 stalled housing and regeneration schemes in London were given £50 million of kick-start finance by the Homes and Communities Agency. This will bring more than 500 affordable new homes to the market. But supply remains tight and some commentators warn of a looming undersupply of new homes because of the fall-off in construction activity, which will lead to the new-build price premium being re-established.
Royal Gallery at Kingston-upon-Thames is one of the kick-start schemes. Launched in mid-September, 2010, a number of the 78 apartments are available through the Government's HomeBuy Direct scheme, which enables buyers to move in for 70 per cent of the price upfront. The remaining 30 per cent is provided jointly by the Government and the developer, and is interest-free for the first five years. It can be repaid at any time or on resale. Prices from £250,000. Call Crest Nicholson on 0870 751 3956.
New development in Kingston has been relatively constrained. Charter Quay is a popular riverside scheme off the market square with a piazza featuring shops and restaurants plus the new Rose Theatre, modelled on the original Tudor one discovered in Southwark. Coming soon is Kingston Riverside, a waterfront scheme by developer St James Urban Living.
Apartments in a listed Victorian former police station in Ladywell, SE13, are for sale through Affinity Sutton housing association. Called The Annexe, one-bedroom flats start at £175,000 (or £70,000 for a 40 per cent shared-ownership stake). Two-bedroom apartments cost from £215,000. A deposit of only five per cent is required to buy. Call 020 8313 0660.
Barratt claims to sell more new homes to first-timers in the capital than any other developer, and is targeting such buyers at cheaper, well-connected outer London schemes such as Park House, Acton, and Evolution, Stanmore. Prices from £250,000. Call 020 8326 7171.
Also in Stanmore, not-for-profit housing provider A2 Dominion is offering 200 affordable homes, a mix of shared-ownership and rental properties. These homes are part of a new 800-home community, with lake, cycle paths, play areas and 24-hour concierge being built by developer St Edward Homes. Prices from £240,000. Call 020 8952 2853.
In much-maligned Croydon, apartments in the handsome, listed Victorian tower of former Queen's Hospital stand out as good value. Two-bedroom flats are priced from £215,000. Call 020 8655 1300.
Follow us on Twitter @HomesProperty, Facebook and Instagram


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Red mucus coming from nose after Rhinoplasty?
I've recently had a rhinoplasty surgery but also had my deviated septum corrected. After all the packing came out I started smelling this nasty foul smell and after using a netipot I realized its this red mucus that comes out from my nose. It smells and tastes awful. Often times people can smell it off me too. I'm 13 days since the surgery and will most likely see my doctor once I can schedule it but I was wondering if anyone could give me some advice on if this is normal or treatable. Thanks
Doctor Answers 3
Malodorous nasal drainage after rhinoplasty
You definitely need to see your rhinoplasty surgeon asap. What you describe is likely some dried old blood from your surgery that got infected. You may need to be treated with oral antibiotics as this can become (if it hasn't already) a sinus infection. In the meantime, if your surgeon gives you permission, you may use the netipot to rinse out the nasal cavities.
Red mucus after rhinoplasty
Thank you for the question. It is rather difficult to fully asses your situation without an in-person examination. If everything appears to be okay after an exam, we usually suggest irrigating with saline to wash out any blood clots or mucus. This will help with the smell that is concerning you. An infection, though unlikely, should be kept in mind and ruled out. An in-person exam with a board-certified plastic surgeon is always the best way to assess your needs and obtain a reliable medical advice. Best of luck! Dr. Michael Omidi.
Red mucus after septorhinoplasty
Some of the blood trapped in sinuses after surgery comes out mixed with mucus and gives it a red or pink color. This is normal and will go away soon. However, if there is a foul odor, then it could be infection and you will need to see a doctor RegardsDr. J
You might also like...
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.


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Hello all,
I am curious as to how i go about tracking the monthly amount of emails received by a single account.
Is there a specific way to go about this in exchange??
we are using exchange 2007 and a mix between 2007 and 2010 outlook clients, this specific client is 2010
all help appreciated
2 Replies
· · ·
Apr 13, 2011 at 6:20 UTC
Keep IT Simple Technology Group is an IT service provider.
Do you have mail relay in place? If so, which one?
· · ·
Apr 13, 2011 at 7:03 UTC
If you schedule this script to run on a regular basis is will track mailbox growth for you aswell as letting you easily view mailbox usage, plus it should draw a nice graph of the growth too i think:


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Jarrow Formulas, Saccharomyces Boulardii + MOS, 180 Veggie Caps
Jarrow Formulas, Saccharomyces Boulardii + MOS, 180 Veggie Caps
- You earn loyalty credit for every order you place at iHerb!
- Loyalty credit is equal to 5% of the value of your order, excluding shipping charges.
- Your loyalty credit will be applied towards your next order as soon as your current order has shipped.
- Your loyalty credits are valid for up to 60 days from the date of your last purchase.
Expiration Date:?Nov 2018Expiration Date
The length of time for the expiration date or "best used before" date depends on the type of product, as well as the brand.
Perishable items (such as flax oils or certain probiotics) generally have shorter expiration dates. Although our warehouse is fully air-conditioned, these more fragile items are put in cold storage (freezer or refrigeration unit) for maximum freshness.
Our receiving department does its best to verify and then enter the correct expiration dates for all incoming products. However, discrepancies do occur from time to time. This being said, the exceptionally high turnover at iHerb ensures that our inventory is among the freshest in the industry.
Shipping Weight:?0.53 lbsSwitch to Metric units
- Product Code: JRW-03029
- UPC Code: 790011030294
- Package Quantity: 180 Veggie Caps
4.8 x 3 x 3 in, 0.45 lbsSwitch to Metric units
|Combo Discount:
|- $4.00
- Non-Dairy
- Room Temperature Stable
- MannanOligoSaccharides
- Gluten Free
- Provides Enhanced Support to the Intestinal Tract
- Probiotic Supplement
- 5 Billion Per Capsule
- Vegan
- Jarrow Formulas Puts the "PRO" in Probiotics
Saccharomyces Boulardii + MOS Contains a probiotic yeast that survives passage through stomach acid and delivers its benefits to the intestinal tract. This strain helps protect and maintain a normal intestinal microflora. It also works to restore the normal intestinal microflora when possible disruptions may occur, such as during the intake of certain medications and during travel. MOS (MannanOligoSaccharides) is an oligosaccharide from the cell walls of S. cerevisiae that can discourage bacteria from adhering to the epithelial cells and reduce their proliferation.
Suggested Use
Take 1 capsule 1 or 2 times per day with water. Or take as directed by your qualified healthcare professional. May be taken with food or on an empty stomach. For immune compromised individuals and children, please consult your healthcare professional before taking this product.
Other Ingredients
Calcium phosphate, magnesium stearate (vegetable source), silicon dioxide and vitamin C. Capsule consists of hydroxypropylmethylcellulose.
No wheat, no gluten, no soybeans, no dairy, no egg, no fish/shellfish, no peanuts/tree nuts.
Suitable for vegetarians/vegans.
Saccharomyces Boulardii + MOS does not require refrigeration and can be stored at room temperature. Refrigeration will, however, extend the shelf life. Avoid temperatures above 77°F (25ºC).
Keep out of the reach of children.
|Supplement Facts
|Serving Size: 1 Capsule
|Servings Per Container: 180
|Amount Per Serving
|Saccharomyces boulardii (a S. cerevisiae strain)
|5 Billion Viable Cells†
|Bio-MOS [derived from S. cerevisiae, source of MOS (MannanOligoSaccharides)]
|200 mg
|* Daily Value not established.
† 5 billion viable cells at time of consumption, under recommended storage conditions and within Best Used Before Date.
Absolutely a must
Verified Purchase
Absolutely a must
I learned that all my problem is related to extreme deficiency in good fungi, this product has helped my to digest cellulose once again which is also the reason to my candida overgrowth. good fungi is very important, don't get confused, it is NOT candida and it is essential in your fight with candida. I keep myself healthy with this product and Korean kimchi (use it for cooking). Remember though, best used 2 h after and 1 h before food so that it can do its magic on empty stomach.
quality and price
Posted by Reviewer2291687 on Apr 09, 2017 | Verified Purchase
very good and a good price
Great Product and I believe Jarrow is the best.
Posted by 5651000006230293067 on Mar 23, 2017 | Verified Purchase
It is being used in conjunction with Vancomycin for C-Dif and there seems to be quite an improvement.
Has been lifesaver for me
Posted by 5015964288027783255 on Mar 10, 2017 | Verified Purchase
I have taken Sacchromyces Boulardii since 2005 because of c-diff. A surgeon wanted removed the affected portion of the colon, but a wise specialist said I should take S.B. , that he felt the whole problem was from the c-diff I picked up from a brief hospital stay and not from colitis. I started with either 3 or 4 /day until symptoms subsided and have maintained on 2/day since--now over 11 years.
It seems and feels like a good deal.
Posted by 4887286535120904794 on Mar 05, 2017 | Verified Purchase
It is a little early to tell, since I only used the Product for two months. But my IBS stomach seems to be calmer and does not "quarrel" as much as it used to. I'm pretty happy with the product so far.
So far so good.
Posted by 5252844991161810676 on Jan 25, 2017 | Verified Purchase
My Lyme Dr. suggested this as a good probiotic to take. I have been taking it for a couple weeks so am not sure how it is doing yet just that it is Dr. recommended.


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People at Savannah: Konstantinos Margaritis Profile
Follows the Profile of Konstantinos Margaritis <markos>.
Open Items submitted by Konstantinos MargaritisNone found
Open Items assigned to Konstantinos MargaritisNone found
General Information
|Real Name:
|Konstantinos Margaritis
|Login Name:
|Email Address:
|Site Member Since:
|Wed Nov 2 11:52:55 2005
|This user did not enable his/her Resume & Skills.
Project/Group Information
- Free UCS Outline Fonts
Member since Wed Dec 7 14:44:24 2005
You Could Send a Message if you were logged in.


text:
I have a green var male...yellow var male...blue var female and a clear yellow female. All born and banded in 2016 ...now ready to breed..$100.00 each…$100
Handfeeding blue Quaker parrots. They were raised by their parents for three weeks. We are now handfeeding g them and will be weaned in July. Take deposit…$300
Precious handfed white bellied caique chicks weaning now! Call or text anytime.$875
Female Moluccan cockatoo. 10 years old, Rizzie is very sweet and super smart. She is very loving and loves to give kisses and be a part of family time…$1,300
Three gorgeous budgies in need of a nice home. Arendelle - Albino Female Pompeii - Lutino Female Kiwi - Green Greywing Female They do not have to go together…No Price Listed
Lost my grey of years and heartbroken If found or seen PLEASE Let me Know. Last seen S.E. th amp Air Depot on May . () - Midwest City Ok. Images and contact…No Price Listed
LOVELY FUN BIRDS . HAVE BABY PEACH FACE WITH YELLOW FACTOR . LOVE BIRDS CAN TALK BUT IF U HAVE 2 THEY TALK TO EACH OTHER . Pictures and contact info on…No Price Listed
... see more at Petfinder.comNo Price Listed
We have cute congo african greys hatching and hand feeding right now These babies will be ready in about months old once they are full weaned. All of our…No Price Listed
Proven pair of blue and gold macaw parrots male is months olds and the female is months old. They are household raised current with immunization and well…No Price Listed


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Home > Product Lifecycle
Product Lifecycle
Optimal Product Management and Product Marketing Training Course$ 1,995.00
Learn All Aspects of the Product Lifecycle to Become a Highly Effective Product Manager and Product Marketer
Optimal Product Management and Product Marketing™ is a three-day course that teaches students the foundation, knowledge and skills that are necessary to be a highly effective Product Manager or Product Marketing Manager. Through a combination of lectures, discussions and intensive hands-on exercises, attendees will learn about all aspects of how to effectively manage products throughout the entire Product Lifecycle and how it applies to their current and future roles. The course is appropriate for both new Product Managers and Product Marketing Managers who need to learn the foundational skills and knowledge of their profession, as well as more senior Product Managers and Product Marketers who want to brush up on their knowledge of the profession and want to learn about the most current trends, best practices and up-to-date methodology. It is the companion course to the one-day People Skills for Product Managers and Product Marketers course which teaches the influencing and productivity skills that are critical for establishing product leadership within an organization.
Become a great Product Manager and Product Marketer!
- Gain the skills and tools necessary to succeed
- Learn the entire Product Lifecycle and how to apply it to your products
- Use the learning from this course as a foundation for the rest of your career
Have a group of 5 or more? Learn About Private Customized Training.
Select the date and location to reserve your seat
- Jun 5th – Jun 7th 2017, in New York, New York
- Jun 19th – Jun 21st 2017, in San Jose, California
- Jul 17th – Jul 19th 2017, in Seattle, Washington
- Aug 21st – Aug 23rd 2017, in San Jose, California
- Sep 11th – Sep 13th 2017, in New York, New York
- Sep 18th – Sep 20th 2017, in Austin, Texas
- Oct 9th – Oct 11th 2017, in London, United Kingdom
- Oct 16th – Oct 18th 2017, in San Jose, California
- Oct 23rd – Oct 25th 2017, in New York, New York
- Nov 5th – Nov 7th 2017, in Dubai, United Arab Emirates
- Nov 6th – Nov 8th 2017, in Los Angeles, California
- Nov 20th – Nov 22nd 2017, in Toronto, Ontario
- Dec 4th – Dec 6th 2017, in Austin, Texas
- Dec 11th – Dec 13th 2017, in New York, New York
Intro to Product Management Training Course$ 995.00
Learn the Fundamental Concepts of Product Management
Introduction to Product Management is a one-day course for new Product Managers and those interested in moving into the profession. Through a combination of lecture and hands-on exercises, attendees get a basic overview of the Product Management role and corresponding strategic and tactical responsibilities. Attendees will leave the class with a clear understanding of the role and its importance to business, learn the basic tasks and overall Product Lifecycle that every Product Manager should follow, and gain a foundation for success in the role.
This Course Is Only Available For Private Training Delivery For Groups Of Five Or MoreLearn More
Product Management Office Professional$ 399.00
All eight of the 280 Group toolkits are included in the Product Management Office Professional—the complete collection to help you be productive and dramatically more effective
Best deal—save $400 versus buying all of the toolkits separately.
Don't spend hundreds of hours learning best practices, creating your own templates and risking the possibility of making mistakes or leaving critical details out of your work. Instead get a copy of the PM Office—it is easily worth the savings you'll get in terms of time, effort, impact and ability to influence your organization
The Product Management Office Professional will help you to:
- Be more productive
- Deliver more effective documents in less time
- Leverage a worldwide-standard product process framework
- Create professional-looking documents with impact
Product Management Office Standard$ 199.00
Product Management Office Standard: The three most popular 280 Group toolkits bundled together
You'll save $100 by buying the Office bundle instead of the toolkits separately, and you'll have everything you need to be a great Product Manager or Product Marketer.
You could spend a huge amount of time creating templates, determining what best practices to implement and possibly making big mistakes with your products. Instead get a copy of the Product Management Office Standard. You'll save time, money and frustration, and you'll be able to influence your product teams, customers and stakeholders more effectively to make your products more successful. The Product Management Office Standard contains the Product Management LifeCycle Toolkit, Product Roadmap Toolkit, Product Launch Toolkit and their corresponding collection of templates and training presentations.
The PM Office Standard will help you to:
- Be more productive
- Deliver more effective documents in less time
- Leverage a worldwide-standard product process framework
- Create professional-looking documents with impact
Product Management Lifecycle Toolkit$ 99.00
Product Management Lifecycle templates and training to deliver more effective and professional documents in less time
The Product Management Lifecycle Toolkit provides you with professional, comprehensive and customizable Product Management lifecycle templates. Built upon best practices and the 280 Group Optimal Product Process, this toolkit contains over 35 templates for the most common documents that Product Management professionals need to deliver.
Save time and write better documents faster
- Easy to use click-and-type templates
- Focus on content, not formatting
- Fully customizable—add your own company logo, header and footer information, etc.
Deliver documents with impact that are more effective and persuasive
- Templates incorporate best practices based on years of practical hands-on experience and research
- Professional, consistent design and formatting standardized across all documents ensures that your marketing plans, MRDs, PRDs, launch plans and other deliverables have the same design and structure.