Gastrointestinal Disease in Pregnancy

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Physiology – ‘A state of Loose tubes and high roids’

The foregut and small bowel speeds up transit of food contents. However, the large bowel slows down and this can lead to constipation, as can pressure of the baby on the rectosigmoid. They have very high levels of circulating steroid hormone.

Constipation

Increasing the fluid intake will often help. High fibre diet. Stop iron supplements and give reassurance.

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Gastro Oesophageal Reflux Disease

Reflux becomes more common. Using salts, alginates, metoclopramide, sucralfate, H2 receptor antagonists and PPI’s can help.

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Peptic Ulcer Disease

This is relatively uncommon. Do not give misoprostol (Arthotec has misoprostol in it). Treatment is PPI / endoscopy in the context of bleeding

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IBS

Do not investigate long-standing IBS, only proctoscopy if needed.

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Try to minimise medication use unless absolutely necessary.

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Abdominal Pain (unexplained – non-obstetric)

Can be appendicicits, pancreatitis, pyelonephritis, cholecystitis, pneumonia, renal colic, iliac vein thrombosis, Budd-Chiari and almost any cause. If you need to do a test then you should do it. However, at 8-15 weeks of gestation the risk of damaging a childs mental development with radiation is higher (>50mGy’s). This is about equivalent to two pelvic CT scans.

Liver Disease

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Acute Liver Failure

Acute viral hepatitis and acute liver failure in pregnancy is still relatively uncommon in pregnant mothers. However, chronic hepatitis (normally hep B and C) need to be managed by specialists. Particularly as there is a risk of vertical transmission.

Acute hepatitis E however, is becoming a lot more common and comes with a 20% risk of acute fulminant liver failure in pregnancy.

Drugs

In general all pre-existing medication should be continued during pregnancy unless it is explicitly teratogenic as good chronic disease control is the most associated with good outcomes. Teratogenic medications should be changed to non-teratogenic ones in general. Beta-blockers can be used from the second trimester onwards in portal hypertension.

Inflammatory Bowel Disease

This has affects on fertility and pregnancy outcomes plus delivery options.

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If you have UC – the disease is likely to reflect the pre-pregnant state (ie. if the UC was well controlled pre-pregnancy then it will tend to remain that way throughout).

Most exacerbations of inactive Crohn’s disease will occur during the first trimester. The vast majority of crohn’s patients will improve when pregnant. Fertility is more likely to be affected in crohn’s as it is strongly associated with prior surgery and the tubes may be involved.

Active disease at the time of conception is associated with an increased risk of miscarriage.

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Acute flares should be treated aggressively and quickly. Medical treatment should be continued in general except for: Methotrexate, Thalidomide and 6-Thioguanine (no data) which are contraindicated [this is even the case for the partner]. Infliximab, Adalimumab, certolizumab, cyclosporin, tacrolimus, budesonide, metronidazole and ciprofloxacin are all probably safe in pregnancy. 5-ASA’s, sulfasalazine, azathioprine, corticosteroids and 6-mercaptopurine are all thought to be safe as long as folic acid supplementation is given.

When using biologic therapy there is some evidence that (infliximab/adalimumab) should be stopped after 30 weeks (third trimester) if possible. This is because of concerns Re: inducing immunosuppression in the infant.

Optimising maternal nutrition is also a major priority. Surgery should only be performed if absolutely necessary.

Previous ileostomy, colostomy is not a contraindication to normal full-term vaginal delivery.

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However, c-section is indicated if the patient has severe peri-anal Crohn’s disease and some pouches (must be discussed with surgeons).

Obscure Gastrointestinal (GI) Bleeding

Can be either overt or obscure. Accounts for up to 5% of GI bleeding (the vast majority can be found either on gastroscopy or colonoscopy.

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This bleeding jet from a duelafoy is obvious, but sometimes the causes of GI bleeding can be hard to spot at endoscopy.

These are some of the more difficult causes to spot. Once these have been excluded in the foregut and colon one needs to start thinking about the small bowel.

Causes here can include:

  • Heyde’s Syndrome (Aortic Valvular Issues -> damaged vWF and vessel abnormalities)
  • Meckles Diverticulum
  • Small Bowel Angioectasia
  • Pancreatic Bleeding

Investigations might include:

  • CT Enteroclysis
  • Small Bowel Wireless Capsule
  • Red Cell Scan
  • CT Angiography
  • Baloon Enteroscopy
  • Push Enteroscopy

Capsule retention is an issue (but rare). This technology has revolutionised imaging of the small bowel.

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Enteroscopy can be done with either a longer scope or a single/double baloon, or spiral enteroscopy. It is hard work and best done under a general anaesthetic as the procedure can take a long time to complete.

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CT Enteroclysis

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Red cell scan tends to be reserved as a second/third line test as it is not as good as the other tests above.

CT Angiography

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If CT angiography fails then virtual capsule endoscopy should be performed within 10 to 14 days.

Following that the recommendation is device assisted enteroscopy. CT enterocylsis would probably be the second line option.

If the capsule is negative in the first instance normally one would try to manage the condition conservatively. If that failed then normally repeating the capsule endoscopy would be the next best option.

Sometimes bleeds cannot be treated endoscopically ie. ++ angioectasia throughout the small bowel. In these cases it is better to think about medical management with tranexamic acid/thalidomide etc.

The role of the Medical Director

 

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The medical director is the manager of the medical consultants. The speaker likened it to being a bit like Manchester United. The medical director is the manager and the players are the consultants.

The players need to be kept as happy (through good management), with good team-working and the best possible patient outcomes. There are 350 consultants in this hospital. This was the model that Salford adopted. Focus on valuing your consultant workforce and focus on safety.

Recruiting Consultants

In recruitment terms: IBM would probably spend days recruiting people over a several day interview. John Lewis has a much flatter structure. The Princes trust has a different structure. All the decisions are values based decisions in these above organisations.

The NHS is still often using older models based on short 1 hour interviews. This causes some problems when it comes to medical recruitment and allows some of these different characters into the consultant workforce. Some of the more eccentric types include:

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The difficult ones – professors etc. Lots of idiosyncrasies. Need a few but only a few.

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The throw the toys out of the pram type – poor insight. They will cause fights and distract department focus.

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The Mr Burns type – moneybags. They will drain resources.

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Saboteurs – few but very destructive. Even one of these can decimate your department or even your hospital.

It has to be emphasised that these groups do not represent the majority. The last 3 – no insight, Mr Burns and Saboteurs that they are trying to screen out. Some ‘professors’ are necessary but only a few.

The Medical Directors’ Roles

The Medical Director has to deal with Job Planning, Doctors in difficulty, SUI’s (serious incidents), SIRI’s (serious incident report investigation), Conflicts, Dysfunctional Departments, Consultant morale, Trust performance, Patient safety, Clinical performance.

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The Consultants

Everyone will look at the consultants to lead and make decisions. They are the leaders in the hospital.

They are the key decision makers. They may be perceived as difficult from the outside and sometimes from within but they have to think differently because they are key decision makers.

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The key question is where do you put them? They are a finite resource and you need to put them where they are most required.

The consultants need to be team players. They need to teach and manage. They need to know the business. They are the guardian of the quality agenda and outcomes. They forge partnerships between doctors and management. They have to be adaptable.

Previously there have been clinician lecturers, clinician scientists/researchers and clinician service providers. However, now the clinician manager is coming to the fore.

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The idea is that clinicians will be forming and developing their services. We shall see whether or not people engage with this.

At the end I asked the group how many would consider becoming a clinical manager as their primary role. At least a quarter put their hands up! Impressive. Perhaps there has been a significant scene change of late.

How to Become a Clinical Developer #doctorswhocode

Before I became a clinical developer I was a relatively technology-naive doctor for 6 years. Sure, I was interested in technology but I couldn’t write a single line of code and I certainly didn’t know what was possible through software, the internet and the coming age of medical technology. For me it all started out as it always does with trying to solve a problem. I was trying to solve the problem of delayed diagnosis for patients with IBS by building an algorithm. This then led to a chain reaction of other discoveries which thrust me down the path towards data science. (Interestingly whilst I did build an algorithm I became instantly dissatisfied with it and thus why I am now obsessed with machine learning.) This is my ‘why’ – I exist to make things better for patients and clinicians through technology and this is my compass by which I make decisions.

That was my situation. The key question you need to ask yourself is: What is my problem? This is the key to unlocking this journey from normal clinician to clinician developer. Now, at this point some people might say why not outsource the solution. This is a very valid point and for an easy problem – like building a landing page for a website for instance you may well want to do this. However, I think that logic is flawed in several ways:

  • Firstly, if you ‘outsource’ things you don’t know how they were built and therefore cannot change them. This means they are doomed to be ‘static’ and static things always atrophy over time – this is a fundamental law of all nature – ignore it at your peril.
  • Secondly, it deprives you of a chance to develop as a person. Developing software is just as much about developing problem solving skills, communication skills, product development skills, business insight and growth/time hacking as it is developing technical skills. If you don’t learn at the start you will pay for it later in other ways.
  • Thirdly, if you start simple and at the beginning, you will grow with your subsequent products. I didn’t start by writing an algorithm. I started by building a blog and experimenting with social media! Why did I do this? It was the best starting point I could think of at the time and it was a great springboard to then learning web developement, then power-use of tools, then coding and then data science! If I had started at the data science end I wouldn’t have gone anywhere.
  • Fourthly, it becomes really expensive. Many startups are bankrupted simply because development costs are so high. Combine this with the fact that most startups fail (because they fail to achieve product-market fit) and you have a recipe for waste. The first bit where you have lots of ideas it both the easiest bit to learn to do yourself and also the most likely to fail. Outsourcing this part of your strategy is likely to end in a costly learning experience rather than a cheap rewarding one.
  • Finally, a lot of things we do simply can’t be outsourced. Healthcare projects by their nature tend to involve confidential-data and the fewer hands involved in the process, plus the more ‘in-control’ you can be as the developer at the source the better you can ring fence your work. Plus there is a massive international shortage of data scientists, and I therefore simply couldn’t outsource what I was working on, and I still can’t. This is why we need clinical developers who have a deep understanding of the problems that only they can solve!

I hope I have convinced you that contrary to popular believe there are some major benefits to getting your hands dirty as a clinician. But now the key question. Where do you start?
This is a question that cannot be answered in a straightforward way. To find the answer you need to start at the end (where you think you want to end up) and work backwards:

  • If your ambition is to build a website to support patient’s with a specific condition, then start by becoming an expert in that condition, joining social media groups and micro-blogging (Tumblr, Twitter etc) – Then when you have a good understanding of what the problems are that they face, build a simple blog of your own on WordPress (I will explain how to do this in a later post, it is extremely simple and requires no coding skills at all). Then focus on building ‘traction’ (again I will explain more about this in future posts). By this point you will have by developed the skills to build a basic site and you can move on to doing more complex things on WordPress (The functionality in WordPress is immense and you can achieve an enormous result without writing a single line of code). Then you need to start learning some HTML, CSS, JS code to take things further (However, many will not want or need to and this is fine as well – you no longer need to code to be a frontend developer. The rules of the game have changed and what counts is results not how fast your page loads.)

  • If your aim is to produce the next killer medical application to make life better for other clinical staff then start by becoming a power user of other people’s applications, take an online course in app design and start simply by building a basic website – This is key (as I will explain in future articles the way to build a killer app is not to start with an app). Then gradually increase the complexity of the site and move towards performing simple backend-functions (Again I recommend WordPress as it means you can obtain results quickly on your own). Then start building a simple web-app (again in WordPress). I suggest you stick with WordPress when you are learning as it is beginner-friendly and you can ‘hack’ quickly (achieve fast results). At this point you need to be thinking about learning either python, ruby or PHP. I suggest you start with python as it is beginner friendly and very readable as well as very powerful. By this point you will have ‘unlocked’ the beginning of the path to becoming a backend developer and you will be well on your way to building the web-app you really desire.

  • If you ultimately want to solve a complex machine learning problem that is specific to your line of work I suggest you start by manipulating big-data in Excel. Then try using some more specialised software. Then learn the programming language Python as this will give you the right kind of mindset to move to the next stage – This will act as a launchpad (I suggest you ignore all other programming languages at the start or you will get confused.) Then do some online-courses (I will recommend which ones later). Then find a dataset that is important to you and start playing with Python packages etc. Go on a bootcamp and start applying what you have learned. One of the features of medical datasets is that they are normally confidential, so I strongly recommend you don’t put them on Kaggle or GitHub (online developer communities) but you can play with other data-sets using these communities.

I hope this makes sense. I plan to write everything in as simple a way as I can because the point of this site is to encourage other clinicians on this journey. If you think I am using language that is too technical please let me know and I will ‘develop’ it.Clinical Developers would like to thank the ‘Python Software Foundation’ for the use of their fantastic logo. We are proud supporters of Python.Originally published on www.clinicaldevelopers.org the network for clinicians who want to develop.

Types of Clinical Developer #Doctorswhocode

 

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There are lots of different kinds of clinical developer but they generally fall into 6 different broad disciplines as represented by the different colours of the octagon above. In a way the disciplines are somewhat artificial, as what really matters is getting results and not which broad category you fall into. For instance you cannot be a frontend developer and not be at least slightly interested in user experience design. However, they help to give others some idea of your background strengths when it comes to building a team.

Note: Not all of these roles even require much coding skill. Some developers can get by without coding at all! I will cover this in future posts.

Clinician Frontend Developer

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‘Frontend’ generally pertains to the parts of the website that you as the visitor can see. These developers focus on producing visible web presence. They range from those who rely entirely on pre-built products (this is a completely acceptable way to start and can actually get you quite far as I will show you) to those who code in HTML, CSS, Javascript, SQL and often other languages as well. If your main aim is to produce a tangible web-presence then this is the route you want to take at the start. 

Clinician Backend Developer

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‘Backend’ is all about the things you can’t see. This type of developer tends to deal with everything from servers and members-only areas on websites, to fully functional web-apps and sometimes whole online platforms. They tend to code in some of the higher-order languages like Python, PHP and Ruby. It is quite difficult to be a backend clinician developer without having at least some basic coding skills. However, there are all sorts of frameworks that make things much easier (I will explain about these as we go on). If you want to build web-algorithms or fully functional websites with members areas etc you will need to know at least some ‘backend’ skills.

Clinician IoS/Android App Developer

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These clinicians focus on phone apps. These require a whole different framework in order to build. I won’t go into it now but this whole area is changing extremely quickly and standalone phone-apps probably aren’t the best way to start-out if you are starting a business. However, once you have an established product there is definitely sometimes a place for building a ‘phone presence’. Some clinicians have built incredibly successful businesses using phone apps.

Clinician Data Scientist

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This is my personal area of interest. The clinician data scientist knows how to use computers to solve complex data issues and build algorithms. They generally code in Python or R and use algorithms to analyse data. Machine learning problems are solved by this group and I believe we are only just at the beginning of seeing the impact data scientists will have on our clinical lives. However, the problems specifically require detailed experience and understanding of the problem in order for them to be solved. This is where the clinician data scientist has a massive advantage.

Clinician UX Specialist

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UX stands for user-experience design. These clinicians focus on making things flow by reducing ‘friction’ and making things ‘human’ shaped. This can be achieved by relentless testing, market research, attention to detail and most importantly focussing on what would best solve their own problems. The clinician is well placed to be a UX expert as they have deep personal experience of the issues which beset those they care for and fellow clinicians. It requires a very open mindset and is not so much about the technical aspects, although many are very adept coders as well. If anything is going to work it needs good UX to be woven into it. 

Clinician Full-Stack Developer

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This is the full package. Fluent in many languages they can basically do everything above to a degree but possibly not to the depth of someone well versed in one discipline. If you need one person to test out ideas quickly this person is your best bet. They can also network very effectively with other developers and because they can iterate ‘build’ very quickly they are a real asset to any development team. In the future they will be common but at the moment they are rare.

To find out more visit : www.clinicaldevelopers.org   – signup to our mailing list for updates, tips and tricks.

Why Become a Clinical Developer?

A time is coming when technology and medicine will be synonymous. For the first time in history you can build your own toolbox for almost no money and iterate (build things) really quickly.

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At present clinicians are increasingly working with developers to produce technology. However, because there doesn’t yet exist a common language between the two worlds this can result in communication difficulty. Enter the clinical developer who knows the difference between an SQL database and a host but also the real problems on the ground and some of the subtleties of healthcare.

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One way a clinician developer can communicate their ideas is by building a prototype. This prototype can be built quickly and enables the clinician to test their concept quickly but also show a professional developer what it is that they want to achieve. As a beginner the best way to start is by using tools. There are hundreds of these available nowadays and they are the best way to ‘get into’ a field quickly to achieve results at a very low cost. Some of the best tools will be covered in a following post.

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Tools may be all that a clinical developer needs to achieve results, and indeed most will. However, some will want to take things further. This is where you need to decide what kind of clinician developer to become. This will be covered in the next post.

To find out more visit: www.clinicaldevelopers.org – signup to our mailing list for updates, tips and tricks.

The Clinical Developers Network #doctorswhocode

Welcome to the Clinical Developers Network,

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Who am I?

I’m Matt Stammers and I just founded the clinical developers network.

I am a Gastroenterology registrar currently working in the UK NHS full-time. I love my specialty and I love the NHS, but I am persistently frustrated by IT issues both within, and outside of the system.

For a long time I have looked on as successive groups have tried to change things without much success. There are many reasons why these projects normally fail – (lack of lean thinking/planning, lack of cooperation/joined up thinking, low involvement of users and lack of attention to user-requirements, etc.) However, if I was to pinpoint the single biggest reason that would be: A lack of engagement from clinical staff. They are not engaged because they were not involved in the project development, they don’t understand how ‘geeks’ think and fundamentally the project wasn’t designed with them in the forefront of the developer’s minds.

This is a major challenge to both software designers and clinicians – until it is addressed there will continue to be failure after failure in implementation.

Enter: The clinical developer

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The clinician developer is a hybrid-doctor who understands both worlds and knows how to speak to both sides. Now the clinical developer comes in many shapes and forms. Some like me love the technical things and machine learning, others love UX and design, others just love building websites and some don’t actually code themselves but they use tools to develop. This is for the majority the best way to start.

After all, the clinician developer doesn’t seek to displace full-time developers but rather to bridge the gap. What does the clinician bring that no other can? A deep understanding of the problems! Only clinical staff have this perspective.

So if you want to find out more then head over and sign-up to join the community. Tell me what you think and most importantly tell us about who you are and what your up to!

Together we can #change #healthcare for the better

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To find out more visit www.clinicaldevelopers.org – signup to our mailing list for updates, tips and tricks.

Paul Gaudin – Accountancy and Numbers #NHSClinEnt

You need to know your numbers. Build the foundations as though you are building a skyscraper (ie. Rock Solid).

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Background and statutory obligations

Take directorship responsibilities extremely seriously. If you get it wrong it can be extremely costly. Meet your statutory, fiduciary (legal responsibilities as mandated in company law) and tax obligations. To ensure you are making profits, to plan, to raise capital, to grow and to value the business.

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Be careful. In different countries there are different structures that exist. Limited countries must have statutory accounts. Audit thresholds – your company may qualify if it has two of the following: annual turnover more than £6.5 mill, assets more than £3.26 mill and 50 or more employees.

Cash accounting models are probably best for most health-tech businesses. You must submit your accounts to companies house within 9 months of the accounting reference date.

Accounts systems and processes

You need someone who likes bookkeeping and cares about it. They need a clear understanding of the key information required to run the business. They need a system to produce clear information on which to base decisions and to monitor performance. Make sure you get on really well with them. Select a system that grows with you: http://www.softwareadvice.com/uk/accounting. Don’t leave this it will always come back and bite you.

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You need information flow to and from the various disciplines in the business, so that managers all understand their role in delivering the business plan and when their area, or another, is causing imbalance.

You need to create balance. Fix the cracks. Take the team away every 3 months to try and iron out differences and maintain relationships. It’s perfectly normal that people get upset.

Board responsibilities and reporting

The board is there to set the ends. To define what the company is in business for. It is the job of the executive to decide which means those are best achieved. You need to have a good executive structure with rules and codes of conduct. There are key elements of good reporting structures: CIMA reporting structure to boards.

The best board decisions will be driven by customer data. What is going wrong? Then you need to have a quarterly management information review. What are the competitors doing? Is our revenue strategy working? How are the customers feeling?

Then use the data to drive the business plan.

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Directors must manage risk – do you have a disaster recovery plan? You must have one! You must have the correct insurance – PL, PI, EL, Life, CI, Medical. Do not store data near electricity sources.

You should have a full shareholders agreement tied in to your articles. Have a plan for critical illness. Workplace pension scheme if you employee people.

Tight purchase and sales contracts which protect you from currency fluctuations an a range of potential issues. You must comply with the data protection legislation in all your local markets.

Business Models

This is simply ‘how you plan to make money’

Synchronise your main client and distributor, discounting, freemium, up-sell, cross-sell etc.

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Deploy a responsive and multi-channel strategy with different pricing models delivered against a common RRP, develop a loyal test consumer group to give immediate responses to product, innovation and pricing. Partner with a market leader to generate revenues to get the business started.

The 1 page business strategy. OGSM Mark Van Eck.

Banking and Investor Relations

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This is a really important relationship – they can give you connections and discounts in all different sectors and industries. When you go international you need really strong investor relationships.

For the lender they are interested in balance sheet.

Secured lending or asset backed. Factoring.

Investors – runway – income and available working capital, proof of concept. NPV (Net Present Value).

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Financial Modelling

Build a spreadsheet. Sales A, Cost of Sales – B. D2c, distributor, international, licence, franchise. Production cost, sales and marketing, human resources, operating profit. share capital and liquidity ratios.

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Balance Sheet

Fixed Assets, Liquid Assets, Share Capital, Liquidity Ratios – a lender will look at all these. Current, Acid, Cash ratio’s.

EBITDA – 3 to 15 times multiple of this. Net profit + Interest + Taxes + Depreciation + Amortisation.  You need STRONG legal advice here.

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Watch out for ‘earn-outs’ – check for anything like this in a contract.

Be careful when being approached for your business to be bought out.

Great accounts and Great due diligence are KEY! When you get someone ready to buy or invest YOU need to be ready as well!

If you are an entrepreneur now you are probably ‘disintermediating’ a process. The data is all connecting. The data is coming into the hands of the patients.

Mike Casey – Future Nova – FlipPad #NHSClinEnt

Mike Casey – FlipPad – a clean case for iPad.

A spray resistant and protected iPad cover for hospitals.

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The idea was to replace the mobile computers in hospital.

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They managed to get funding and got Apple involved. It takes a long time to get Apple to get used to the company. However, they loved it and it went into their enterprise range.

Then a surgeon in the US left a review on medgadget after he tried to destroy the product in a surgical theatre and failed: Their sales took off!

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Then companies including a super glue factory became interested and sales took off so much that they had to move factories.

At one point a German factory challenged them on whether or not the product could survive a various list of chemicals. It turned out to be the only product that could!

Leo Innovation Labs Foundation #NHSClinEnt

When you take the Data, 3D printing, Health apps, DNA, Wearables, Partnerships.

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Exponential realities become obvious when it’s too late to react. Deceptive dissapointment is what comes before.

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The problem comes where the lines cross over. By the time people realise the exponential tech is going to hit it’s too late. Between the technologies you find opportunity, chaos and amazement.

Leo pharma cam about to innovate and improve life for people living with a skin condition. It is a foundation not primarily focussed on profit.

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They have a ‘traction-pipeline’ and a graveyard. They will kill any products that will not survive.

They always have the end user in mind. They listen to the small things

Either they will build solutions themselves, or they will invest in the best-in-class or they will curate and intermediate products.

They are looking for tech, data, service and solutions & talent. These are the things they look for when making an investment. Even if the tech and data was fantastic they would not invest in it without the right team.

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When you start ‘early partnering’ can be a dangerous thing. You need to prove you have a case before you start getting investment. Investors will cost you heavily unless they know they are backing a winner.