2012-08-21 11h15 EM Rotations in India

If we are going to change education and get beyond all of the boring Power Point presentations…if we are going to change the way we teach our kids…if we are going to finally realize that a lot of how we teach doesn’t work that well…then we need to be creative and shake things up a bit.

Comedian John Cleese tells us what we need to know about being creative. Although this isn’t specifically focused on medical education, it’s an interesting perspective on creativity.

http://www.youtube.com/watch?v=VShmtsLhkQg

Want to change the face of education? Want to get the creative juices flowing? Get started by watching this video.

I couldn’t resist adding a short snippet from Monty Python’s Flying Circus. Enjoy.

http://www.youtube.com/watch?v=kQFKtI6gn9Y

The post Creativity in Medical Education appeared first on iTeachEM.

In einem Gespräch mit den Kollegen diskutierten wir über verschiedene Möglichkeiten, wie bei Patienten mit Chest Pain tatsächlich die identifiziert werden können, die einen Akuten Infarkt bzw. ein Akutes Koronarsyndrom haben. Und die hohe Sensitivität des cTnT trägt durchaus zur Verunsicherung bei.



Nun zu ein paar Fakten bzw. interessanten Daten:
1) Der Biomarker der Wahl bei der Abklärung von akuten Thoraxschmerzen ist zwischenzeitlich das kardiale Troponin (cTnT oder cTnI). Die Bestimmung von CK bzw. CK-MB hat keinen Nutzen und wird deshalb nicht empfohlen. Es sollte aus diversesten Gründen überhaupt nicht mehr bestimmt werden (einzige Indikation könnte sein der Patient mit Niereninsuffizienz bzw. der Patient mit subakuten Infarkt mit erhöhtem Troponin und V.a. Reinfarkt). Wer mehr zu diesem Thema wissen möchte, kann bei Saenger et al. nachlesen: "Requiem for a heavy-weight"

2) Nun zum eigentlichen Thema. Gibt es eine Möglichkeit, die Patienten at risk sicher zu identifizieren? Sie kennen ja vielleicht den TIMI-Risk Score, oder den GRACE Risk score, die zumal schon unterstützen. Spannend finde ich eine aktuelle Publikation zum ERLANGER HEARTS 3 Score (hat nichts mit der schönen mittelfränkischen Stadt um die Ecke zu tun). In der Publikation von Fesmire wird der Vorteil dieses Scores diskutiert und gleichzeitig ein Online Calculator angeboten

3) Nachdem wir uns ja mit diesem Thema beschäftigen, hänge ich noch eine aktuelle Studie von der Basler Gruppe dran. Tobias und Kollegen haben einen Algorithmus entwickelt, der anhand der absoluten Werte von cTnThs und den Veränderungen der Werte nach 1h eine Aussage zulässt, welcher Patient einen INfarkt hat und wer nicht. Dies wird die weitere Abklärung von betroffenen Patienten beschleunigen. Ein begleitendes Editorial führt sehr gut auf die entsprechenden Überlegungen bei Chest Pain Patienten ein.

ABER Vorsicht: Diese Untersuchung ist zwar ein Meilenstein nach vorne, aber muss erst noch in anderer Settings validiert werden. Wir verwenden nach wie vor das 3 Stunden-Protokoll, wie es in den Leitlinien empfohlen wird.


Hier noch die zentrale Abbildung der Arbeit von T. Reichlin et al.:

Anatomical Macarons! Delicious!

Hi folks.Tonight’s episode is on ECMO retrievals with Dr Anne Creaton, Flight Physician and Retrieval Medicine Specialist with Adult Retrieval Victoria, based in Melbourne.

We discuss the history behind Adult Retrieval Victoria and ECMO retrievals, the logistics involved and the indications for this level of support for interhospital transfers.

We conclude with a shout out to an exciting new retrieval medicine course that Anne and her colleagues are providing.

Check it out at Medicine on Location.

Enjoy

Minh

Now on to the Podcast

Right Click and Choose Save-as to Download the Podcast.

Filed under: Aeromedical retrieval, Emergency medicine and critical care, Interviews of interesting people, prehospital and retrieval medicine podcast Tagged: anne, creaton, ECMO, itunes, retrieval

This is the discussion for "Snapshot: 64 Year Old Male–Chest Pain".

First, let's talk about the patient presentation.What is concerning is the substernal chest pain, radiating to the shoulder and neck area. While this occurred about 30 minutes after exercise, it did not occur during exercise, so that is somewhat atypical. Still, enough red flags in the history to be very concerned.

Here is another look at the 12 lead:

It is a regular sinus rhythm, at a rate of 65. The PRI is on the long side of normal at 200 ms, and the QRS is slightly wide at just over 100 ms. The axis is normal, and there does not appear to be anything causing secondary ST changes.

The question is, do we see signs of ischemia on this ECG?

This is not an obvious ECG, so as we would expect, many of you said yes, and many said no. Is this a normal ECG? We don't have an old ECG for comparison, but I would say this ECG is not normal.

Let's break it down. What jumps out at me most on this ECG are the morphologies in leads I and aVL:

 

 

There is almost 1 mm of flat ST depression in lead I, and a very notable T wave inversion in aVL.

While the T waves look large in leads III and aVF relative to the size of the QRS, there appears to be no ST elevation at this time.

Dr. Stephen Smith, of the famed Dr. Smith's ECG Blog, has written numerous times that depression and/or T wave inversions in aVL will often precede ST elevation in the inferior leads in IWMI.

Also see this recent case by Dr. Amal Mattu for another case on this subject.

Are there any other findings on this ECG that might support these concerns?

There is about 1 mm of ST elevation in V1. Could there be RV involvement? 

At the very least, I would be very concerned about a developing IWMI. The patient's discomfort is diminished, but not resolved. His complaints of "indigestion" are common with IWMI, and diaphoresis is another red flag.

Having said that, would I activate the cath lab based on this ECG? I have to say I would probably not activate based on this ECG alone.

I think this ECG is very concerning, but not yet diagnostic. I would certainly acquire serial ECGs and scrutinize the inferior leads for any subtle signs of change.

Dynamic changes would be a clincher. I would also treat with ASA and NTG, and would divert to PCI center if any changes in the ECG evolved.

This being a "Snapshot" case, we do not have follow up on this patient, or repeat ECGs. 

We run into this in the field often. The spectrum of ACS is far and wide, and we are often presented with borderline ECGs.

I think the best course is to treat based on what is best for the patient, and do serial ECGs!

Thanks for all of the insightful comments on this case!

Any additional thoughts?

 

 

The "headline" you'll see from this article is that the Canadian Head CT Rule outperforms the New Orleans Criteria for radiographic imaging in minor head trauma.  Specifically, it outperforms it in this prospective, observational cohort from several hospitals in Tunisia, consecutive patients with blunt trauma to the head and at least one symptom secondary to the head trauma.

The most striking thing about this article, however, remains the gruesome number of false positives generated by each of these head CT decision rules.  While, obviously, the intent is to capture all the cases requiring neurosurgical intervention, the New Orleans Criteria could not rule out potential need for neurosurgical intervention in 1,180 out of 1,582.  When the theoretical purpose of these rules is to prevent "scanning everyone", we're not getting much bang for our buck.  The Canadian Head CT Rule was better - but still indicated a need for scan in 656 out of 1,582.

While the article focuses mostly on the need for neurosurgical intervention in GCS 15 patients, it's interesting to see their "secondary outcomes" which did not need "intervention".  Only 34 total patients in their cohort required intervention - while they found 133 skull fractures, 41 subdurals, 45 epidurals, 69 subarachnoids/hemorrhagic contusions, and 1 case of pneumocephalus.  The Canadian rule would have missed 11 of the 218 "clinically significant" findings, for a sensitivity of 95%.  The article does not specific precisely which types of findings were missed, but, clearly, many of those may be argued to be not significant.  Unfortunately, deriving a better rule based on a more liberal definition of "clinical significance" is likely to result in more missed interventions - but it's still probably worth trying.

"Prediction Value of the Canadian CT Head Rule and the New Orleans Criteria for Positive Head CT Scan and Acute Neurosurgical Procedures in Minor Head Trauma: A Multicenter External Validation Study"
http://www.ncbi.nlm.nih.gov/pubmed/22251188

There’s a reason that the greatest speakers of truth in our society are still the comics and the poets.  As a member of the medical profession I would like to imagine that in our own way we aspire to offer truth to our patients. Sadly, we often fall short of this high aspiration.  For example, I will be discussing the practical implications of the IST3 trial in an upcoming post, but first I have to calm down.

To the IST3 collaborative I only want to say, I understand, sometimes being able to say what you really mean is hard, and when the emperor has no clothes it’s even harder.  So this EM Notecard is for you, I’ve tried to sum up the findings of your work as concisely as I can. You should know I have found the act of distilling several thousand words of important sounding medical speak into a few lines of verse profoundly cathartic.  I can only hope is has a similar therapeutic effect for you.

For everyone else, I have bundled up the latest postings on the subject. If you click on the card above it will link you to the EM Notecards in verse Pinterest board with a link to the IST3 study for your perusal. I also suggest the wonderful summary by Ryan Radecki of EMlitofNote, the post by Amit Maini over at EDTCC, and David Newman’s discussion on SMARTEM as well as his alway erudite blog post on the subject. Then come back here for a second helping of thoughtfulness on this amazing study.

Filed under: Notecards in Verse

I've put together a short Prezi on Ultrasound guided vascular access, which you can find here. The anatomy portion is currently devoid of images as there is probably a bit of an issue with just cropping images from Fank Netter's beautiful compliation. I'll put in images of my own, unless any of you out there have some non-copyrighted originals that you would be prepared to allow me to use; with full credit of course. The "How to" section is a series of You Tube videos that I found useful. I'm kind of surprised there aren't more. (Come on Ultrasound Podcast!!). Some of the videos wouldn't embed so I've provided the URLs. Anyone who wants to, can use this Prezi for talks at their own institutions. Have fun.

{jcomments on}

Anche da noi la pratica di farsi tatuare il corpo è andata via via diffondendosi. Dopo un'iniziale preoccupazione riguardo alla possibilità che questa pratica fosse un veicolo di infezione, è...

[[ This is a content summary only. Visit my website for full links, other content, and more! ]]

Tamworth Masterclass 2012 from hneemergency on Vimeo.

 

hope we don't have to make an adriano zumbo croquembouche

I hope to see you all there.

This is a sample low carb meal my hospital gives diabetic patients. We are a diabetes center of excellence. No wonder we can’t control obesity and diabetes in our population

In an effort to help you all out when visiting the blog, I have added a bunch of new links to the right that will send you to pages where my posts are linked by category.  For example, click Cardiology and you’ll see all my Cardiology related posts in isolation.  Also, please check out the links page, where I have linked to a few of my favorite blogs and educational websites.  

Let me know if this helps, and as always thanks for reading!

Dr Haney Mallemat of Baltimore produces yet another short but incredibly helfpul screencast video on how bedside USS can assist in emergency tracheal intubation. Check it out! Got no Endtidal CO2 monitor, got no video laryngoscope? Well grab your bedside USS and avoid those awkward, uncomfortable moments immediate post intubation when you and your colleagues dont know if the tubes in the right hole or not!

USS and intubation

Haney, love your work!

Minh

 

Filed under: airway, Emergency anaesthesia, Emergency medicine and critical care, Online critical airway training Tagged: haney-mallemat, intubation, ultrasound

Master Jim DuCanto is back, demonstrating a Glidescope/Bougie assistend tracheal intubation. He is testing the Pocket Bougie by Bomimed

Note his improvised crankshaft maneuver to disimpact bougie tip from anterior tracheal wall, allowing easier passage.

Note the right arytenoid cartilage arresting passage of the railroaded ETT, requiring anticlockwise rotation of the ETT.

Minh

and here is another video of him using the Pocket Bougie with a standard Macintosh laryngoscope

Its an excellent demonstration of proper bougie assisted tracheal intubation, even if there is no bougie prepass.

Filed under: airway, Emergency anaesthesia, Online critical airway training Tagged: airway, bougie, glidescope, intubation

This ECG is from a 84 year old female.

Click to enlarge

Splenic artery aneurysms - only aneurysms that are more common in women – 4:1 female:male ratio - occur secondary to systemic arterial fibrodysplasia / portal hypertension / increased splenic AV shunting that occurs in pregnancy - symptoms – LUQ pain … Continue reading →

From American College of Chest Physicians

Chest 2012;141:7S-47S (Executive Summary)

For outpatient treatment, start 10 mg daily for the first 2 days followed by INR measurements

Give 1 day of LMWH or UFH before initiation, if treating VTE

If the patient is on VKAs, avoid NSAIDs and certain ABX (table 8 from full guidelines)

Avoid anti-plt agents unless clinical condition warrants

Normal goal is 2-3, including antiphospholipid

No need to taper when d/cing

Heparin – 80/18 for VTE, 70/15 for cardiac or stroke patients

For outpatients with VTE treated with SC UFH, they suggest weight-adjusted dosing (first dose 333 units/kg, then 250 units/kg) without monitoring rather than fixed or weight-adjusted dosing with monitoring

High INRs

4.5-10, no bleeding: no vitamin K necessary

> 10, no bleeding: Oral Vitamin K

If anticoagulant related major bleeding: 4-factor PCC and Vitamin K Slow IV Injection

See Michelle Lin’s Paucis Verbis on the same

Critically Ill Patients

Recommend against routine screening

Use LMWH or LDUH in all patients unless contra-indicated

For travelers at risk of VTE, use graded compression stockings; do not prescribe aspirin or anticoagulants

Diagnosis of DVT

Low Risk

moderate sens d-dimer, high sens d-dimer, or CUS of proximal veins only. D-dimers are preferred

If d-dimer is positive, get Compression Ultrasound (CUS) of proximal veins

Moderate Risk

Use High sens d-dimer, CUS of prox, or CUS of whole leg

Can stop if high-sens D-dimer is negative

If no d-dimer or d-dimer postive, need a second CUS 1 week later if only prox CUS done

If whole leg CUS is negative, you are done

High Risk

Prox CUS or Whole Leg CUS

If prox CUS and d-dimer negative as well, done

If d-dimer positive or only prox CUS, get 1 week f/u CUS

If whole leg CUS is negative, you are done

Recurrent

In patients with past DVT, recommend high-sens d-dimer, if positive get Prox CUS and 1 week Prox CUS

If negative, get just one Prox CUS

If the old CUS is not available, confirm with venography if positive CUS

Upper Ext

Go right to Doppler CUS for upper extremity dvt suspicion

Treatment of DVT

Start with IV or SQ UFH, LMWH, or fondaparinux (Latter two preferred)

If high pretest, start heparin immediately; If moderate, start heparin only if diagnostic tests are expected to be > 4 hours delayed

Isolated distal DVT-serial CUS rather than treatment unless severe symptoms or risk factors for extension (see full text)

Ambulate DVTs, no bed rest

In patients with hypotension (SBP) < 90 and PE, give systemic thrombolytics (through peripheral, rather than PA cath)

Atrial Fib

Chads 0 – nothing

Chads 1/2 – VKA/oral anti-coag; Dabi is preferred

If a-fib > 48 hours; give 3 weeks of VKA/dabi before cardioversion. Or get TEE with LMWH. Follow with 1 month of Vka/oral anti-coag

If a-fib < 48 hours; Start LMWH and then VKA for 4 weeks

If hemodynamically unstable, treat with anticoagulation ASAP preferably before cardioversion and then continue for 4 weeks

Treat a-flutter like a-fib for all of the above

Stroke

If hemorrhagic, can start heparin between days 2-4, LMWH preferred

What is EMCrit Drinking?

A White IPA–Boulevard # 2

 

 

 

 

 

 

Les fièvres hémorragiques sont un vaste ensemble d'infections virales fébriles avec potentiel syndrome hémorragique. Par fièvre hémorragique africaine on entend généralement la fièvre à virus Ebola ou de Lassa, car ce sont elles qui ont le plus marqué les esprits par leur gravité. Elles sont endémiques ou responsables d’épidémies en Afrique centrale, mais on a [...]

Sanofi acaba de anunciar la aprobación de la FDA para su inyector de epinefrina Auvi-Q. El dispositivo guía al usuario verbalmente sobre cómo utilizarlo en caso de una reacción alérgica severa.

Here we go with what I hope will become a regular feature of the St. Emlyn’s blog – a cardiology case of the month.  This is something I’ve been running for short while in my department, so it makes great sense to start sharing the cases with a wider audience, in the interests of #FOAM.

I certainly can’t promise to live up to the genius of Amal Mattu or Steve Smith, but still I hope you’ll find this a worthwhile feature!  They’re the scribbles of a busy academic emergency physician so please bear with me if there are one or two typos.  The details will be based on real cases from my experience but, in the interests of confidentiality and after speaking with our data protection experts, key details will always be amended to ensure that no patients are identifiable. On to case 1…

A 45 year old man is brought to hospital by paramedics after being found by passers by sat on the roadside.  The paramedics can’t obtain a coherent history and score his GCS as 13/15 (E3V4 M6).  They perform an ECG and transport him to hospital.

On arrival the patient is agitated and non-compliant, has a blood pressure of 90/40, a GCS of 13 and 2mm equal and reactive pupils.  You elicit generalised abdominal tenderness with guarding.  The patient denies chest pain.  The ECG is below…

Case discussion

Diagnosis

Treatment

Outcome

Rick Body

For my emergency medicine colleagues, add this on to your differential in the next month or two when working up ...
Continue reading

Before we answer the question, let’s talk about how to approach these and break them down.  

First, let’s look at the question type.  This is a type 2 question.  Type 1 questions are simple, straightforward questions.  ”What is the recommended door to balloon time in a patient presenting to the ED for STEMI?”  Simple question, simple answer.  Type two questions require a mental leap.  They propose a scenario, require you to come up with a diagnosis, and then ask a question about how to either treat or diagnose that condition without giving you the name of the condition.  So for this question, I clearly want you to think the patient has a AAA.  

This brings me to the question itself.  The exam writers put information in there for a reason, and information is sometimes excluded for a reason.  So let’s go back to my question:

“A 65 year old make with a history of hypertension and a 50 pack year history of smoking presents s/p syncope and abdominal pain.  On exam, his HR is 110/min, BP 82/40, RR 16, and Pox 98% on RA.  You note abdominal tenderness in the midline, and a palpable pulsitile abdominal mass on exam.  What is your next step in the management of this patient?”

He has a history of HTN and smoking, two major risk factors for AAA.  He passed out, complains of abdominal pain, and has a palpable pulsitile mass on exam.  This is their way of telling you he has a AAA without just saying “A patient comes in with a AAA.”  

So now you made the diagnosis.  The question then, based on the answers provided, is what is the best way to make that diagnosis in this patient.  Again, look at the question above.  Your patient is hypotensive (with a history of HTN), and tachycardic.  The answer is easy if you rephrase the question as a Type 1 question:

“What is the best way to diagnose AAA in an unstable patient?”  He is unstable, so CT and MRI are out, and when was the last time you ever did standard arteriography to diagnose AAA?  The answer, of course is bedside US (Choice D). 

Another strategy I find helpful when studying is to think about how the question could be worded differently and how that would change the answer, or if different answers were provided.  What if the patient was stable, and US was not a choice?  What if instead of angiography, one of the answers was “Establish 2 large bore IV’s, volume resuscitate, type and cross for blood and early surgical consultation?”  Think about different ways the question could be phrased.  AAA is a must know for EP’s, so you know you’ll see it.  

 

My personal opinion is that the majority of tattoos make people look trashy.  No, you don’t look “edgy”, you look low brow.  Not to say that everyone who gets one IS low brow, but it cheapens your appearance. Especially if you are super pale, fat, and or schlubby with skinny little arms.  It also depends on where it is, what it is,  and the size.  In general, isolated small ones of things like roses or other flowers on the ankle look OK, while “Tramp Stamps” and “sleeves” make you looks like a slut, poseur,  IVDA patient trying to cover up needle marks,  or a hoodlum.  I don’t get these stupid-assed reality shows that glorify the tattoo business. It appears that many of the people that work there are either drug addicts, recovering addicts, or ex-cons.   Also, just think how it will look when you are 85 years old and all shriveled up?  Personally, if I were an ED director, I would not hire a doctor with a tattoo visible in work clothes.

Anyway, enough of my personal opinions. There is another reason to be wary of tattoos.  Infection. Traditionally, infections come from nonsterile needles or from artists who don’t wear gloves.  Hepatitis and AIDS are of course the most worrisome things you can get from a tattoo. However, now there is a new source of nastiness.  The ink.  A recent outbreak of a bacteria, Mycobacterium chelonae, a relative of tuberculosis, in people who got tattoos from a parlor in New York, was found to originate from an unopened bottle of ink.  In the past, ink has caused infections because it was diluted with nonsterile water, but this was in untouched samples. Not much you can do about avoiding that – except not getting a tattoo!

Another ripper ultrasound case this week!  I was doing a Sunday – my favourite day!  No lab, no Xray department, no Admin folk doing QI stuff etc…..   Just straight clinical work.  Of course it is tourist season – so the average age of Broome goes up about 30 years!

Elderly chap presented with 24 hours of vomiting.  He had had a bit of diarrhea the week prior, but then went on a rough boat ride and developed a tender lump over his umbilicus.  Being a stoic fellow he didn’t present until the vomiting was bilious and he was all out of buckets!

On exam he looked pretty crook with a distended belly and a firm, red, warm lump ~ 5 cm above his umbi.

Medical school diagnosis really – SBO secondary to incarcerated umbi hernia.  But, here is the trick.  This chap had a list of comorbidities a page long, was on another page of meds and was not the sort of person I would usually opt to anaesthetise.  Having said that – not a good candidate for a 12 hour plane ride either!

So I wheeled out the trusty beside US machine and here is what we saw.

So what to do?

A quick call to the surgeon – he wants to have a look.  There are 2 operations we could do here:

(1) A small hernia repair – if the gut is viable and no bowel resection is required.

(2)  Laparotomy with small bowel resection of dead gut, possible ileostomy etc – this is major stuff for Broome, especially with a man with this many chronic problems.

 

So how do we decide what to do?  Traditionally I think we would have gone in and hoped for the best, with a plan to evacuate ASAP if it turns out to be a major resection.

BUT bring back the US machine with the surgeon at the bedside…

Add a little colour to the image!

So – off to theatre and a modest incision, nice healthy bowel returned to the peritoneal cavity and a mesh in.  Of course we used the US to do a few TAP blocks at the end of the case – no opiates if we can get away with it.

Over all – a very satisfying case, a happy patient and a lot less stress for all concerned.

WHat do you think – how would you play this one?

Die Thematik plötzlicher Herztod und kardiopulmonale Reanimation berührt Profis und Laien gleichermaßen und wir unternehmen viele Anstrengungen, die Versorgung betroffener Patienten zu verbessern. Gleichzeitig dieses Thema sehr, sehr komplex und es ist oft erstaunlich wie in der Laienpresse aber auch von Profis unscharfe Vorstellungen verbreitet werden. Aus diesem Grund ....
... finde ich einen aktuellen Artikel von Hulleman und das begleitende Editorial höchst interessant:

Hulleman präsentiert Daten aus Holland und stellt dar, wie sich die Inzidenz von "out of hospital cardiac arrest" (OHCA) mit Kammerflimmern bzw. einem nicht-Kammerflimmern-Erstrhythmus entwickelt hat. Die Ergebnisse sind erstaunlich: Die Abnahme eines Schockbaren Rhythmus bei OHCA konnte im Verlauf gezeigt werden und wird auf die Errungenschaft des AICD zurückgeführt. Gleichzeitig nimmt die Inzidenz von nicht-schockbaren Rhythmen als Erstrhythmus eines OHCA signifikant zu. Hierzu gibt es natürlich 1001 verschiedene Erklärungen. Dies können Sie im Originalartikel als auch im Editorial detailliert nachlesen. Auch die zur Prävention eingesetzte medikamentöse Therapie (z.B. Betablocker) könnten hier einen Beitrag geben.

Im begleitenden Editorial wird sehr detailliert auf die verschiedenen Aspekte der Prävention und der Therapie des plötzlichen Herztodes eingegangen. Wirklich lesenswert. Zumindest mir wurde in einigen Aspekten die Augen geöffnet.

Extrem spannend bearbeitetes Thema. Any comments?

Check out my entry on Just Watch Lah.

Very tempted to go. Need to double-check my cousin's daughters' schedules first. Taking major exams this year...

And for the purpose of happy reminiscing, my blog review of the Broadway show, posted in October 2007.

World Sepsis Day is on Thursday the 13th of September.

 

Here is a link to a game to help you learn about sepsis

Septris

 

On World sepsis day follow the conversation on twitter

Twitterchat – an international conversation via Twitter in relation to sepsis.

We will host an international Twitterchat and ask the audience 3 questions

related to sepsis, this will generate a conversation across Twitter. This is a

fantastic opportunity to discuss topics related to sepsis treatment and

management, connect with people interested in similar topics and discuss

strategies to overcome challenges. We will be using the #WSD12, please join in.