What's going on guys, welcome to a new video. So today we're going to be discussing the budgets in which you put into your Facebook ads. And more specifically, do five pound Facebook ads still work in 2021. So the budget in which you dedicate towards your Facebook ads can significantly impact the results. And unless you understand the impact it can have and kind of like the role in which your budget plays, then it can lead you to making poor decisions. So for example, if you've been running an ad set for three, four, five days and you just think the results are really poor, obviously you're going to switch that particular ad set off. Whereas if you had had perhaps dedicated a bit more budget, it might have then gone on to optimize and make you hundreds of pounds, if not thousands, if not tens of thousands. When you look at successful ad accounts, what you'll usually find is that there's perhaps only maybe half a dozen ad sets, which are responsible for bringing in like 90% of the total revenue, the total sales. But then to find that one ad set which can potentially make you hundreds of thousands of pounds sometimes takes you say 30 ad sets or 40 ad sets to test and kind of sift through what's working, what isn't working to then go on and scale the correct one. And this is why your budget plays such an important role. And with that being said, guys, thanks for tuning in. Hope you enjoy the video. I hope you learned something new and let's jump straight into it. So five pound Facebook ads then, do they still work in 2021? In order to understand this, we need to first understand how the Facebook ads, pixel works and how the system actually works. And then you can understand the role in which your budget plays, which will then kind of make everything a lot more crystal clear and more understanding. So when optimizing, this is taken from the Facebook business manager helper. If you're not familiar with it, I definitely recommend bookmarking it and using it as your reference when it comes to understanding and learning how the algorithms and the pixel works and so on and so forth. So what they say, this is Facebook themselves is when optimizing for conversions, we recommend choosing one that happens 50 times per week at a minimum, the minimum, the keyword there being minimum. Our system needs that many to learn from. Our system needs to learn so it can deliver your ad to the right people at the right time to get you the best results. So basically what does this mean? If you're not achieving this, your ad sets are not optimized. So if you're running conversion ad sets at the moment with a purchase objective, if that particular ad set isn't getting 50 conversions every single week, then essentially it's not optimized and it's not performing at its best. Therefore, obviously, five pound Facebook ads are not an efficient way to run profitable campaigns unless in the very rare case, you are achieving super cheap conversions. So if you're spending five pounds per day in this example here, that equates to 35 pounds per week. If we take that 35 pounds divided by the 50 conversions, unless you're achieving a conversion of 70 pence, then unfortunately your ads won't be optimized and they won't be performing at their very best. Now obviously this is super unrealistic if you're running purchase campaigns. I would typically try and budget for anywhere between sort of 10 and 15 pounds when starting off. That is if it's going out to a cold, interested audience. When it comes to things like retargeting campaigns or look-alike audiences to some extent, then you can achieve cheaper conversions of maybe five to 10 pounds. But to try and run a business consistently, hoping for conversions of around a pound or 70 pence, in my opinion, it's just not going to happen. You're not going to be able to sustain that for very long, if at all. So what does this mean for five pound Facebook ads? Then there is still a place for them if you use them in the correct mind, in the correct purposes and this is when you are running a test. So when you're running a test, then it's not so much about getting every ad set to optimize and because it's going to cost you a fortune basically. It's about giving each ad set in which you're testing an equal spend, which can be five pounds per day, switching them all off, evaluating the results and then choosing the ones to then progress into the scaling and optimization phase. If you've watched my past videos on Facebook ads, you'll hear that I talk about two different things when you're running a Facebook ad you either have a testing strategy or you have a scaling and optimization phase. When it comes to scaling, when it comes to optimization, when it comes to making a profit, then in my opinion, there's no place realistically for the long term for five pound per day ad sets. As a test though, they can be used because it's not so much about trying to be as profitable as possible. It's just about kind of throwing your ad out there and seeing where the bites come from, where the interests come from. So your budget is kind of not irrelevant, but it's kind of relevant, relative, sorry, to what your overall budget is. So if you're looking forward to basically spend five pound per day on 10 different ad sets, let's say, then by all means go ahead and do that. One thing that's really important to keep in mind when you are running these testing campaigns is because of how much you will have spent and because they won't have been optimized, you have to keep in mind how many you've reached, how many people you've reached in comparison to your overall audience size. So if you've got an ad set out there now which has an overall audience size of five million people and you're spending five pounds per day, then over the course of three days you're gonna reach roughly one to 2,000 people, let's say, and one to 2,000 people against the overall five million audience size, that's such a tiny, tiny percentage that it's not gonna give you an accurate representation of that audience as a whole of whether it's a good or bad one or not. And that is why smaller audiences can sometimes be a better option for you. Do not neglect them, make sure you test smaller audience sizes, everything from 10K to 50K to 100K, upwards of five, 10 million if you so want to, just make sure you don't rule them out altogether. A better way to kind of explain this or put it into context is if you wanted to sell something at auction, whether it's a particular product or antique or your house, before you put it up for auction, you went into the auction room of 200 people and you wanted to first find out if anybody was gonna actually buy it or not before you commit to selling it. So there's 200 people in the auction room and you go up to two people and ask them and they both say no. If you take their word as kind of like a representation of the whole room, you might kind of walk away not knowing that the other 198 people that you didn't ask would actually be super interested because there's lots of people interested in your product. It's gonna drive the price up and it's gonna be super profitable. So just keep that in mind. The higher percentage of the overall audience in which you can test, then the more accurate representation of whether that's a good audience interested in your products or not. Hopefully I've made that as clear as possible and you're kind of following along and starting to understand the point that I'm trying to put across. But any questions at all, make sure you do ask. Just put them in the comment section down below. I do respond to everybody so I'll be more than happy, sorry, to help you out in the comment section below. So what does all this mean then? Just a very quick recap before you go. You need a higher budget when scaling and optimizing for maximum profitability for two reasons. Number one, to outbid everybody using five pound. Facebook ads, five pound is such a common budget. If you don't know, then Facebook ads works on kind of like a bidding system. The two biggest kind of influencers are the budget because obviously Facebook is gonna give the more higher value kind of impressions to the people spending more, it makes sense. And number two is how well your ad is suited for your audience. If you have a really poor quality ad, doesn't matter how good your budget is, you're always gonna get kind of like the dregs or the lower quality side. And then point number two, the most important one to optimize your ad set by hitting 50 conversions per week minimum. If you can, try and go for 100 because the more you get, the more optimized, the more kind of informed and the faster your pixel will learn, your ad set will learn and the better the results will be. So ultimately then, is there a place for five pound Facebook ads? Yes, but only when testing. For example, if you achieve a cost per purchase of 10 pounds and you want to get that 50 conversions per week, roughly you'll have to spend 500 pound weekly budget for one ad set in order to get it optimized. Now obviously this is super unrealistic if you're testing because if you wanna test 10 different audiences at 500 pounds each, you're looking at five grand just to run a test. So in this case, it'll be much better to use the smaller budgets and kind of just keep in mind the things I've spoke about in this video that might not necessarily be optimized or the most accurate representation, but at least then it gives you an idea because every ad set you do test will have spent the same amount and you can pick the ones with the highest click-through rate, the ones with the cheapest clicks, the ones with the highest quality ranking, one with the most purchases and then take those into your scaling and optimization phase where you can use this formula then to work out how much you need to spend per week in order for it to optimize and essentially produce maximum probability. And with that being said then guys, I'm gonna wrap the video up there. I really hope you learned something new. I really hope you understood the kind of points and information I was trying to put across. Any questions that follow on from this, please do make sure you leave them but I'll be more than happy to help you out. And then one final very quick thing before you go, if you are looking for a course by myself that comes from my full support and guidance. So if you need help with Facebook ads right now, if you were to join, we can jump into your ad manager right away, start looking at the campaign, start looking at your store, anything you need help with business-wise, then I can help you out with that. All you've got to do is make sure you're a part of the Ecom Academy. There is of course the content side of things as everything. I'll put a link in the video description below so you can check out all that info out first. And if you still have your hesitations and questions, there is a free callback service. So if you click here, book a callback with me, we can hop on the phone, me and you, talk one to one and just talk about what's involved and how it can help you. Thanks again for watching and I'll see you in the next one.


If you are considering buying a driver anytime soon, I suggest you watch this video. In particular if you think that Custum Fit is not very important, then watch this video. If you think that all driver heads are the same in terms of technology, then definitely watch this video. I think the message is just watch this video. So in today's video we are going to use two very different driver heads and try and demonstrate why, like I said Custum Fit is mainly important. Felly rydyn ni'n gwybod y dweud yn gwneud o'r ddweud o'r ddweud â'r ddweud ar hyn o'r ddweud a wnaeth ydw i'r gweithio i'r ddweud. A dyna ni'n mynd i ar y cerdd iawn i'r ddweud. Mae'n gondol am y cerdd iawn i gynnwysu'r ddweud o'r ddweud. Mae'r ddweud o'r rogu stryb, y phobl, mae'r ddweud o'r cerdd iawn i'r eu ddweud o'r ddweud o'r ddweud o'r ddweud. Ionwch yn ddimenau triple dimen LS, ychydig i'r nifer 460cc neu'r ddweud yng Nghymwys Cymraeg, bod ydych chi'n gwneud o'r ddweud, ac yn fawr i'r rhai cyfnod, mae'n rhaid i ddweud o'r ddweud y gulfo'r, felly mae'n gweithio a'r cyfnod o'i gweithio ar y cwm yng nghymru, ac mae'n gweithio i'r ddweud o'r gulfo'r, ac mae'n gweithio yn gweithio ar gyfer y gulfo'r. Felly mae'n gweld ei ddod i'r adegau, fel y tu un oherwydd mae'r byd yw yma. Rwy'n cael ei wneud y ball yn ni yn digwydd. Yr un ddweud y ball wedi'i gyda'r Dymian Dael S. A mae'n gweithio yr hyn... Ac mae'n meddwl yn ydych chi eich cymryd yn yma yw yma yw'r max. Y max yn yma. A byddwn yn ddiwedd yn fwy o'ch cymryd i'r cyfryd, mae'n ffordd o'r ddweud yw i'ch gwymoedd ar hynny. Yn myfyr yw yw am ysgrugol, y bowd hyn yn ylynwys cymryd gyda'r bod ystod yn dweud gyweishio ar蒙gyntionedd yng nghymru. Rhyw hwnnw hwnnw hyn yn mynd i ddechrau, yn cymryd y tu bawb y 1 nesaf. Be ddod y cwestiynau hwnnw yn digwydd yn y gylwm ddechrau a'r pwlad yn y gael gymryd yna yn ddwy origin, ddwy'r blodd yn y gallu fwy yr un. Dyna y gallu bwlad yn los i fusidio ar gyfer beth allu'n ceilio, a cyddiwyddiol sy'n gyfnwys mewn drws, ond yn ei ddefnyddio'r wrth yn y cynhyrchu gael gyda'u meddwl. Cyddiwyddiol Uran II drws y gallwch i gydig eich gyddiwyddiol yn ddechrau'r ei cyddiwyddiol yw bod y brun i ddweudd o'r model yn ei miracles i'r cyddiwyddiol, fydd eich cyddiwyddiol wrth hyn o'i gwirioneddol againsts. Felly mae'n gweld peth gwnaeth oedd. Felly y gallwch yn y cyddiwyddiol ar maen nhw'n cyddiwyddiol. yng Nghaelweithrdd F persona Max mae gennych i gwrth i'r cyhoeddi, efallai gwrthau yn ymdilygrau gwybr tystioli i 50-20 gwahanol fel fyrdd. Mae'r ddechrau ben. Mae'r dechrau hynny'n mynd yw yng nghyddigau. Ac wrth gwaith roedd gennym iddyn nhw'n mynd i'r ddiffryd y byddai y gwirbyn yn eu cerdd. Er o'ch pan oedd yma yma, bod y L-S model, o'r cyfaron llyslwyr, o'ch gwrth S model, mewn hwnnw'n feddwl i'r wneud o'r ffosi. I'm not sure whether it would be anywhere near that max ball with the kind of spin that it's obtaining because what max does really well is not a really high spinning model so it's a good combination of a decent spin number, a decent launch angle and therefore that combination of the two is really what you're looking for and that's why custom fit is so important. Obviously there are different scenarios to consider, we're playing at a Parkland course right now with no breeze so the high launch in higher spinning max product isn't being impacted on in Parkland golf so much but let's say you play at Lynx golf, you play in amongst the wind most weekends then that low spinning triple diamond well that's certainly probably more on the lower flighted driver probably the driver head that you're going to lean towards. The idea of the video is simple, maybe I am stating the obvious but what I want to clearly demonstrate is that like I said technology is different in every driver head as is in the shaft and that's why I keep saying the same thing. Custom fit is made to be important, what I want to know from you is who's believing yet that custom fit is a thing and is important and who has actually been persuaded differently from what they've seen in today's video. So two shots maybe just leaked out a little bit right, far from being perfect but they again demonstrate in terms of ball flight how these things differ. The idea of today's video is to show exactly what I said in the first intro, how much difference there is in terms of driver technology from head to head. Often it's kind of scoffed that in terms of technology if that's what you're going to call it. Even I've been sceptical myself of the kind of weighting systems and draw and fade bias drivers in terms of how much impact they have on performance but it's without doubt that you can see bore out in results here on the fairway. Totally different ball flight alone is given or gotten rather from the rogue ST with that weight position at the back doing exactly what it should do and that triple diamond LS, totally different ball flight and again aimed at a totally different golfer looking at totally different results from what they're expecting to see from their driver performance. A real big difference for you to see there and the idea on this whole is to try it a little bit right to left which we've tried to do and once again playing slightly uphill so again the higher launch in max has got enough height to get where it needs to be. Not quite managed to do that with the LS model but what you do see and hopefully you can still pick it up on the camera is just how much that ball kicks on again with the low spin. So it'll be interesting when we get up there how different they are in terms of where they finish but again massive massive difference in terms of launch being the major thing that you've seen in terms of the differences throughout this video. Right so pretty much come to the end of my video and my test really and I really get interested personally as to how these things pan out and I'll give you my verdict at the very end but first of all just see some dry ball date that we collected earlier on this morning. That gives you a much clearer indication of the differences between the two driver heads and how they perform differently exactly as you would expect. Spin number is a lot lower on that LS model but what that means is if you look at the sort of carry distances there's a big difference there and the launch angle is different as well. But it's not necessarily as obvious as that in terms of a clear winner, yes in terms of carry there's a clear winner but if you look at the overall it's something that's suggested overall in Trackman then it becomes a very close affair. I would suggest that's what we've seen out here on the fairways that the ball gets there A to B in different ways but then where it actually finishes on the fairway I don't think there's going to be a great deal to split them. So it's shown for me a couple of things. Heads are different. There's no doubt about it. Technology in driver heads are different. Shafts are different. These two I was fitted for both of these heads and interestingly got better results from different shafts and we've tried both in each so again for me I don't believe in that one shaft fits all. I don't believe one head fits all and I think that custom fit is majorly important. That's why I said at the beginning of this video please don't buy a new driver and spend £500 and not get custom fit because that's the only way of optimizing results for you. And interestingly for me I'm slightly confused in many ways because I'm not sure which I prefer in terms of my own personal setup. The triple diamond LS sort of sits on a board line where I think I just about swing it quick enough to get enough launch on it to see some perhaps really interesting results and out here on the fairway it performed really really well. So I would be torn between the two. The max is definitely perhaps the most forgiving and why it would favor more somebody of my ability and probably would sway it perhaps that way. But a real interesting test down here at Cardin Park. The rain held off. I hope you enjoyed it as much as I did carrying out the test. Give me a feedback. Don't forget what your thoughts on custom fit, what your thoughts on driver technology as your opinion changed after watching today's video. Thanks for watching. See you soon.


Hi, I'm Priyanka. I've been working with Adobe for the past four years. I've worked on fireworks, which is a web graphic design tool and in the past one year we have been working on a web tool that would generate graphics for the web and It would export to SVG as well. So today what I'll do is I'll share all the cool things that I I personally think are cool about SVG so Before we proceed, how many of you have heard of SVG? How many of you have used SVG? So what we'll do is we'll go over what SVG is and why we should use SVG and how you can use SVG and HTML and All the SVG elements and its properties and how you can animate and interact with SVG So SVG it is graphics that scales well across multiple screens Without any loss of fidelity What I mean by this is here. I have two versions one is a PNG version Which is a bitmap and I have a SVG When I scale it as you can see the image gets distorted, but with SVG There is no loss of fidelity and it works well across multiple screens Coming to HTML SVG and CSS SVG has been around for a while but what has changed in the recent past is that there is support for inline SVG now and Why is inline SVG important? It's because you can add SVG directly to your DOM and You can interact with it as you do with any other DOM elements So that is where you can make your web pages richer by making use of the goodness of HTML, CSS and SVG So coming to the properties of SVG SVG is Stylable you can use CSS or SVG styles. It's responsive. It works across multiple devices multiple screens Platforms and it works well with media queries as well. It's interactive. You can add event listeners to it and Walk with it as you would with any other DOM elements. It's Animatable you can add CSS or SVG animations to it here. You can see that the gradient is being animated and It is scriptable as well What I mean by this is you can generate your SVG and added to your DOM dynamically Frameworks like Raphael or Snap makes use of the scripting capability of SVG and it generates really good graphics that you can use directly within your HTML So in ways to include SVG in your HTML with X HTML you could use it as an image You could use it as an object with the object or the embed tag You could use it as a document with the iframe and with HTML 5 You can use it directly within your document or we'll be speaking more about inline SVG in this session So let's take a minute to look at all the SVG elements that are there You can use the SVG tag like this in your body or depth and It provides basic shapes like rectangle ellipse circle that you would expect any graphical language to have It has SVG text as well, which we'll look at in a while And it has other shapes like line polygon polylines, and it also has path with which you can Draw your shapes and busy your curves For styling we have SVG gradients and you can use SVG patterns You can use clip paths where you can define your shape and embed your bitmap within the shape There are SVG filters like blur grayscale and you it works well with CSS styles and There are transformation properties like translation or rotation Coming to SVG text a lot of things are being worked on to make the text rendering better on the browser with the new CSS specifications we have CSS regions and CSS shapes if you're not aware of it What CSS regions does is you can put your Text within your container and you can make the text flow from one container to the other and There are CSS shapes where you can embed your text within a particular shape but this is not yet supported on all the browsers and even with that CSS can't do something like this where I have the text on my path and It's really simple to do with SVG where you just define your path and have the text follow the path We look at some more examples on what you can work with SVG text in some time Animations so SVG has these presentation attributes Presentation attributes are more like fill stroke that CSS understands and we can use CSS animations to animate the SVG for other attributes like path which cannot be Handled by CSS because it doesn't understand it. We can use SVG animations Now we look at both right here So how many of you have played flappy bird? Here. So what I have here is my own pretty version of flappy bird As you can see it flaps. All it's doing is flap. It's not a game. So What I can do with this is what I have here is an SVG version and it's really simple to do this As you can see I have the bird The bird claws where I've defined my path for the wing and the rest of the bird And what we can do is the right wing that you see here We'll animate that using CSS And this is again really simple I'm using the webkit transform or the normal transform as well and I'm translating the bird to move up and down so it Shows the flapping of the bird Now that I have a flapping bird. I would want to make it move around Moving around a straight line is pretty simple, but what if I want to make it move across a shape like this This would be really difficult to do but with SVG This is a really simple to accomplish. All you have to do is you have to define your path Which you can create using any of the desktop tools like in scape or illustrator Or you can use online tools for this like SVG edit or Mondrian and Once you have your path what you have to do is use the animation motion tag and Just say which path to follow provide an ID and say okay follow this path This is how simple it is to do. There is no just to involve to do this at all it's really simple and One more thing that you can do is have SVG draw something like this with SVG path capabilities you can animate and make your Website much more richer and to do this again It's a really simple you just have your path and use the animate tag to animate it We'll just look at a real-world example of where this is being used So this is a New York Times article So New York Times is doing have these multimedia stories where they're exploring all the new web technologies and Using them to improve their user experience. So this is one which uses SVG path So what what this article talks about is the journey from one place to another So let's see how you how it goes. So it's from Petersburg to Moscow As the story progresses you can see that for every stop it kind of animates it like right there You can see that every stop animates really well and it Enhances your user experience with this. So this is what you can do with SVG And it's really simple to do and it improves the user experience CSS or SVG again, let's take a look at example So how many of you seen the Twitter fail whale? Quite a few of you. So there is an animated version of our Twitter fail whale. That's available online On the internet. So this was created completely using HTML and CSS and What I've done is I've created my own version of Twitter fail whale with SVG completely in SVG and as you can see it is responsive and there's no loss of validity because SVG itself is scalable and Here is a CSS version. Although this can be made responsive It's very hard to draw something like a bird using CSS and HTML SVG has the shape attribute just to draw something like this. So this is where you would want to use SVG instead of CSS pretty It's not bad the performance is not very bad. I've seen it. It has only like three transitions We can take a look at it. We'll look at it after we're done with the demo. I mean session Coming to interactions Now that we can use CSS Sorry SVG right within your HTML document. It works well with CSS interactions as well Here I have a path. So as I hover on it, you can see that I'm changing the fill color How this is done is that I define my path and since we have our Presentation attributes, which is fill which CSS understands we can Anime we can apply transitions on hover All I'm doing is on hover change the fill color. So this is how simple it is to do this and More role-world example would be to create something like an image map what I have here is a map and There are different locations of the map which on hover changes the color What I can do with this is as I hover on it. I can provide more information about the particular location or Take take the person to that location which would provide some more information about this location And it's really simple to do as well without any JavaScript again here I have the clip park and I'm using the image which is which I'm embedding within the Park and again on hover I change the fill color Okay, coming back to text This is one of the things that you can do with text right here What I'm doing is I have a path and I'm making the text flow on the path As you can see here, it's moving around How I can do this is again define my path and Get the text to follow the path using the animate attribute So let's look at some more animations that you can create. This is available in SVG. Wow This this will run through all the effects that you can do for text So it's like 40 seconds video that shows all the So these are the capabilities that SVG provides and So as you can see it, you can create really rich animations with text and SVG So coming to more richer interactions So we saw the word that we had back then It was following a path. So what I'll do now is Draw my own path that it should follow so I create my path and I'll go to follow the path that I just created So you can do a lot of drawing and interactions with using SVG and There's another example right here Where if you click on it, it adds an element and you can drag it along This is completely done in SVG And so these are some of the things that you can do but to do more complicated interactions you would want to use a library like Raphael or Snap or D3 which would help abstract all the complexity and make it simple for you to use it so this is what you can do and Coming to a browser support. This is a support for inline SVG As you can see most of the current browsers and devices supported Except for Opera Mini in SVG itself is supported across all the browsers, but this is the statistics for in Normal SVG when SVG is not supported you might want to use modernizer or a simple PNG to fall back on and What should you not do with inline SVG is you shouldn't create your entire HTML application using inline SVG because the performance of SV I mean your web page would slow down in crept incredibly because you should use it in web components like a logo or Components of your website rather than the entire website And you should also not use it when there is a lot of re-rendering of your assets That is required in that case. We would want to use something like canvas And these are where I found all the things from and let's look at another example So this is completely done in SVG again. So this shows the interaction where I click on it and it changes I can animate it These are the things that you can do with SVG and to improve the user experience and You can reach me write your sp.lk slash has geek and Yeah, that's about it. Do you have any questions? Yeah so canvas is what you use for bitmaps where you need a lot more like a gaming application a complicated gaming application which need not be responsive, but SVG is when you need more interactivity in your HTML applications Hello Can you hear me? Yeah. Yeah. Hi. So I wanted to ask why is it? It's suggested that you shouldn't use smell animation for SVG. It's in my I mean it's better to use Besides the fact that it's not supported in Internet Explorer. I mean is there any other reason why it's not the perform It's not. Yeah, that's one of the reasons that you shouldn't be using because it's not supported across all the things and the performance of CSS animations or SVG animations is a lot better than SMIL But smell animation SMIL animation is SVG animation, right? I mean that animate motion You have to choose between a CSS and SVG when So CSS animations are supported on browsers much more than a lot of How do I say this? so it SVG has a lot of geometrical operations that it has to do to do any of the animations like drawing a path involves a lot of geometrical operations or mathematical operations that you have to do but with CSS animations if it's just a transition It wouldn't have to look at any other path to follow So that is that code is not really embedded inside your browser to do it Actually, I'm not really asking between CSS animation and SVG animation Okay, because you can't do everything you can do an SVG animation using CSS animation I'm asking with regards to smell animation versus using something like Maybe a snap SVG or Raphael snap again uses the same thing But I mean instead of having the animation tags within SVG Uh-huh, you know if you want to do a small component So if you want to animate a small say I had a logo there If you want to just animate that you wouldn't want to get the entire library within your web page If it's small things that you're looking for then you can directly use inline SVG capabilities and add it right there but To do more complex things that is when you would want to use Library as such. Okay. Okay. Thank you. Does that answer your question sort of? Yeah, I can talk to you later. There's a question for you on screen Is there an SRC property for inline SVG? Yes inline SVG. What does that mean with an image tag? Okay, whoever asked has to clarify that now If you have an image tag and you provide the B64 is that what you're talking about? Yeah, so another binary format image I would have to use base 64, but since SVG is text anyway Can I just put the text inside the SRC tag rather than you know linking to an external? This or using base 64. Oh, I mean like can I use an SVG document right inside a Place where a data URL is expected for example in the image SRC or maybe in like inside CSS Exactly correct, but I do not want to link to an external SVG resource because that will cost the browser to you know You can embed the entire SVG within your inside say you you want to put it within a DevTag You can always do that, but unless you want more capabilities like interact with it Then it would not it's not really advisable because it just loads it right. Yeah, okay Slightly related question. I want to use a background image on you know using CSS, right? I want to add a CSS background image and again I can use a data URL over there background image URL, whatever So is there is it possible to use SVG over there? Yeah, you can just again get your SVG right there I mean you just provide your URL with the SVG file that you have Yeah Without using an external in it file. I mean embed it inside in not sure about that Yes, you can do that I mean you can always have SVG as Like if you've got an SVG file in your folder, then how if you got an SVG file in your folder Then how do you put the URL for a like is SVG property in the SVG property like I frame We are equal to right. Correct. Like if it's SVG attribute, how do you which attribute is we can give for like I have an SVG tag and what do you want to do with it? Yeah, SVG tag is there, but I don't want to put the complete SVG nodes in the HTML file I want to put I want to use an external SVG. Okay. How do you do that in there? The other Why we like why I need is like because I don't want to put the complete SVG pro tags Inside the steamer you can use the image tag or I frame or then it will work exactly the same as in line SVG No, it doesn't work like in line SVG is something that is present right within your DOM Yeah, so there is no option to put it like you and you just go to the SVG and get copied right here There are libraries which actually do that once you give the SVG it Optimizes that optimizes it and because otherwise if you want to use some in line SVG things Anyway, I need to put it inside the browser can I steamer completely right? Yes If I want to put it in a separate SVG and then use a single SVG is no option. That's right. Oh, no Come to a question in the back. Yes, you can do that So within the depth can I just go? Okay, so there are there's a particular track called a depth where you can define all your parts and you can use the use tag Okay, I'll just show So there is a tag called depth where you can define your Okay, I don't have it here So what you do is you have the depth tag where within which you can define all your Parts or attributes that you want to reuse and use the use tag again It's again use tag which you can reuse it providing the link the ID So I couldn't find that but I have it right here. I can show you the examples later. If you meet me offline Hello, can you have it one more question? Hello. Hello. Yeah, Piyanka one question the fact that you can actually You know in an image tag you can actually call a SVG file, right? Is it safe to assume that? in terms of the The way it renders like SVG versus an image is is it safe to assume that? It's just a different format But the way it behaves is similar For example, I mean like an image is a rasterd file Type and this is a scale. What happens is say Internet Explorer, right? It doesn't understand what SVG is so it might not really render it So you need to have a fallback for that. So yeah, I mean You know, I know that there are some You know products that give you a fallback in in the form of a PNG or whatever But I mean, I think this is also a follow-up question to you know, what someone asked I or rather I just wanted to clarify Can SVGs be also used as background images? Yes, you can Okay, and the what do you call it? The the size of an SVG is how you had saved it originally as in What is so for example, if I call an SVG file Is that what is the default size of that because it's obviously your XML file? So it's really small compared to no, no, I'm talking about the physical size. So for example, oh The dimensions even you can always change it right within your image tag But the default is how you saved it in your application. Okay, that's Okay, okay, cool That's it. Thanks Hello, so if I use the image tag to include an SVG How much of the DOM capabilities do I get or can I get? with image tag Mostly what you can do is say as the whole effects that image tag allows but not the SVG capabilities and you'll still get the Responsiveness and the scalability, but what you won't get is the SVG attributes and SVG Animations that if you ask the animations, etc. So what you still want to have like a hover But if you want to change the color again that comes back to SVG So you need to have inline SVG for that, but if you just want to say add the filter effect on Hover that you can easily do with so what if I want to use an external SVG resource? I just use the SVG tag Along if there's a SVG stored as an external resource, I want to load it Which is like the effect is similar to inline SVG. What do I do? I use the SVG tag and it has some source No, what if it's an external resource the SVG file that I want to load Then you should you need to put it within the image tag, but you need to copy and paste it right here You there is no way to just load it as I mean there are libraries that do that But so no Derek. So essentially I use the image tag to load it And then I load some external library which enables the DOM elements with the abilities SVG I forgot I'll get back to you, but yeah, there are libraries that Optimizes and puts it right into your DOM Snaps out that yeah Sorry Okay, is it good? Oh, yeah It's by the creator of Raphael only So it's really good. It's the it's basically Raphael 2.0, but with a lot more capabilities than Raphael We were using SNAP and we were building the tool so


This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation on medical error prevention, understanding serotonin syndrome. We're going to start out by defining serotonin syndrome. A lot of us are a little bit familiar. We may know a little bit about it, but not enough to really understand how to identify it, what to do about it, or why we as non-prescribing clinicians would really care. So we're going to talk about that. We'll explore the drug interactions that often cause serotonin syndrome. And we'll look at some of the different ways that we may not have thought about how serotonin is actually increased in the brain. We'll explore risk factors for serotonin syndrome, discuss why mental health clinicians need to know about it, and learn about treatment for serotonin syndrome. We're obviously not going to treat it, but it's good to know. So if we're referring a client to their primary care or sending them to the emergency room, we can give them some sort of reassurance about kind of what's going on so they're not as stressed out because serotonin syndrome can be extremely scary. So understanding some of the serotonin receptors. And there's, if I remember, 17. The ones we're really going to be looking at today and not in huge depth because this is more about serotonin syndrome, not the pharmaconetics. 5HT1A is one of the ones that a lot of our typical antidepressants work on. 1D is involved with locomotion and muscle tone. 2A, neuronal excitation, learning, peripheral vasoconstriction. 2B, stomach contraction. 3, nausea, vomiting, and anxiety. And 4 is gastrointestinal motility. And you're thinking to yourself, yes, so why do I care? Because when we're looking at serotonin syndrome and we look at the symptoms, these are the symptoms we're talking about. We're seeing an increase in serotonin causing extreme gastrointestinal motility, i.e. diarrhea, nausea, vomiting, anxiety, stomach cramps, really high fevers. So we know or think, hypothesize that the increase in serotonin is affecting these different receptors. Ways serotonin is increased. We increase serotonin synthesis. That is the body making serotonin. Well, serotonin can only be made from tryptophan, which is an amino acid. If people start taking amino acid supplements, which can be dangerous when you start taking supplements and they're not in the ratio that nature has presented them to us, sometimes that can prompt too much serotonin to be created. Now, that also assumes that the body is going to take that extra tryptophan and go, hey, we've got excess building blocks, let's make more serotonin. But that is one way to increase serotonin. Reduction in serotonin breakdown. So you have serotonin and it's put into the space in the synapse. And instead of breaking down as quickly. These drugs typically are MAOIs and we can all think about when MAOIs were used, you know, back before tricyclics. But the MAOIs prevent serotonin from being broken down. So if you've already got it, you may have enough of it, but it's getting broken down too quickly. All right, that's fine. The third way is an increase in serotonin release. And this is caused by a lot of different things, but primarily we're looking at amphetamines, including ADHD medications and MDMA. So legal prescription, illicit, you know, anything that's going to be a extreme stimulant. Your antiretics, your appetite suppressants, which generally are also amphetamine based like dexadrine. And anti-migraine medications, such as Tegretol and valporic acid. So it's important to understand some of these things because if you've got a patient who's on SSRIs and they're also taking some of these other medications, they may not have told their psychiatrist that they're taking their migraine medicine. They may not have thought to do that, that they weren't necessarily trying to be snarky or trying to be manipulative. It may have just slipped their mind because it's something they take PRN. The fourth way we increase serotonin is through stimulation of postsynaptic receptors. So you've got serotonin, it's released into the synaptic cleft, and then these receptors are out there. And now going back to neurobiology 101, receptors are kind of like lock and key sort of things. Well, stimulation of the postsynaptic receptors mean we're stimulating, we're activating more of these locks. Boosperone, lithium, and opioid-based pain medications can all stimulate postsynaptic receptors. They've actually kind of a little side note here. Started looking at the use of opioids for people with major depressive disorder that are not responding to your common SSRIs. So we know from some of those studies that serotonin is stimulated and involved when opiates are used. So that's a whole different presentation and discussion on using opiates for depression. But being aware that some people will, maybe they go to the doctor, they're on SSRIs and they go to the doctor and they have a root canal. Well, when my son had his root canal, or not root canal, but has wisdom teeth out two months ago, the doctor gave him like 30 percocets. You know, thankfully he used half of one, but someone who was on SSRIs taking pain medication after an outpatient or a minor surgery may not realize that the two of them could be additive and cause serotonin syndrome. Which is why, again, it's important to inform the physician who is doing the outpatient surgery. Some of those physicians, dentists, whatever title they have may also not be overly educated on serotonin syndrome and how opiates interact with SSRIs. Hopefully they are by now, but it's something to consider. As clinicians, we're going to have clients coming in and telling us that they're getting ready to go in, possibly getting ready to go in to have their wisdom teeth out and they're stressed about it or something. If we know that they're on SSRIs, we can tell them ahead of time to make sure that they inform their oral surgeon about the fact that they're on antidepressants and inform them about the interaction between antidepressants and opiates. Is it a problem for everybody? No. Can it be a problem? Yes. So it's good to just be aware. We use serotonin reuptake inhibitors in a lot of different ways. We have our SSRIs, our Paxil, our Prozac, our Zoloft, typically the ones that we think of. So people can be taking those. Ultram, which is actually a pain medication, also stimulates the mu receptor, which is one of your opiate receptors, which is why not only does it inhibit the uptake of serotonin, it also binds with your pain receptors. So is it typically used as an antidepressant? No, it's typically used as a pain medication, but we do know that it prevents the reuptake of serotonin. So if somebody's already taking an SSRI and they take Ultram, basically they're kind of doubling up on their SSRIs. Trasadone is a serotonin agonist and reuptake inhibitor, so it increases the serotonin and it prevents its reuptake, so it keeps more of it available. Typically you wouldn't see trasadone prescribed with an SSRI, but you know, every once in a while you do. Your tricyclic antidepressants like elevil, trophanil, and pamelor, probably not going to see those with SSRIs, but you may see those with opiates or something else. And we're going to talk about some over-the-counter medications. The reason I'm going through these is, I know for me, I get familiar with the medications that the docs around where I'm at prescribe. And generally, like when I worked in community mental health, our psychiatrist prescribed pretty much the same thing, you know, pretty much the same 5 or 10 drugs. So I was really familiar with them. And then when we have somebody come in who wasn't already in our system, so to speak, they may or may not have a unique medication that I'd have to look up. But I became familiar with some of the ones and I would recognize the names and go, okay, that's an antidepressant or that's an anti-anxiety medication or whatever. Being aware of that, knowing just the general category can help you identify when you're taking their assessment history or when you're doing just counseling sessions and they start talking about new medications they're on or procedures they're going to have. You'll be more aware and more able to educate them about what serotonin syndrome is and what to be on the lookout for. Some people, and you know, I don't do it as a matter of course, I don't want to scare my patients, but some clinicians have taken it upon themselves when they know that a client is taking an SSRI. They give them handouts or point them in the direction of education about serotonin syndrome. So they're more aware of any potential drug interactions and they can better protect themselves. I'm hoping the psychiatrist, the doctor, the pharmacist has already done this. Obviously we all get that list, that huge 16 page microtype font of all the different side effects you could have and warnings when you pick up medication at the pharmacy. Honestly, I don't think anybody reads it. So it is incumbent upon us potentially to inform our clients about potential side effects and things they need to be aware of. Another one we want to look at is your smoking cessation medication. Well butren and Zyban, for example, are used to help people with smoking cessation. If they are taking that and they start taking some of these other drugs that increase serotonin, they could be setting themselves up for problems. Other drugs that act to raise serotonin, LSD, ecstasy, cocaine and fetamines. If you work in a mental health clinic, you may not ever hear about these from your clients. If you work in substance abuse or co-occurring disorders, you may. If you're working in mental health and you're working with younger clients who may still go to raves or whatever they're called now, they may also talk to you about how they did some X or experimented with LSD. So it's important, again, to be aware that that will raise serotonin so we can help them understand. It's probably kind of risky. I had a client one time, and this doesn't really relate to serotonin, but to give you an idea of how some of our clients think, he was on anti-psychotic medications, had schizophrenia, and he was abusing cocaine. And I said to him, you know, John, I'm really worried about you. If you're taking your medication and you're also using cocaine, that could be really dangerous. He said, oh, don't worry, Dr. Snipes. I made sure not to take my medication for two days before I started using the cocaine. Okay, I appreciate his will to live and I appreciate his concern and understanding of the potential drug interactions, which led us to another conversation about medication compliance and, you know, et cetera. But just talking to our clients and making sure when we do our session by session mental status exam and we do our kind of check-ins, how's your medication going, anything new, that we listen for some of these sorts of things. Herbal supplements people may take, they're touted on the internet. They're touted on Facebook. They're touted on, you know, some of the popular health magazines like Prevention or Self. You'll find articles occasionally that are touting certain herbs like St. John's wort, ginseng, nutmeg, or 5-HTP. All of these raise serotonin levels and some do it really dramatically and really quickly like 5-HTP. So, not only can a client overdose or create serotonin syndrome just from taking any of these independently in an amount that's too much for their brain to handle, but if they're taking it in combination with other things, it can also cause a problem. Over-the-counter cough and cold medicines containing dextromethorphan, Delsham or Musinex DM. Delsham is one we use. It's one of those long-acting cough syrups, which is really nice if you want to give, help your kid not cough all night long or yourself for that matter when they've got a cold. However, the trend recently has been for some people to abuse dextromethorphan, especially using rectal suppositories. Doing that gives them the high, gives them the feeling that they're looking for, but it can also increase serotonin levels in the brain to just dangerously high levels. So, you can get it over-the-counter. You can go to Walmart and you can actually get something or wherever and get something over-the-counter that can cause serotonin syndrome. Anti-nausea medications such as Reglan and Zofran can impact you. So think about this.  You're going on vacation and you're somebody who's already on SSRIs or maybe you're taking St. John's Ward or 5-HTP for anxiety or depression. And, you know, you're feeling pretty good.  Well, that could be a problem. Having those on could increase the serotonin levels high enough to be dangerous. Xivox, which is an antibiotic. I mean, we're not even talking about mood-altering drugs right now. We're talking about an antibiotic has been linked to increasing serotonin levels. And Norver, which is an antiretroviral medication, can do that. So if you've got a client who has HIV or AIDS and is taking an antiretroviral program, it's important for them to understand that that raises serotonin. So if they also happen to be on SSRIs or if they get a cold and start taking dextrum with orphan to suppress their cough, they need to be aware of what the symptoms of serotonin syndrome are. So what are those symptoms? I keep talking about them, but we haven't talked about them. C stands for cognitive changes, including agitation, confusion, euphoria. Think about increasing those serotonin levels in somebody's brain, insomnia, hypomania, and hallucinations. Now, I also want you to think while I'm going through these things, these symptoms, if you had a patient and you didn't know anything about them, and they presented with some of these symptoms, what else might you suspect is going on? Because a lot of times our mind doesn't immediately go to serotonin syndrome. It goes to, or at least mine does, it goes to intoxication or psychotic episode or something else. So we want to pay attention to what these symptoms are and be aware what our clients are taking. It's not up to us to diagnose unless you happen to be a medical doctor. It's not up to us to diagnose serotonin syndrome, but if we suspect that that might be going on since it can be life-threatening, it is up to us to advocate for our client and ensure they get to a place where they can get the care and differential diagnosis that they need. So the agitation, hypomania, hallucinations, cognitive changes, difficulty thinking, then you have A, which stands for autonomic changes, including tachycardia, fast heartbeat, fever, and this can be one of the most life-threatening symptoms of serotonin syndrome. Arhythmia's irregular heart rate, so it may not be too, it may not always be really, really high, sweating and dilated pupils. Now, again, when those pupils start to dilate, people start thinking more in terms of intoxication often, not serotonin syndrome. Could you argue that it's a form of intoxication? Well, yeah, but this is probably one that they didn't bargain for. N stands for neuromuscular changes, including tremor, rigidity, incoordination, and seizures. Obviously, if our patients are having a seizure, we're going to be calling 911, but if we notice that somebody's uncoordinated, they may have a tremor, do we want to assume that they are intoxicated? No. We want to do our best to try to figure out what's going on and not just go, well, come back to group when you're sober. That doesn't work. So can. Cognitive, autonomic, and neuromuscular changes. These are the things that we need to be on the lookout for and help our clients understand. Other symptoms, confusion, agitation or restlessness, dilated pupils. We already talked about headache is another one that can be present and that goes along with some of the other changes that our clients may be experiencing. So if a client starts taking a new medication, an SSRI, or they start taking some herbs or something like that and they start getting a wicked headache. This could be a sign that serotonin levels are getting too high. It could also be a sign of 100 other things, but it's not something that we want to summarily dismiss. When I had surgery about two years ago, and I am a real lightweight when it comes to pain medications. I take like a quarter dose of what you can take. And I'm feeling good. I'm basically non functional at that point. So I don't need a whole lot and they were giving me the regular adult dose when I was in the hospital. And I couldn't think straight. I could barely see my head was killing me. And I didn't really realize what was going on until I started looking at this presentation going, you know what? I think I probably had too much medication in my system. Changes in blood pressure or temperature. If somebody is feeling hypertensive, they're probably going to get a headache with it. High fever, like I said, is a dangerous sign. If they feel nauseous or vomiting, we don't want to just wait till they're puking. If they're starting to feel nauseous, remember those serotonin receptors, one of them is responsible for nausea. This could be an early sign. We don't want to wait until it's life threatening before we go. Hmm, might be a problem. Diarrhea, rapid heart rate, tremor, loss of muscle coordination or twist, twitching muscles, shivering and goosebumps. If you've worked in substance abuse treatment, you may be familiar with people who pick at their skin or itch a little bit, which can be kind of mistaken for shivering and goose flesh, noting it. Could they have the flu? Certainly. Could they have something more troublesome? Possibly. So we're going to talk in a minute about how to kind of differentiate when does somebody need to be referred to the ER. In severe cases of serotonin syndrome, it can be life threatening. So if your client is experiencing high fever, seizures, irregular heartbeat or unconsciousness, go figure, you need to immediately call 911 and get them to the hospital. Now, if they're experiencing a few of the other symptoms and you start talking with them and you find out that they've either, well, that's on the next slide, they've either recently started taking or increased the dose of a medication known to increase serotonin levels, take more than one drug known to increase serotonin levels, take herbal supplements that increase serotonin, or use an illicit drug known to increase serotonin, which is one of the reasons I really encourage mental health counselors in addition to substance abuse counselors to be open to talking with their patients about illicit drugs they may be taking in as non-judgmental of a way as possible. If somebody is using cocaine, okay, I would rather have them tell me that so I know and I can help advocate for them and help them get information they need to protect themselves than them to hold back because they're fearful that I am going to report them to the Department of Children and Families, or I'm going to send them immediately to residential substance abuse treatment. So I try to keep it as open as possible in my sessions. That's how I handle it, but I've been working with co-occurring disorders most of my career. If you want people to be able to tell us has something changed in terms of anything that they're taking, and it's helpful. If you have a checklist that you can go through with them that goes through, let's see, back to these medications, illicit drugs, herbal supplements, counter cough and cold medicines, anti-nausea, and then the antibiotic and antiretroviral in addition to the opiate pain medications, because they may not be thinking about these things and they may not realize that certain medications they're taking are increasing serotonin. Most people only think about antidepressants as affecting serotonin and some of those herbs that are touted as antidepressant alternatives. But there are so many more things that will do this. So from a clinical perspective, it's important for us to help clients understand that serotonin syndrome can appear after just one dose. So ecstasy or if they're taking any of the amphetamines, if they're taking diet pills in addition, are anorectics, even over-the-counter anorectics that have stimulants in them. And one thing I didn't mention, if you work with people who happen to be into working out and they take a lot of supplements, especially pre-workout supplements, pre-workout supplements are notoriously loaded with high levels of caffeine, guarana, and a bunch of other things that are stimulants, which are going to act as an amphetamine, possibly increasing serotonin, causing tachycardia and some other things. But if you combine that with some of those other drugs that we've been talking about, they could harm themselves. The reason I keep bringing this up is this is not just a substance abuse issue. This is anybody who takes anything that messes around with serotonin from cough and cold to anti-nausea medications. Think about for yourself. Even if you don't take antidepressants, think about for yourself if you've ever taken any of the drugs that we talked about. Go back to them. Herbal supplements. I think all of us have taken cough and cold medicines at one time or another. Anti-nausea medications. So maybe you took those at the same time because you were on vacation. Pain killers. People often take pain killers in combination with a lot of other things. If you've got a client who has chronic pain, you may be seeing them for depression related to their chronic pain or disability that is caused by their chronic pain. So they may be taking opiate-based medications in addition to antidepressants or they may not want to see a psychiatrist for antidepressants, so they may be trying to treat that on their own, which can be dangerous. 60% of patients present within one to six hours after the initial administration of the drug or combination of drugs that are causing serotonin syndrome. So if they take something, 60% of patients are going to have a clinically significant response within one to six hours and they're going to go to the emergency room. The scary part is 40% of them won't. And they wait and they continue taking that combination and continue to raise the levels of serotonin in their brain. Which is why it's important in terms of from an advocacy standpoint for us to help them advocate for themselves and not be turned away until it's a life-threatening crisis where they can go to their doctor, where they can go to the walk-in clinic and go, hey, I just started taking this stuff. I'm feeling really lousy. Yes, it's not life-threatening yet, but there's a potential, something's a little bit hinky here, and I need a physician to help me out. I've heard on many, many, many occasions, unfortunately, of people being turned away because they present with kind of flu-like symptoms, nothing that presents as extremely life-threatening. So they're turned away and they continue to take that combination of medications because their prescribing physician can't get them in for three more weeks. So they continue to take that to be med compliant and they end up exacerbating their condition until they get to the point where they're presenting again in the emergency room, but this time with a life-threatening problem. And it's not, that's just not good on so many levels, not only for the patient because that freaks them out and they may not want to take any medications. But it's also, you know, not good for us from a liability standpoint and not good for the community because if a patient presents, they say there's a problem and we go, oh, no, there's not. Bye-bye. And then it ends up turning into a problem and they're like, see, I told you so. They feel less confidence in us, and I use us in terms of the medical community at large, not us necessarily as counselors. But they feel less confident in the people who are supposed to be in the know. One thing you might try doing if you have ever encountered this or if, you know, you're here in some of this and you're going, you know what, I think I want to be prepared for that. There are links in your classroom that will take you to different sites on serotonin syndrome, Mayo Clinic, some of the real common layperson sites where you can print out the symptoms of what's going on. You can also add to that a checklist of the different medications the person's taking and the different subgroups so they can take it if they go to the walk-in clinic and go, these are the medications I'm on. And when I started taking those, these are the symptoms that started, which seems to be related to serotonin syndrome, so I need your medical opinion. That gives them a little bit more information in case the doctor they're seeing is not, has not had their training on serotonin syndrome, or in case their doctor they're seeing has not been, is not one to look at preclinical or prediagnostic levels. So many of our clients are on medications for depression, anxiety, pain, migraines, smoking cessation. Some of our clients may be on medications for every single one of these, which just, you know, scares me half to death. So it's important in my mind to educate clients as much as possible, and we don't have to necessarily do a group on it. You don't even have to take precious time during your assessment. I know, and I don't mean that sarcastically, I worked in community mental health where we had 78 pages that needed to be completed in an hour and a half, and that was just the way it was. And we had back to back intake so we couldn't spend a lot of time doing psycho ed. You can have it in a handout in your lobby. It's amazing how much clients will read if it's in handouts in your lobby while they're waiting to come in for their appointments, because they're bored. I mean they can flip through magazines, or they can start reading some informational pamphlets. So that's one thing that you can do is put this information out there. You can provide information to if you want to go deep into advocacy. You can provide informational handouts to the pharmacists that are in your community so they can potentially educate clients as they come in. Not all pharmacists are going to be open to it, but some will appreciate having the heads up or the ability to have something to educate clients. Some will require that you take all of your branding off of it and just have it be a generic handout. That's fine. So talk with them about what they're willing to hand out if you're doing it as a as an advocacy activity and not as a promotional activity. It's important for clinicians to inform clients about the risks of serotonin syndrome. Well, I think I covered that we as clinicians should be able to identify the can criteria. Cognitive autonomic and neurological for serotonin syndrome and refer to a physician immediately if it seems like the persons may have started taking a combination or they just recently started taking an SSRI or an herb like 5-HTP or St. John's wort and they're starting to have some of these symptoms. We don't want it to build up in their system. So we should make that referral now. Probably if unless they have the life threatening criteria, probably not worth calling 911 and having an ambulance come get them. But document in your clinical notes any symptoms that they presented with if you have suspicions make a note that you made the referral to what doctor and then in the next session or even call the next day depending on how concerned you are. Follow up and document that in your notes as well that way you can show that you were doing due diligence to help the client protect themselves against some of the side effects of serotonin syndrome. Another one we didn't talk about in here is alcohol. Alcohol does affect serotonin levels and if you have there are a lot of clients out there. Who are on serotonin reuptake inhibitors or serotonin and norepinephrine reuptake inhibitors so our antidepressants. We'll just kind of lump them all together. Who are also drinking alcohol or they're taking pain medication and drinking alcohol, which usually are warned about but they do it anyway. Alcohol, since it increases serotonin levels can also trigger a serotonin, serotonin crisis, if you will. Educating clients if they're telling you that you know they're on some antidepressant and they're telling you they're drinking a couple drinks before they go to bed at night, not, you know, or drinking excessively but if they're drinking anything. We do want to point out how dangerous that can be. They're going to make their own decisions, especially if they're in outpatient. They're going to be making their own decisions about whether they continue to drink or not. But we can identify that they said that and identify that we notified them of the problems. Now potentially depending on what your attorney says, what your policy is, you may also need to tell their prescribing physician. When I worked in community mental health, we were all part of the same group. The psychiatrist, you know, it was a comprehensive treatment center. So the psychiatrist would read in my notes that they had this going on, or if somebody told me that they were taking drinking alcohol while they were on taking SSRIs, I would let them know that they need to tell their psychiatrist and I would also let them know. I think it's important that you get an appointment now and I'm going to have to put this in the notes. Just so they're aware that the psychiatrist knows and the psychiatrist is aware because a lot of times the psychiatrist, they're not going to tell the psychiatrist. Oh yeah. By the way, you told me not to drink but I've been drinking anyway. A lot of that comes down to agency policy and what and who you have assigned release for. And then looking at your own ethics of whether that is do no harm. If you go and tell the psychiatrist or you tell the doctor who's prescribing the antidepressant or opiate meds that the person is taking other stuff and not letting them know. Does that protect the patient? Yes. Does that corrupt your relationship with the patient? Possibly. So it's one of those tricky ethical things that you're going to need to take a look at. Definitely run it up the flagpole with your attorneys, with your supervisor to see what the thought is at that point in time. Part of it's also going to depend probably on the degree to which the clients are using additional substances and or willing to talk to the prescribing physician about what they're doing. Even if a patient isn't on an antidepressant, he or she may be at risk for serotonin syndrome by combining over the counter medications like cold medications and illicit drugs or combining multiple different cold medications and weight loss medications. The abuse of DXM or dextromethorphan is becoming increasingly popular among youth, which can put them at risk of serotonin syndrome. Remember, it only takes one time. It doesn't have to be a buildup effect. Some patients also fail to tell their doctors about herbs, illicit drugs or drugs prescribed by their providers they are taking, which again puts them at increased risk. Alcohol does increase serotonin, so someone who's on the brink of serotonin syndrome, you know, they've already got a pretty high level. They're functioning. They're not having, they're not symptomatic, but then they drink alcohol. It may be too much for their system to handle so it can precipitate a serotonin crisis. References. There's a bunch of stuff. If you really want to get down into the weeds about serotonin syndrome and how it happens and what it looks like, you can go and read all of these. I did put the one in here about how they're using opiates with in looking at treating intractable major depressive disorder because it is really informative article, scary, in my opinion, but informative. So you may want to take a look at that because you may see that in some of your patients who have persistent major depressive or recurrent major depression. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allceus.com slash counselor toolbox. This episode has been brought to you in part by allceus.com providing 24 seven multimedia continuing education and pre certification training to counselors, therapists and nurses since 2006.


Happy birthday to you. Happy birthday to you. Happy birthday dear Joseph. Happy birthday to you. What is it? Happy birthday Joseph. What do we have? Joseph look at the uh just look at all the uh decorations. What is it? Look at the chain. All right we are not like a huge cereal family but Aunt Mackenzie and Uncle Joseph know how to know how to make cereal. They know how to pull out all the stops for the birthday boys so they sent us cereal that was a package that arrived yesterday that I thought was possibly for me. But it was for Joseph James on his birthday cereal day so we're doing fun cereal on this fun day. Okay you ready for tricks? They bought me. I'm not sure if that was a good uh present to get. He was crying his eyes out. He's way braver this time. He's so brave. Oh In two three happy birthday happy birthday to see you tomorrow. See you tomorrow.


All right, we're gonna have a little episode of outside the box quick because something happened here with a Certain person from Xbox and an IGN reviewer that I just want to briefly touch on So super's lucky super lucky stale Came out recently on Xbox and some people have given it decent reviews others have not a Certain person from IGN was one of those people that didn't In fact that person's name is Ryan McCaffrey He did not give it a favorable review It was you gave it a pretty poor review and said that it's a pass basically that people probably shouldn't waste their money on the game This person Responded to a tweet. I mean, here's the full context So this guy named Mark Yabera put up a tweet from Eurogamer showing off a Lucky's Tale review And this other guy responded so while really according to Ryan the guy from IGN the game is bad I'll give it a whirl opinions and all Robert Garcia Responded by saying IGN reviews are the worst the game is currently rated a 4.7 out of 5 on the Xbox store If you let reviews influence your gaming at least go with her views written by actual gamers Not paid so-called journalist and Ryan himself Ryan McCaffrey the guy who wrote the IGN review fire back by saying this Actual gamers on the Xbox store don't even have to play the game to leave a review and I know about that That's actually a flaw in the Xbox store pretty much anybody can review the game And then he goes on to say actual critics and journalists don't quite think so highly of the game And then he links the Xbox one medic critic score for it, which is not very good But see none of this matters right that's all that in that self is fine.  Ryan McCaffrey and said this Ryan. I appreciate your review I thought you made some good points. You don't need to actively discourage people from playing the game though and Here in lies the issue that we're gonna talk about here on outside the box is here is a person high up at Microsoft telling a game critic that they don't need to actively discourage people from playing the game Essentially what he's saying is the review is good But you shouldn't tell people not to buy the game in the review Which kind of defeats the purpose of a review right in many cases a review is trying to determine if other people should spend money on that game and If Ryan McCaffrey, which he did conclude that the game isn't very good and people probably shouldn't buy the game um It's very interesting to have someone high up at Microsoft tell Ryan that he shouldn't do that now Obviously they're not taking review copies away from IGN. They're not forcing IGN to change the score of the game And I know there's been a lot of thought out there that all companies pay IGN and other other places to give higher review scores And blah blah which clearly isn't the case especially when you see here That someone from Microsoft is a little upset that Ryan is telling people not to buy the game But it's just an interesting conversation around What's the purpose of reviews and should people high up at companies like Microsoft be telling reviewers How to review games basically saying you can have all these criticisms, but you shouldn't conclude by telling people not to buy a game It makes me wonder what is Microsoft in this case or this person that Microsoft actually think the purpose of reviews are Because it's not just feedback and criticism. That's for the developers in the feedback and criticism About the game is to inform potential consumers and if the information present makes Ryan want to suggest that people shouldn't buy the game That's totally fine. Now to be fair Shannon does later tweet Also folks, you know because there's obviously defense force come out for Microsoft and Shannon Shannon did tweet later saying also folks, please lay off Ryan He works incredibly hard and does great things for gaming and gamers because obviously she wasn't ill intent here She wasn't intending to make you know, Microsoft fanboys go after Ryan for his review of the game and the thing is they're gonna go up to Ryan they have to go after several more outlets because The Metacritic score is not good. So I Throw this at you guys What role do video game publishers in this case, I think Microsoft publishes game Have in telling reviewers how to review games Obviously the big thing here is that the publishers control who gets review copies of games, right? So they can literally tell IGN sorry no more review copies of Microsoft Xbox games that are exclusive Of course, they're not going to do that Because there would be major backlash From the gaming community, but it's still interesting to see someone in this high-up position at Microsoft being like hey man Don't tell people not to buy our game. Even though you just got done complimenting the review I mean literally says Ryan. I appreciate your review. I thought you made some good points You don't need to actively discourage people from playing the game though It's it's not just actively discouraging people from playing the game He's actively discouraging people from buying the game saying their money is basically spent elsewhere So I don't know. It's just a weird situation Thankfully Nintendo doesn't find themselves mixed up in situations like this very often, but it's not the first time I've heard of this I've seen other publishers sometimes even developers trying to tell reviewers what they can and can't say In regards to whether or not people should buy games I've seen NDAs and review embargoes So you're not allowed to give this game a score And this also gets the point where like some you know publishers will actively avoid giving copies of games to Reviewers that they know are not going to put you know Review their game well because they want to bump their medic credit score. In fact, we found out again It's so silly. This is still part of the industry But that certain publishers out there are still giving incentives and bonuses based on medic critic scores Which to me just seems absolutely ridiculous, especially since medic critic scores are completely weighted to favor specific outlets That doesn't necessarily mean it's a bad thing. It's just not something that you should really base Like oh, let's put it this way Let's say you release a game that gets a 70 a medic critic would sell 5 million copies You don't get a bonus on those 5 million copies sold because your medic credit rating didn't hit 85 or something That's why it's ridiculous. It should just be BS and sales like if the game sells so many units Hey, you should get a bonus for having a game exceed expectations for sales Or exceed expectations even for revenue if they want to base it on a revenue model Hey, how much money do we want to make from this game if we make more than that? We should get a payout I think that feels a lot more fair than basing things bonuses on medic critic You know, you guys let me know what you think about all of this in the comments below because I personally stand by The stance that I don't think publishers or game devs or anything should be telling reviewers One how to review their games and two what they're allowed to say about the games in terms of their opinions on it and Three they definitely should not be telling them that it's not okay to tell people not to buy the game because That's the whole purpose of reviews to consumers to inform them with information and opinions If they think the game is worth spending money on anyways folks That's why take on it. You let me know your hot take down in the comments below I am Nathan Ruffa gents from Nintendo Prime and if you liked this video You know what to do and if you dislike the video that is alright as well dislike that video Subscribe for more content and you know what folks I will catch you in the next one


Smoky's a woman that lives here in my neighborhood. Nobody seemed to care that she was like sleeping in the dirt. So I just jumped in the car and ran to Home Depot and started buying wood. When I gave her the house, it was very emotional for both of us. I mean, even though it was really tiny, it's just having that four walls and a door that she could lock just meant the world to her. She couldn't remember the last time she slept so good. Nobody should be homeless, especially in one of the richest countries in the world. The housing first model works. Give people a safe place to be, you know, of their own, and they're then self-motivated to better their lives. The way we build tiny houses is kind of magic. Craft it, you know, looking like a real house. Not only makes the structure very sturdy, but it feels like something, it feels like home. So I was able to go in there and be able to close the door and feel secure as opposed to being out here in the streets with no sense of security. I've been raped three times, living in a tent. Some of these gangbangers know that veterans get automatic deposits every month, and they've been rolling these guys every month for their pensions, you know, or their benefits. And like, when you leave, people go to your tents to go through your stuff. It's just so hard out here, you know, to keep a level head because there's no resources, there's nothing. You're stuck here. And day after day, it gets really, really tiring. So I started replacing tents that were the overpass bridges of freeways. It worked, and it stirred up the city where, like, I mean, not only did they not want to listen to any plan, they just wanted to shut me down. That's really just when the controversy really started. The councilman in that district gave the order to come and take a few of them. He sent the cops down to pull people out of the tiny houses we had built for them. I mean, they threw them up against the wall, told them they were all getting arrested and their houses impounded. We had to remove the houses and tuck them away in someone's backyard. That day that I had to go and take people's houses back from them was probably one of the worst days of my life.  It doesn't make much sense. We're homeless. You're the chaps. You know, we don't like to live in the streets. Nobody does. The city having 7,500-plus vacant lots, they could designate some lots or buildings that they could let people camp in. You know, it's like, you know, come safely be here until we figure the rest out. I will always just, you know, keep going, keep pushing out there and keep trying to reach as many people as I can to get involved and help me do this. And behind me here is the first mobile shower that I've been working on. People need a shower, and there's no place for people out on the street to get a shower. All of this is going to be under $2,000. It doesn't have to be expensive.  If I'm not, you see, I should not be deprived of the same. Just so simple, food, water, and shelter, you know, they're not optional for human survival. And it's just the right thing to do. If somebody falls down, you pick them up. And that's what you do. That's what you're supposed to do.


The offense absolutely exploded there in that fifth inning. How are you guys able to get to Thornton? Just keep grinding them out, having good at bats and hitting his mistakes. I mean, we did a great job just pushing the envelope and getting it done. Can you describe the feeling in that dugout, in that inning as you're batting around continuing to put up runs? Yeah, I almost missed my second one, actually.  So we're having fun and working hard, and it's most important.  Just how invaluable has his left-handed bat been to this lineup? Unreal, unreal. He's come up huge for us all year, and I did it again tonight and last night. And we got in late, so it was a big win for us. Quietly, Jordan Montgomery is having himself a very nice year so far. What stood out to you about the way he has been throwing the ball consistently? Man, he's fearless. He's just, he pounds his own. He keeps guys off balance and just a tough at bat the whole time. You sweep the raise. Now you come in here after that late night, like you mentioned, getting in and handle business against the Jays tonight in game one. Just what type of statement do you think you're making against the AL East right now? That's big. It's big. All these are huge, especially one like today where that long travel for us and to smack them first was good, so we need two more.


The new model work health and safety laws provide the basis for consistent rules and approaches to workplace health and safety across the country. The new rules focus on the work being undertaken. The worker and the business, that is, the persons conducting a business or undertaking or PCBU, both the worker and the PCBU have responsibilities and must work together to minimise any risks. And there's lots more. How do we meet these requirements for our TRIPES artists, especially if they're performing in different locations and how am I meant to be responsible for what these guys do? Anyone that undertakes any work is your responsibility. This means you must be clear in giving instructions, clear about what work is being undertaken, who is to do it and under what conditions. You're not expected to have the knowledge or expertise of the performer, but you should note anything that might be a risk to safety. Work through with your people. Work through what responsibility you each have. I've always been serious about consulting on safety. Isn't that enough? You're already talking about safety every day. That's great. But in the future, you should also keep a brief record of the talk. You should document what's been discussed, even if it's just a summary. This is just one of my businesses. What are my responsibilities? What are my obligations? You do need to develop a clear understanding of WHS in your workplace. You can't delegate these responsibilities, but your manager and operator have responsibilities too. You must be proactive and you must set up processes and systems to ensure the business and your people do what they should. Most are responsible for guys when they test-drive a car on the road. Under the new laws, you are responsible anywhere that work is undertaken, so even down the road is your workplace. But what if I asked him to wear a seatbelt and he doesn't? The new legislation is clear on this, and the worker must take responsibility too. He or she must wear the seatbelt, or whatever protective equipment is provided for their safety. I already have an induction process for my new workers. I'm told I have to have something extra for young marine experience workers. Is that right? My site supervisors all look after four or five sites. Who is the PCBU when only contractors are on site at any one time? The circus is all about risk. That's the point. So how can I manage this? I've heard I have to involve my supplies in the WHS process. Does that mean I have to supervise when they're unloading? There are so many questions about workplace health and safety in Australia and they are great questions to ask. But what's even more important is finding solutions to those questions. That's the task of all of us. I'm a cyclist in my spare time. I ride push bikes on roads. I know there are risks and I know there are road rules. The same in the workplace. There are rules and there are common sense solutions. Go to the Services of the Australian Chamber of Commerce and Industry, the Chambers of Commerce of Australia and also the Industry Associations of Australia and you'll be able to find some of those solutions. The services on our website will direct you not just to understanding the rules but will give you some common sense solutions. So act now, act safely, do the right thing by workplace health and safety in your business and become a leader.