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If medicine is your passion and you want to help people in pain, then medical office assistant is the career for you. The medical office assistants help the doctors in the medical practice and help the patients with medical insurance forms as well. Thus if you have an affinity for medical practice you can opt to be a medical assistant You have to be competent in administrative work as well and oversee the daily activities of the hospital. The smooth operations of the hospital depend mainly on the medical assistant.
Training programme
A formal training has to be undertaken to be a certified medical office assistant. To enroll in a training programme, you need to complete your high school education. After your training you need to be certified by Commission on Accreditation by Allied Health Education Programs (CAAHEP). Only on acquiring your certification can you start working. The candidate needs to have a good communication skill to interact with the patients and their families, good administrative skills with knowledge in basic computer skills. He must be aware of billing software and medical coding. However the person must be very alert and efficient.
Career Scope
In recent times, this has become a popular career as there is a lot of opportunity for growth. Every medical facility has such a department and it is especially useful in small facilities. The average salary for medical assistant is around $ 34,000. However this range varies with experience. As there is a general rise in the medical care facilities, there is a growing requirement for such medical office assistants. Medical assistants need to be extremely efficient and multitask between medical role and administrative role. The accounts, the billing, the schedule of doctors everything has to be orchestrated by medical office assistants. Additionally he needs to be sensitive to the needs of the patient as well.


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Boy does this cake have a ton of dimension!!! Spidy jumps right up at you! Best Spiderman cake I've ever seen. Wonderful job!! Some little boy was thrilled with this cake!!
Thank you CarolAnn :) I had so much fun doing this cake !
love it!!!
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Anyone Noticed a Big increase in Psychic Abilities Recently?
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me and my family have had prementions in dreams of disasters before, but no i cant say ive noticed an increase.
its probably that you personally are more in tune at the moment some how.
Thanks for that, hmmmm... my premise was that other people who are a bit sensitive would be experiencing the same thing. The UFO guy thought maybe the sense of doom was about an impending alien invasion.
What's different for me is the frequency, intensity and increase in the variety of premonitory dreams. I'm getting several types:
1. 'Big' dreams about catastrophes, lit by blinding white light. In these dreams, I am there, experiencing it. What do I see? Oh, you'll laugh, I know, but I'll risk the trolling and tell you anyway: HUGE tidal waves, multiple, enormous , earthquake shattering large public buildings (yes, I know, that one's symbolic), and yes, you'll kill me for this one, but I'd be lying if I said otherwise - UFOs killing everyone.
2. Short black and white dreams about everyday events. I may be having a conversation with someone or may be working. These short scenarios are then repeated in real life shortly afterwards.
3. Short black and white dreams where I'm seeing through the eyes of someone who is out and about locally whilst I am sleeping. These are people experiencing some distressing situation.
4. Out of the body experiences, where I'm out of my body and pressing up against the windows of my home or out in the garden whilst my body is still in bed asleep.
Big increase in all of the above.
Intentionally Blank
the women in my family have always been kind of intuitive but lately i've been getting weird apocalyptic dreams :S it's been the same one, but i've dreamt of it 3 times in maybe the last year or so. i hope, they're not predictions obviously, all the times i have woken up shaking or crying, etc. (that sounds weird, but i hardly if EVER get nightmares, but i dream very intensely)
it's just like i'm in a large city (i live in Chicago, so it doesn't surprise me & a lot of my dreams take place in "cities") and we're getting bombed or attacked from above. either planes or helicopters dropping bombs, fire in the air, plane crashes, things crashing out of the sky, people screaming. the last one i had (on Sunday actually :P) i could tell it was the same type of scenario but it was somewhat different, now it's kind of fuzzy.
i was at home, lots of family members were coming over, everything was very somber, explosions going off, an almost militant like environment outside. sort of like how on Halloween night (at least by me) it's so smoky outside, & it looks like thick fog so you can hear explosions in the distance. but yeah my parents called me to make sure everyone was getting inside safely. she just seemed sad, not paniced (SP?). a friend of mine who lives nearby but who i haven't seen in a while comes over & tells me that we can come over to their shelter or whatever. a while later, we didn't leave yet, as we were keeping watch out the blinds/curtains, we see people outside. random groups. single people, scattered. people are looting. someone breaks into the back door of our home, my uncle & someone else were trying to fight them off. i don't remember much after that but i woke up pretty soon after that :(
yeah /endrant
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In case you missed Robot Chicken: Star Wars -- Episode II on Adult Swim, the whole thing is online for your enjoyment.
The sequel contains plenty of funny moments, including a scene where the Emperor confides in his hairdresser, another bit where a Stormtrooper decides to participate in "Take Your Daughter to Work Day" and another Stuart LIttle parody.
If all of this makes you nostalgic for the first Robot Chicken: Star Wars special, you can watch it here.
Whitney has been writing about pop culture for USA TODAY since 1999, when Pop Candy began as a weekly column. Her interests include music festivals, mustaches, Lost, comic books and Andy Warhol. She lives in New York City. More about Whitney | E-mail Whitney


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Water is one of the public's most important resources, and water operators are the individuals making sure that safe water delivery functions smoothly in communities. It takes an enormous amount of work to deliver water from natural sources – and eventually deliver it into our homes. It is an equally complicated process to convert the wastewater from our drains and sewers into a form that is environmentally safe – this is also the duty for the operators.
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With the population growth in the US, and increasing suburban geography, demand for operators is predicted to outpace the average for all occupations. Employment of water and liquid waste treatment plant and system operators is expected to grow by 20 percent between 2008 and 2018.


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NBA 2K14 cyberface mod for Paul George of the Indiana Pacers. The texture is based on the screenshot taken from the next-gen version of the game.
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ACU Scholarships and Bursaries
Applications for 2012 ACU Scholarships and Bursaries are now open. Applications can be made via the Scholarships and Bursaries Browser. Pre-assessment of the eligibility of applications is underway. A Helpful Hints webpage has been created to assist applicants in submitting strong applications.
ACU scholarship and bursary selection committee meetings will commence April 2012 and conclude mid-May 2012.
Commonwealth Scholarships
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Please direct all Scholarship queries to email@example.com


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Doctor insights on:
Symptoms Of Pinched Nerve In Leg
It started with severe back pain and nummness and pain down right leg, chiroprictor made back better, was pinched nerve. Still having pain right thigh?
Leg pain: Your chiropracter helped the muscle pain, but it sounds like something else is going on. I would suggest you see your family doctor, an neurologist or an orthopedist and evaluate further. Nerves can be pinched by many things, including disc fragments, bone spurs and even tumors. ...Read more
Nerve (Definition)
The brain and spinal cord communicates with what is occurring in the internal organs and limbs by nerve fibers where are like electrical wires with insulation (myelin) and the "copper" (axon). Within brain and spinal cord these nerves connect to other nerves via synapses on both axons and dendrites. A nerve can carry information regarding sensations, and ...Read more
Can u subconsciously get symptoms that other ppl say they have.like my sis said she had tingling n her leg for pinched nerve and now I have tingl to?
You can: This phenomenon is seen with many symptoms, like itching, yawning, etc. I would encourage you to do this, if your symptoms persists, progress or you feel like they are compromising your ability to do anything then you should seek an inperson consultation with a healthcare provider. Best of luck. ...Read moreSee 1 more doctor answer
Have pinched nerve with leg symptoms (muscle spasm in morning) and limited on activity. Is it safe to use muscle simulator device on those muscles?
Stimulators Safe: Massaging or stimulating your spasmed muscles should be safe. And if it improves your symptoms keep doing it. If it worsens them stop the stimulation. Other helpful treatments are gentle stretching, ice and/ or heat to the effected area. ...Read moreSee 1 more doctor answer
How long does a pinched nerve in leg take to heal?
Weeks to Months: Generally most people can get relief from sciatic pain doing the conservative care within 3-6 weeks. If it persists after that, it can take up to 6 months to heal by itself. You may still be a candidate for epidural steroid injections that may help relieve the pain while your body heals itself. ...Read moreSee 1 more doctor answer
What can u do for a pinched nerve in your leg?
Inactivity: Having your hips flexed in the seated position for an extended period of time can cause your psoas muscle to spasm. You can reduce that spasm by stretching the psoas(ie lunges) and the hamstrings. If driving long distances, try stretching for 5-10 minutes every 2-4 hrs. ...Read more
What is the best medicine to take when u have a pinched nerve in my leg?
Pinched nerve: Anti inflammatories, mucle relaxers, and lyrica (pregabalin) or neurontin just to name a few ...Read moreSee 2 more doctor answers
I have a pinched nerve. I have been takibg antiinflamatories for almost 2 weeks. Should i stop? My leg is the worst in the morning.
No: You may also need to consider a tapering dose of steroids. (anti-inflmmatories, not the type that are famous with elite athletes). Your doctor could prescribe this. If your leg pain fails to respond or you were to begin to feel any weakness in the leg of foot you should see a doctor for a thorough exam and an mri>. ...Read moreSee 2 more doctor answers
Pinched Nerve in the hip and leg, how long it takes to heal?
Weeks to Months: Generally most people can get relief from sciatic pain doing the conservative care within 3-6 weeks. If it persists after that, it can take up to 6 months to heal by itself. You may still be a candidate for epidural steroid injections that may help relieve the pain while your body heals itself. ...Read moreSee 2 more doctor answers
Pinched nerve in back making my hip and leg swell. What to do it's been 2 days?
Be sure: There could be more worrisome reasons for the swelling, so please have this evaluated by practitioner. Though nerve irritation from sciatica can impact neurovascular function and contribute to swelling, be certain it is not more worrisome cause. ...Read moreSee 1 more doctor answer
Why does my leg still feel a ripping sensation and severe pain/numbness after 9 mos of waiting for a supposed pinched nerve to heal? Standings awful!
Radiculopathy: See your doctor....Doesn't sound like your nerve "healed." you may need updated testing and possibly more definitive treatment. ...Read more
- Talk to a doctor live online for free
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Craftsman Collection
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Call us today to speak with an Amish Furniture Specialist with any questions you may have. We can be reached toll-free at 866-272-6773.
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ryan tubongbanua photography
de Ryan Tubongbanua
Acerca del libro
Características y detalles
- Categoría Catálogos
Apaisado grande, 33×28 cm
32 Páginas
- Fecha de publicación feb. 19, 2008
Acerca del creador
Ryan Tubongbanua is the premier wedding, portrait, and event photographer in the Bay Area. Located in Milpitas, CA, his studio services the city of San Jose and the entire Bay Area. Studying photojournalism at California State University, Fresno, Ryan Tubongbanua honed in on capturing strong candid and emotional photographs of fleeting moments in time. His storytelling images are not only timeless but are an accurate representation of you and your emotions. You can see Ryan getting low to the ground, standing on chairs, and getting in the middle of your dancing mob. His approach ensures that you will get photographs that capture rare moments and details that you would not normally see.
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Jasmine may refer to:
- Jasmine Carver, an officer of the Royal Manticoran Navy.
- Jasmine Haines, a Havenite trade attaché.
- Jasmine Neng, a Solarian politician.
|This is a disambiguation page — a navigational aid which lists pages that might otherwise share the same title. If an article link referred you here, you might want to go back and fix it to point directly to the intended page.


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We're more than just an online marketing and social media service for small businesses using WordPress. We also become your Webmaster, helping you with various tasks like backups, security scans, updates and more. We're basically offering you a complete, worry-free solution for advertising and maintaining your website so you attract more visitors and leads.
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The World Bank approved a $350 million loan today for Pakistan. The money is intended to support the government in its plan to improve the tax system and repair battered investor confidence.
The investment climate was clouded by the freezing of foreign currency accounts after nuclear tests in May 1998 and bitter disputes in the power sector that snarled relations with the World Bank.
The 35-year concessional loan will be paid in one installment and has no repayments due for 10 years.
Pakistan is hoping to improve its economy with World Bank lending and a $596 million loan from the International Monetary Fund, which was approved late last year.Continue reading the main story


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Business Intelligence:
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- InfoCube
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Demand Planning:
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- Deployment
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- Real time Scenarios
- Project Explanation
- Overview of PP/DS and GATP


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Study: Many wary of health system Care often seen as lacking by poor or nonwhite Arkansans
Many Arkansans who are black, Hispanic, Asian or poor whites distrust doctors and hospitals, according to a study presented Tuesday at the state Capitol. After researchers talked to 148 people around Arkansas, study co-investigator Dr. Eduardo Ochoa said they found "a deep-seated suspicion of the health care system."
Compendium of HIV Prevention Interventions with Evidence of Effectiveness
The Centers for Disease Control and Prevention (CDC) developed this Compendium of HIV Prevention Interventions with Evidence of Effectiveness to respond to prevention service providers, planners, and others who request science-based interventions that work to prevent HIV transmission. All interventions selected for this Compendium came from behavioral or social studies that had both intervention and control/comparison groups and positive results for behavioral or health outcomes. We required des
hs-CRP and Heart Disease
Dr. Sanjay Kapur, ZRT Laboratory Scientific Director, talks about the relation between CRP and heart disease. Read more of Sanjay's blogs at: http://sanjay-kapur.blogspot.com/
Adrenal Dysfunction
Dr. Alison McAllister, ZRT Laboratory Clinical Consultant, talks about the symptoms, physiology and treatment of adrenal dysfunction.
PharmGenEd™ Asthma
This webinar was presented on Tuesday, November 2, 2010 by Dr. Alice Gardner. Dr. Gardner discusses select pharmacogenomic effects in patients with asthma.
Yellow #5
Thesis (M.F. A.)--Wichita State University, Dept. of English.,"May 2006."
Reassessment of intra- and extra-ovarian expression of growth differentiation factor-9
Mammalian ovarian organogenesis is characterized temporally by oogonial mitosis, oogonial apoptosis, rescue of germ cells via interaction with somatic cells to form primordial follicles, and entrance into meiosis. Recent studies suggest that germ cell's activity participate in this process via the production of local regulatory factors. Growth differentiation factor-9 (GDF-9), a novel transforming growth factor-family member, is expressed in ovaries of various species as a crucial factor in ov
KS2 Numeracy SATs revision 2
The levels test basic skills - addition, subtraction, multiplication and division (without a calculator!) - along with using brackets and questions where a missing number needs to be found. One level tests tables, and finally there are some questions where a calculator may be used, against the clock. Each question uses an on-screen keypad for entering the answers. The order of questions is randomised. Progress is tracked and numerous awards given for achievement at each level.
"What is it?" Exploring the roles of women throughout Raymond Carver's short fiction
A majority of critics examine Raymond Carver's fiction in terms of minimalism, but in this thesis, I highlight the themes in Carver's work rather than emphasize the format. Many women in Carver's work contrast the futility of their male counterparts by showing a determination to move on with their lives. By looking at each of Carver's major collections of short stories, one may find a progression in the way women react to the hopeless situations in their lives. Carver's early stories,
The end and the beginning:a model for analyzing visual/verbal news broadcasts of protest coverage
This project brings together two areas of prior research: framing and visual rhetoric. Framing as it relates to news coverage of protests constitutes the core theoretical foundation. In using prior research by McLeod, Gitlin, and Lee, we see how news coverage can potentially bias an audience against protestors. However, this research focuses extensively on newspapers or transcripts of televised news. Consequently, by combining visual theories like semiotics, gestalt, and film theory into a visua
Will you be my friend? An analysis of friendster.com
Friendster.com was launched in California in 2002 with 20 users. Today, it has more than 27 million members and it is especially popular among Southeast Asian women. It differs from other online dating sites in that users must be approved before they can become part of a user's personal network. This study explores what may have made the site so attractive, as well as how its users represent themselves in their personal profiles. Drawing on social constructionist and feminist theories, this th
The first year impact of a professional learning community on low achieving 7th and 8th grade studen
The purpose of this study was to measure the impact on low achieving learners within the first year implementation of a professional learning community in a large suburban middle school located in the Midwest. Interventions through collaborative efforts were devised for low achieving learners and implemented. Grade trends for students earning below average and failing grades in all subject areas in the 7th and 8th grade were examined from each quarter of the previous four years and compared to g
Basic computer literacy training to increase comfort levels with computers and improve behaviors of
This study researched the effect of a basic computer course on the comfort level with computers and Internet on 17 Spanish-speaking, non-computer literate adults. It also identified any increase of the participants' integration of computers and Internet into employment related activities. Five male and twelve female Hispanic adults completed a four-day basic computer literacy training course. Data collected through pre and post content exams; pre, post, and follow-up comfort and use surveys, a
System Identification and Parameter Estimation
This course is about non-parametric system identification based on estimators of spectral densities and its application to open-loop and closed-loop systems. Furthermore parameter estimation for linear and non-linear systems playes an important role. At the end of the course, a choice can be made out of three final assignments, for which recorded signals are available. The available demonstration programs have to be adapted in order to estimate proper transfer functions and model parameters. St
Getting Lost in Buildings
Most everyone has experienced getting lost in a building -- hospitals, museums, libraries and shopping malls top the list of structures that leave us turned around and wondering where to go next. University of Notre Dame Psychology Professor Laura Carlson researches why people get lost in buildings. http://newsinfo.nd.edu/news/17446/
Creative enterprise in west Yorkshire Arts organisations
This report describes and theorises the findings of a workshop discussion, commissioned by WYLLN, into the views of arts organizations on the challenges they face in becoming more enterprising and less grant dependent.
PH Measurement in Flowing Water
Short video introducing and illustrating the measurement of PH in flowing water. Aimed at students without previous field experience of measuring the physical environment in water.
Particle technology : membranes and colloids
This is a video of the sixth lecture in the module Particle Technology, delivered to second year students who have already studied basic fluid mechanics. Membranes and Colloids covers the different types of particle related pressure driven membrane separations and models of flux decay and fouling. Colloidal behaviour using the DLVO theory is also covered, including colloid stability. This material is suitable for HND, BSc, BEng, MEng, and MSc levels. This open educational resource was rele
Distributed Web Systems - Distributed Systems Architectures
This lecture forms part of the "Distributed Systems Architectures" topic in the Distributed Web Systems module.
Two dimensional heat conduction (UH-Case 2)
This is a video about two dimensional heat conduction (UH Case 2). This open educational resource was released through the Higher Education Academy Engineering Subject Centre Open Engineering Resources Pilot project. The project was funded by HEFCE and the JISC/HE Academy UKOER programme.


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Sunday, Aug. 17, 2014 4 p.m. to 5 p.m.
Location: 2699 Route 2, Hermon, Maine
For more information: 207-848-5946
Ecotat Gardens will hold the Six Basin Street All Women
Dixieland Band Sunday, August 17, at 4 p.m. The gardens
are located at the intersection of U.S.Route 2 and Annis Road, Hermon. Please bring a lawn chair and park in the Annis Road parking area.
This post was contributed by a community member. Submit your news →


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35-44 year old woman treated with Inspira Breast Implants
*Treatment results may vary
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This 35 year old woman had cohesive silicone gel breast implants placed under the muscle. The breast im-plants, sized 325 cc were placed under the muscle with a peri-areolar incision. This patient was a 34 A cup bra size preop and is now a 34 C cup postop. Postop photos at 1 year


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Diffuse hair loss: Its triggers and management
- Felix Terry
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1 REVIEW CME CREDIT EDUCATIONAL OBJECTIVE: Readers will recognize when hair loss may be the result of a trigger disrupting the normal cycle of hair growth Shannon Harrison, MBBS, MMed Clinical Research Fellow, Department of Dermatology, Cleveland Clinic Wilma Bergfeld, MD Co-director, Dermatopathology, Departments of Dermatology and Pathology, Senior Staff, Department of Dermatology, Cleveland Clinic Diffuse hair loss: Its triggers and management Abstract Diffuse hair loss can affect both sexes at any age. Anything that interrupts the normal hair cycle can trigger diffuse hair loss. Triggers include a wide variety of physiologic or emotional stresses, nutritional deficiencies, and endocrine imbalances. Loss of telogen-phase hairs is the most common. Hair loss during the anagen phase is usually caused by chemotherapy or radiation therapy. Finding the cause, or trigger, of the hair loss requires a thorough history and examination and will enable appropriate treatment. Patient education is key in the management of diffuse hair loss. Key Points Early androgenetic alopecia can present as episodic telogen hair shedding, before the distinctive pattern of hair loss is seen. Telogen effluvium is a sign of an underlying condition and, thus, is not itself a complete diagnosis. Androgenetic alopecia should not be overlooked as an important cause of diffuse telogen hair shedding. doi: /ccjm.76a iffuse hair shedding is distressing. In Dmany cases, the patient notes an increase in hair on the pillow, or when brushing, or in the shower drain. 1 It is usually recognized more readily by women than men. 1,2 However, diffuse hair loss can affect both sexes at any age. In this article, we review the triggers of diffuse hair loss and outline an approach to diagnosis and management. the normal hair cycle Scalp hair grows in cycles, with each hair follicle undergoing 10 to 30 cycles in its lifetime. 3 Diffuse hair shedding is the result of a disruption of one phase of the hair cycle, 2,4 ie, anagen (active hair growth), catagen (involution), or telogen (resting) (figure 1). The anagen phase can last 2 to 8 years, 5 the catagen phase lasts 4 to 6 weeks, and the telogen phase lasts 2 to 3 months. 5 The exogen phase (the release of dead hair) coincides with the end of the telogen phase. 6 Normally, each hair follicle cycles independently, so that while some hairs are growing, others are resting and others are shedding. Thus, the density of the scalp hair and the total number of scalp hairs remain stable. Most people have about 100,000 scalp hairs, and normally 10% to 15% of these are in the telogen phase. 6 Shedding of 100 to 150 telogen hairs per day is normal. 5 Anagen hair loss is never normal. The most common type of diffuse shedding is telogen effluvium, in which anagen-phase hair follicles prematurely transition to the telogen phase, resulting in a noticeable increase in hair shedding at the end of the telogen CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 76 NUMBER 6 JUNE
2 HAIR SHEDDING Shedding of 100 to 150 telogen hairs per day is normal phase 2 to 3 months later. 2,4 Telogen effluvium is a sign of an underlying condition and, thus, is not itself a complete diagnosis. the differential diagnosis of diffuse hair loss Telogen hair loss Telogen effluvium has many triggers, and these determine the characteristics of the telogen hair loss. Telogen effluvium can be acute (lasting < 6 months), chronic (6 months or more), or chronic-repetitive. 1,7 If a trigger is acute and short-lived, the telogen effluvium will likely be acute and will resolve. If a trigger is ongoing, if repeated or sequential triggers occur, or if a trigger is not reversed, then the telogen hair shedding can be ongoing. 7 Rule out androgenetic alopecia. Important in the differential diagnosis of telogen hair loss is early androgenetic alopecia (pattern hair loss). Early androgenetic alopecia can present as episodic telogen hair shedding before the distinctive pattern of hair loss is seen. 8 Androgenetic alopecia is a distinct condition, but the signs of telogen hair shedding can be noted. Anagen hair loss Anagen hair shedding is due to the premature termination of anagen hair growth or anagen arrest, after an acute, severe metabolic insult. 9 It is most often iatrogenic, caused by treatment with cytotoxic drugs 9,10 or radiation. 9 Rule out alopecia areata. Important in the differential diagnosis of anagen hair loss is alopecia areata. A detailed history and physical examination to identify the temporal association of possible triggers and any underlying systemic disease should be done in patients with a history of hair shedding. In some cases, further workup is required. Triggers of diffuse telogen hair loss Triggers of telogen effluvium are numerous. 2,4,11 13 Physiologic stress Physiologic stress such as surgical trauma, 4 high fever, 4 chronic systemic illness, 4 and hemorrhage 11 are well known to cause telogen effluvium 2 to 3 months after the insult. Telogen hair shedding can be experienced 2 to 4 months after childbirth (telogen gravidarum). 4 Emotional stress The relationship between emotional stress and hair loss is difficult to ascertain, and hair loss itself is stressful to the patient. 14 Historically, acute reversible hair loss occurring with great stress has been reported. 11 However, the relationship between chronic diffuse hair loss and psychological stress is controversial. 11,14 Evidence for this association appears to be weak, as everyday stresses are likely not enough to trigger hair loss. 3,14 Medical conditions Both hypothyroidism and hyperthyroidism can cause diffuse telogen hair loss that is usually reversible once the euthyroid state is restored. 9,11 Chronic systemic disorders such as systemic amyloidosis, 14 hepatic failure, 4 chronic renal failure, 4 inflammatory bowel disease, 4,14 and lymphoproliferative disorders 2 can cause telogen hair shedding. Telogen hair loss has also been reported in autoimmune diseases such as systemic lupus erythematosus and dermatomyositis, 14 as well as in chronic infections such as human immunodeficiency virus type 1 9 and secondary syphilis. 11 Inflammatory disorders such as psoriasis, seborrheic dermatitis, and allergic contact dermatitis can all cause diffuse telogen hair loss. 7,15 Dietary triggers Nutritional causes of diffuse telogen hair loss are zinc deficiency and iron deficiency. 11,14 Severe protein, fatty acid and caloric restriction with chronic starvation 2,11,14 and crash dieting 12 can also induce diffuse telogen hair loss. Malabsorption syndromes and pancreatic disease can precipitate telogen hair shedding. 11 Essential fatty acid deficiency can also be associated with diffuse telogen hair shedding usually 2 to 4 months after inadequate intake. 11 Vitamin D is an essential vitamin in cell growth, and vitamin D deficiency may be associated with diffuse hair loss. 1,7 Biotin deficiency can result in alopecia, but this is a very rare cause of hair loss CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 76 NUMBER 6 JUNE 2009
3 HARRISON AND BERGFELD MM The hair cycle and diffuse hair loss The scalp hair grows in cycles of anagen (growth), catagen (involution), telogen (resting), and exogen (release of dead hair) phases. A wide range of triggers can disrupt the normal cycle and lead to diffuse shedding. Diffuse loss of telogen-phase hairs is the most common form of diffuse shedding. Diffuse hair loss during the anagen phase is usually caused by chemotherapy and radiation therapy. Anagen phase Active hair growth, 2-8 years Exogen phase Release of dead hair Telogen phase Resting, 2-3 months In telogen effluvium, a trigger (eg, surgery or a nutritional or endocrine imbalance) causes anagenphase hair follicles to transition prematurely to the telogen phase, resulting in a noticeable increase in shedding of scalp hairs 2 to 3 months later. Catagen phase Involution, 4-6 weeks FIGURE 1 Medical Illustrator: William Garriott CCF 2009 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 76 NUMBER 6 JUNE
4 HAIR SHEDDING Androgen excess, as in polycystic ovarian syndrome, can cause diffuse or patterned hair loss TABLE 1 Taking the history: Identifying triggers of diffuse hair loss Duration of hair shedding Episodic or continuous hair shedding Estimation of percentage hair lost Identification of triggers and their temporal relationship to the hair shedding Recent surgery, fever, illness, childbirth, psychological stress History of chronic disease, malignancy, infection, autoimmune disease, liver or renal disease Menstrual history Hair care procedures Dietary history and weight loss noted Family history of androgenetic alopecia, alopecia areata, autoimmune disease, thyroid disorder Medication history including over-the-counter drugs and botanicals History of radiation therapy or exposure to heavy metals Drugs that cause hair loss Drugs can cause telogen hair loss that starts about 12 weeks after starting the drug and continues while on the drug. 10 Dosing changes can also precipitate hair shedding. 7 Any medication or over-the-counter product the patient is taking should be suspected in hair loss. Drugs known to cause telogen effluvium are oral contraceptive pills, androgens, retinoids, beta-blockers, angiotensin-converting enzyme inhibitors, anticonvulsants, antidepressants, and the anticoagulants heparin and warfarin (Coumadin). 10,14 Changing or stopping any oral contraceptive can precipitate telogen hair shedding. 10,14 Oral contraceptives containing an androgenic progestin and hormonal replacement therapy with high-dose progesterone can cause telogen hair shedding with or without patterned alopecia. 7,11,14 IDENtifying the triggers Normal hair shedding usually goes unnoticed. However, at the onset of telogen effluvium, hair shedding increases by 25%. 7 To determine the true trigger of telogen hair loss, the relationship between the trigger and the hair loss must be reproducible, with improvement of the hair shedding following correction of or removal of the trigger, and deterioration on rechallenge. 3 In acute telogen effluvium, ie, the acute onset of telogen hair loss 2 to 3 months after an acute, short-lived triggering event, 4 a detailed history is important to determine an accurate timeline. No trigger can be identified in some cases. 2 Regrowth is not visible for 4 to 6 months. 7 If the trigger is identified and removed, recovery can be expected to be complete. 4,7 In chronic diffuse telogen hair loss, ie, telogen hair loss lasting more than 6 months, 3,14 a range of triggers can precipitate the hair loss. It can be due to idiopathic chronic telogen effluvium. It can also be secondary to prolonged, sequential, or repeated triggers, such as a nutritional deficiency or underlying systemic disorder, and shedding can be less pronounced than in acute telogen effluvium. 7 Chronic telogen effluvium is an idiopathic condition with telogen hair shedding lasting longer than 6 months, and with a fluctuating chronic course over many years without an identifiable trigger. 16,17 These patients can present with a full head of hair or with bitemporal recession and no widening of the midline part. 16,17 Histologic study shows no miniaturization of the hair follicles. 17 The diagnosis of chronic telogen effluvium is made by the exclusion of causes of diffuse telogen hair loss, including androgenetic alopecia. Androgenetic alopecia typically presents as well-defined, patterned scalp hair loss in patients with a family history of androgenetic alopecia. Diffuse hair loss over the vertex and widening of the central part in women, with or without frontal accentuation ( Christmastree pattern), is characteristic. 14,18 The functional mechanism of patterned hair loss is related to a shortening of the anagen phase and a progressive miniaturization of the hair follicles. 18 In some instances, androgenetic alopecia may present as diffuse scalp hair loss with episodic increases in telogen hair shedding. 8,14 This presentation can be 364 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 76 NUMBER 6 JUNE 2009
5 HARRISON AND BERGFELD mistaken for other causes of diffuse telogen hair loss. 14 Although, most women with patterned hair loss have normal androgen levels, 14 androgen excess disorders such as polycystic ovarian syndrome can cause diffuse scalp hair loss or patterned hair loss. 7,18 Laboratory testing can exclude other causes of telogen hair loss, and an androgen screen should be performed in women who present with signs of androgen excess, such as irregular menstrual periods, hirsutism, or acne. 18 Scalp biopsy can confirm the diagnosis of androgenetic alopecia. 14 Anagen Hair Loss: key features Anagen hair loss, the result of interruption of the anagen hair cycle, presents as abrupt anagen hair shedding with a severe diffuse scalp alopecia. 9 A serious insult to the hair follicles can cause up to an 80% loss of scalp hair. 7 The time course for anagen effluvium is usually rapid compared with telogen effluvium, occurring within days to weeks of the insult to the hair follicles. 9 The hair-pull test (see below) is positive for dystrophic anagen hairs with tapered ends. 9 If the insult ceases, hair growth restarts again within weeks. Causes of anagen effluvium include cancer therapies and alopecia areata Antimitotic chemotherapeutic agents induce arrest of the anagen phase and present a toxic insult to the rapidly dividing hair matrix. 9 Hair loss usually begins 1 to 2 weeks after chemotherapy is started and is most noticeable by 1 to 2 months. 19 The scalp hair is usually most affected, but all body hair including eyelashes and eyebrows can be affected. 10 Other triggers of anagen hair loss include radiation, 9 heavy-metal poisoning, and boric acid poisoning. 19 Radiation has also been known to cause telogen hair loss and permanent hair loss. 9,10 Alopecia areata is another cause of anagen hair shedding. 9 This autoimmune condition of the hair 20 can cause patchy hair loss, complete hair loss of the scalp (alopecia totalis), or complete loss of scalp and body hair (alopecia universalis). The importance of the history in identifying triggers A careful history is key to identifying triggers in any patient with diffuse hair loss (Table 1). The duration of the hair shedding and whether the shedding is continuous or episodic should be noted. The patient should also estimate the percentage of hair lost. The history should concentrate especially on events in the 3 months before the start of the hair loss in the case of telogen hair loss. A history of recent illness or surgery should be recorded. A dietary history is also helpful. 21 A detailed drug history including new medications or over-the-counter supplements should be recorded, as should any change in dosages. As mentioned above, other important factors include recent chemotherapy or radiation therapy, a family history of pattern hair loss such as androgenetic alopecia, oral contraceptive use, and hormone replacement therapy. Physical examination Given the complexity of the diagnosis of diffuse hair loss, the clinical examination is of great importance. The scalp should be examined for degree and pattern of hair loss. The hair shafts should be assessed for length, diameter, and breakage. 21 The scalp should be examined for inflammation, erythema, and scaling. 21 The hair-pull test should be done in all patients with hair loss. 22 This involves gentle traction from the base to the tips of a group of 25 to 50 hairs. Normally, only 1 or 2 hairs are dislodged. 1 However, in shedding conditions, 10 to 15 hairs can be dislodged. 1 Light-microscopy helps differentiate the pulled hairs into telogen hairs or dystrophic anagen hairs. 1 Hair shaft microscopy can also indicate nutritional deficiencies. 11 A daily count of shed hair can sometimes be useful, 22 as can a hair collection. 7 A hair collection is done by the patient at home over 2 weeks. 7 The shed hair is collected daily at one specific time, usually in the morning, and is placed in dated envelopes. It is important to note the dates of shampooing. 7 Daily hair collections of more than 100 hairs per day suggest effluvium. 7 Hairs can then be examined and identified as telogen hairs or anagen hairs. Educating the patient is an essential part of management CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 76 NUMBER 6 JUNE
6 HAIR SHEDDING Changing or stopping an oral contraceptive can cause telogen hair shedding Laboratory evaluation and scalp biopsy A laboratory workup can identify triggers or causes of diffuse telogen hair loss. This should include the following: A complete blood count and serum ferritin level to look for anemia and iron deficiency A thyroid-stimulating hormone and thyroxine (T 4 ) level to detect thyroid disease A serum zinc level to detect zinc deficiency A comprehensive metabolic panel to exclude chronic renal or liver disease. If the history and physical examination suggest lupus erythematosus or syphilis, serologic testing can be ordered. Also, an androgen screen should be performed if signs of hyperandrogenism are present 18 or if a hormonal cause for the telogen hair loss is suspected. Scalp biopsy is helpful in most cases of hair loss. 21 Lack of identifiable triggers, chronic hair loss, miniaturized hair shafts, and failure to exclude alopecia areata are all indications for scalp biopsy. 1,2 Two 4-mm biopsy specimens are recommended to provide for adequate horizontal and vertical sectioning. 7 Terminal and vellus hair counts can be done, and the anagen-totelogen hair ratio can be calculated. In acute telogen effluvium, a reversal of the normal anagen-to-telogen ratio can be seen. 23 Miniaturization of the hair shafts and low terminalto-vellus hair counts are seen in androgenetic alopecia. 23 Characteristic peribulbar lymphocytic inflammation can be seen in alopecia areata. 20 Management: the importance of patient education The most important aspect in the management of telogen effluvium is educating the patient about the natural history of the condition. The normal hair cycle should be explained, as well as the relationship between triggers and the timing of hair loss. For example, in telogen effluvium, shedding usually is noted 2 to 3 months after a trigger, although it can in rare cases begin as soon as 2 weeks after a trigger. 7 To help identify triggers, a health diary or calendar can be useful. The patient should be instructed to record any stresses, hospital admissions, surgical procedures, new medications, dosage changes, or other potential triggers of hair loss. 1,7 The patient should understand that, once the trigger is identified and removed or treated, the shedding settles but can continue for up to 6 months. 1 Regrowth can be noted 3 to 6 months after the trigger has been removed, but cosmetically significant regrowth can take 12 to 18 months. 1,7 In acute telogen effluvium, if the trigger can be identified and removed, the shedding is short-lived and no further treatment is required. 1,4 Patients can be reassured that they are unlikely to go bald. Adequate nutrition is essential. If a drug is suspected, it should be ceased or changed for at least 3 months to determine whether it is a contributing factor. 3 Any underlying scalp inflammation (for example, seborrheic dermatitis or psoriasis) should be treated with an anti-dandruff shampoo and a topical corticosteroid. 1,7 Chronic diffuse telogen hair loss is more complex because multiple sequential or repetitive triggers can be involved. 7 Nutritional deficiencies, thyroid disease, systemic illnesses, and infections should be treated. For acute telogen effluvium, chronic diffuse telogen hair loss, and chronic-repetitive telogen effluvium, biotin and zinc replacement can support hair regrowth. 1,7 No specific medical treatment exists for telogen effluvium, but applying the topical hairgrowth promoter minoxidil (Rogaine) 2% and 5% to the scalp once a day can be useful in chronic diffuse telogen hair loss and chronic telogen effluvium 7 (W. F. Bergfeld, personal communication, November 12, 2008). In men, medical treatment of androgenetic alopecia includes topical minoxidil 2% or 5% and oral finasteride (Propecia). 18 Women can also use topical minoxidil; however, only the 2% solution is approved by the US Food and Drug Administration for female androgenetic alopecia. 18 Antiandrogens such as spironolactone (Aldactone) are used off-label for females with androgenetic alopecia. Antiandrogens cause feminization of the male fetus; hence, all women of childbearing years should be on a reliable form of contraceptive. 18 Small studies 366 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 76 NUMBER 6 JUNE 2009
7 HARRISON AND BERGFELD show spironolactone combined with an oral contraceptive can be useful in the treatment of androgenetic alopecia in women. 18,24 Anagen hair loss is usually managed with observation and support, as the cause will be obvious from the history. If no iatrogenic cause can be found for anagen hair loss, then other causes such as alopecia areata and heavy-metal poisoning should be investigated and the underlying condition treated. References 1. Bergfeld WF, Mulinari-Brenner F. Shedding: how to manage a common cause of hair loss. Cleve Clin J Med 2001; 68: Headington JT. Telogen effluvium: new concepts and review. Arch Dermatol 1993; 129: Harrison S, Sinclair R. Telogen effluvium. Clin Exp Dermatol 2002; 27: Kligman AM. Pathologic dynamics of human hair loss. I. Telogen effluvium. Arch Dermatol 1961; 83: Paus R, Cotsarelis G. The biology of hair follicles. N Engl J Med 1999; 341: Rook A, Dawber R. Chapter 1. The comparative physiology, embryology and physiology of human hair. In: Rook A, Dawber R, eds. Diseases of the Hair and Scalp. Oxford, UK: Blackwell Science Publications; 1982: Bergfeld WF. Chapter 9. Telogen effluvium. In: McMichael J, Hordin MK, eds. Hair and Scalp Diseases: Medical, Surgical, and Cosmetic Treatments. London, UK: Informa Health Care; 2008: Sinclair RD, Dawber RP. Androgenetic alopecia in men and women. Clin Dermatol 2001; 19: Sperling LC. Hair and systemic disease. Dermatol Clin 2001; 19: Tosti A, Pazzaglia M. Drug reactions affecting hair: diagnosis. Dermatol Clin 2007; 25: Rook A, Dawber R. Chapter 5. Diffuse alopecia: endocrine, metabolic and chemical influences on the follicular cycle. In: Rook A, Dawber R, eds. Diseases of the Hair and Scalp. Oxford, UK: Blackwell Science Publications; 1982: Goette DK, Odum RB. Alopecia in crash dieters. JAMA 1976; 235: Pillans PI, Woods DJ. Drug-induced alopecia. Int J Dermatol 1995; 34: Fiedler VC, Gray AC. Chapter 10. Diffuse alopecia: telogen hair loss. In: Olsen EA, ed. Disorders of Hair Growth: Diagnosis and Treatment. 2nd ed. New York, NY: McGraw-Hill Publishing; 2003: Apache PG. Eczematous dermatitis of the scalp. In: Zviak C, ed. The Science of Hair Care. New York, NY: Marcel Dekker, 1986: Whiting DA. Chronic telogen effluvium. Dermatol Clin 1996; 14: Whiting DA. Chronic telogen effluvium: increased scalp hair shedding in middle-aged women. J Am Acad Dermatol 1996; 35: Olsen EA, Messenger AG, Shapiro J, et al. Evaluation and treatment of male and female pattern hair loss. J Am Acad Dermatol 2005; 52: Sinclair R, Grossman KL, Kvedar JC. Chapter 9: Anagen hair loss. In: Olsen EA, ed. Disorders of Hair Growth: Diagnosis and Treatment. 2nd ed. New York, NY: McGraw-Hill Publishing; 2003: Madani S, Shapiro J. Alopecia areata update. J Am Acad Dermatol 2000; 42: Shapiro J. Clinical practice. Hair loss in women. N Engl J Med 2007; 357: Piérard GE, Piérard-Franchimont C, Marks R, Elsner P; EEMCO group (European Expert Group on Efficacy Measurement of Cosmetics and other Topical Products). EEMCO guidance for the assessment of hair shedding and alopecia. Skin Pharmacol Physiol 2004; 17: Sellheyer K, Bergfeld WF. Histopathologic evaluation of alopecias. Am J Dermatopathol 2006; 28: Burke BM, Cunliffe WJ. Oral spironolactone therapy for female patients with acne, hirsutism, and androgenetic alopecia. Br J Dermatol 1985; 112: ADDRESS: Wilma Bergfeld, MD, Department of Dermatology, A61, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; ccf.org. Let Us Hear From You Let us hear your opinions about the Cleveland Clinic Journal of Medicine. Do you like current articles and sections? What topics would you like to see covered and how can we make the Journal more useful to you? PHONE FAX WWW Cleveland Clinic Journal of Medicine Cleveland Clinic 9500 Euclid Avenue, NA32 Cleveland, Ohio CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 76 NUMBER 6 JUNE
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Ashley Rider, Hannah Shaw & Taylor Shay – Driving Test
Released: May 20, 2016
Beautiful driving examiner Taylor has to bring a young lad back to the office midway through his exam as he has got a bit excited in the car. Hannah goes to see if he is OK and is shocked at the tent in his trousers. The older women take pity on him and decide the only way he can take his test is if…
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text: PVH Corp. Sees Underwear Growth in 2013 The company is planning several launches and product extensions for next year. By Jean E. Palmieri on December 12, 2012 PVH Corp. has big plans for the underwear and loungewear division in 2013 — and that's not counting the impending addition of the Calvin Klein underwear label to the stable. "Underwear has been a very healthy business for a while," said Mitchell Lechner, president of the PVH Dress Furnishings Group. "It's been the strongest segment of furnishings for over a year. The men's wear industry is becoming more aware of the opportunities and importance of the men's underwear category. Underwear provides the male consumer an opportunity to add an element to his wardrobe that complements his style and personality." WWD logo To Read the Full Article SUBSCRIBE NOW Already a Subscriber? Log in. Tap into our Global Network Of Industry Leaders and Designers load comments blog comments powered by Disqus


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Transformers: Requiem at Wikia
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-Since the dawn of time the Cybertronian Civil Wars have ravaged the known galaxies. Ignited by the ideals of a self-serving empire, the fires of war have expanded at an exponintal rate to consume thousands of worlds, and hundreds of intelligent species.
Fought by two groups of sentient robotic
By the year 2498 the war for domination for the planet Cybertron galaxy as a while had grown frustrated


text: The Eastern Company (NASDAQ-EML) today announced the results of its operations for the second quarter and six months of 2012. Sales for the quarter were $41.6 million, compared to $35.5 million for the same period in 2011, a 17% increase, while net income was $2.6 million or $0.42 per diluted share, compared to the $1.5 million or $0.24 per diluted share, reported in the second quarter of 2011, a 78% increase. Net sales for the six months of 2012 were $82.1 million compared to $68.7 million for the first six months of 2011, a 19% increase. For the six month period ended June 30, 2012 net income was $4.7 million or $0.75 per diluted share, compared to $2.6 million or $0.42 per diluted share for the same period in 2011. Leonard F. Leganza, Chairman, President and CEO, stated, "All three of our business segments experienced increased sales and operating earnings compared to the second quarter and six months of 2011. The Metal Products segment continued to benefit from the strong demand for our proprietary products serving the coal industry. As a result, sales of several of our proprietary mining products increased in both the second quarter and first six months of 2012 as compared to the 2011 periods. In addition, our contract casting business which provides products for various industrial markets also benefited from increased revenues compared to a year ago. These increases in contract castings were driven primarily by sales of new products for the railroad and solar panel industries." Mr. Leganza continued, "The Industrial Hardware segment benefited from stronger military sales in the first half of 2012 on increased orders for latching hardware used in the military's Family of Medium Tactical Vehicles program. The military Humvee program which we had participated in providing our latching systems, will be discontinued in 2012. A new program which is now in the design phase will be for a new Joint Light Tactical Vehicle and we expect to participate in that program. The Industrial Hardware segment's strong 2012 results were also affected positively by a robust Class 8 truck market where the demand for our engineered hardware products and our lightweight composite panels used in the manufacture of sleeper cabs and truck bodies increased over prior year levels. We have currently launched a new product line of two-way air vents used on Class 8 trucks which has opened up additional opportunities for sales of related hardware into that market."


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Let C be a circle with centre P0 and AR be a diameter of C. Suppose P1 is the mid point of the line segment P0 B, P2 is the mid point of the line segment P1 B and so on. Let C1 C2 C3 be circles with diameters P0P1, P1P2, P2P3, respectively. Suppose the circles C1 C2 C3 are all shaded. The ratio of the area of the unshaded portion of C to that of the original circle is


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YPO San Joaquin Mobile App
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This is a private secure app for Young Presidents Organization San Joaquin Chapter. Within the app you will be able to access the Chapter Directory, View Event invites and download Chapter documents. YPO San Joaquin's App will put the chapter in the palm of your hand.
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text: I am looking for a good used VW Air cooled Engine for my Beetle project. Any year or size would be fine. Would take transmission too if you have it. Would be willing to take complete car away for you if required. Please let me know what you have. Thanks.


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Trevor has been developing for the web for 15 years as a freelancer and currently holds a position as a Senior Software Engineer at a large telecommunications company. In his position, Trevor has developed large-scale enterprise applications using technologies such as HTML, CSS, and JavaScript/jQuery for the frontend and PHP, MySQL, and Perl for the backend. Outside of work Trevor enjoys golfing, fishing, and playing sports with his family.
Mentors in: Frontend Web Development, Flexible Web Development Bootcamp