is cholecystitis fatal

Acute acalculous cholecystitis (AAC) is an acute inflammation of the gallbladder in absence of gallstones. It is a potentially fatal form of acute cholecystitis that usually occurs in critically ill patients. The disease may often go unrecognized due to the complexity of the patient's medical and surgical problems.

Pitfalls of Diagnosis of Acalculous Cholecystitis. Case Presentation and Literature Review. A Mohamed, M Riaz, F Emran Keywordsacalculous cholecystitis, congestive heart failure Citation A Mohamed, M Riaz, F Emran. Pitfalls of Diagnosis of Acalculous Cholecystitis. Case Presentation and Literature Review.. The Internet Journal of Surgery. 2009 Volume 23 Number 2. Abstract

Recently, there is a reported increase in the incidence of acalculous cholecystitis in outpatients without typical predisposing critical illness. We report a case of congestive heart failure and pulmonary embolism which was diagnosed initially as acaculous cholecystitis discussing the pitfalls of diagnosis of the disease which usually result in under-estimation of the condition in seriously ill patients (appropriate patients) and over-estimation of the condition in the outpatients without typical predisposing critical illness (inappropriate patients). Introduction Diagnosis is of acalculous cholecystitis is difficult. Clinical examination is often not helpful, as many patients are receiving mechanical ventilation and have decreased mental awareness. The diagnosis is usually made by radiological tests, most often by sonographic examination of the gallbladder. The role of the various imaging modalities in acute acalculous cholecystitis is still somewhat controversial. In general, no single imaging study is ideal. The three primary imaging modalities (ultrasound, CT scan and cholescintigraphy) often are complementary. Early diagnosis and management is of vital importance as without immediate treatment the condition rapidly progresses to perforation or gangrenous cholecystitis with very high mortality. A timely diagnosis will depend on a high index of suspicion in the appropriate patient, and the combined results of clinical findings (admittedly nonspecific), plus properly interpreted imaging. Case presentation A 68-year-old female was presented to the emergency department at KFMC, Riyadh, with complaints of recurrent upper abdominal pain and vomiting for two months which got worse 4 days before her presentation. She had no past history of medical illness or surgery. On admission to the emergency department, she was fully conscious, oriented, not jaundiced or cyanosed. Her pulse was 93/minute, blood pressure 104/70 mm of Hg, temperature 37.6°C, respiratory rate 22/minute and oxygen saturation 98% at room air. The chest was clear and abdominal examination revealed tenderness in the right hypochondrium and epigastric region, and a positive Murphy’s sign. The rest of the abdomen was soft and not tender. CBC showed an Hb of 10.2 g/dl, WBCs of 10.8 x10³ and platelets of 27 x10³. Urea and electrolytes and liver function test showed elevated urea, creatinine and liver enzymes with marginally elevated serum bilirubin and alkaline phospatase (table 1). Figure 1A CT scan of the abdomen reported an echo-free gallbladder with thickened wall, mucosal enhancement, and pericholecystic fluid. The liver showed no obvious intrahepatic bile duct dilatation or focal lesion. The findings were suggestive of acalculous cholecystitis; however, further correlation with ultrasound study of the biliary system together with the laboratory and the clinical findings was recommended by the radiologist (Figure1). Figure 2Figure 1: Abdominal CT scan showing mucosal enhancement of the gall bladder wall with pericholecystic fluid and fat stranding The ultrasound showed a normal liver without focal lesions or biliary duct dilatation. The gallbladder was echo-free with a thickened wall (figures 2 and 3). There was free fluid seen in Morison’s pouch, the infrahepatic area, around the left and right kidneys (figure 4 and 5), and also in the pelvis. The ultrasound findings confirmed the CT findings of features of acalculous cholecystitis. Figure 3Figure 2: Ultrasonography showing an echo-free gall bladder with edematous thickened wall Figure 4Figure 3: Ultrasonography showing thickened gallbladder wall surrounded with pericholecystic fluid together with right perinephric fluid. Figure 5Figure 4: Ultrasonography showing right perinephric fluid Figure 6Figure 5: Ultrasonography showing fluid around the left kidney Up to this stage the patient was only seen by the emergency physicians and junior surgical staff. Admission to the surgical ward was planned on the assumptive diagnosis of acalculous cholecystitis. Fortunately enough, the patient was seen by a clinically oriented senior surgical staff member who discovered that what was thought to be a positive Murphy’s sign was in fact enlarged tender liver and that there was obvious increase in jugular venous pressure and bilateral lower limb edema. Diagnosis of congestive heart failure was established and immediate cardiac consultation was sought. A bedside echocardiogram showed a dilated right ventricle and atrium together with a right atrial mass (thrombus) extending through the tricuspid valve into the right ventricle. Immediately after performing the echocardiogram, her oxygen saturation dropped and the patient required endotracheal intubation and ventilation. A spiral chest CT scan was ordered to rule out pulmonary embolism, but on reviewing the upper cuts of the abdominal CT scan by a senior radiologist, it was obvious that there were pulmonary emboli almost completely occluding both the right and left pulmonary arteries (figure 6). Figure 7Figure 6: Upper cuts of abdominal CT showing emboli almost completely occluding the right and left pulmonary arteries (arrows)The patient was admitted to the CCU with a multidisciplinary team including cardiology, pulmonology, hematology and surgery. Retrospectively, it was very clear that the radiological findings of acalculous cholecystitis had distracted the junior staff from a more serious medical issue that was immediately endangering the patient’s life. Discussion Acute acalculous cholecystitis (AAC) is an acute inflammation of the gallbladder in the absence of gallstones (1). It was first described by Duncan in 1844 complicating surgery on a patient with incarcerated hernia (2). Acute acalculous cholecystitis is rare, occurring in only 5 % to 10 % of patients with acute cholecystitis (3). It is a potentially fatal form of acute cholecystitis that usually occurs in critically ill patients (4). Acalculous cholecystitis is more likely to be found in patients with recent severe trauma, critical illness, cardiovascular surgery (5, 6, and 7) or severe burns. It has also been found in association with total parenteral nutrition (8), mechanical ventilation, and the use of narcotic analgesics, as well as in major cardiovascular disorders, complicated diabetes mellitus, autoimmune disease (9-12), AIDS (13) and after radiotherapy (14). The precise mechanism of the disease is unknown: the commonly postulated theories regarding its pathogenesis are bile stasis, sepsis and ischemia (15, 16, and 17). Although recognized for more than 150 years, acute acalculous cholecystitis remains an elusive diagnosis. This is likely because of the complex clinical setting in which this entity develops and lack of large prospective controlled trials that evaluate various diagnostic modalities (18). The disease may often go unrecognized due to the complexity of the patient's medical and surgical problems. Clinical examination is often not helpful, as many patients are receiving mechanical ventilation and have decreased mental awareness. It is usually difficult to elicit right quadrant tenderness or Murphy’s sign in those patients. Biochemical markers are nonspecific and contribute to the delay in diagnosis and treatment (19). The diagnosis is usually made by radiological tests, most often by sonographic examination of the gallbladder. A timely diagnosis will depend on a high index of suspicion in the appropriate patient, and the combined results of clinical findings (admittedly nonspecific) plus properly interpreted imaging (18). Ultrasound is usually the first line of investigation because it is widely available and can be performed at the bedside (20,21). The most significant ultrasonographic findings are thickening of the gallbladder wall of more than 3.5 mm, gallbladder distention, pericholecystic fluid, and a sonolucent intraluminal layer (22, 23). Although ultrasonography is considered as an effective and accurate diagnostic test for acalculous cholecystitis (16), the reported sensitivity and specificity of sonography in the evaluation of acalculous cholecystitis vary from 23-95% and 40-95%, respectively (24). Computed tomography usually demonstrates the same findings of ultrasound (21, 22). The advantage to CT compared with ultrasound is that it is superior at detecting pathology elsewhere in the abdomen that could be the cause of the patient's fever or pain, but it cannot be applied at the bedside, which is necessary for many critically ill patients. The diagnosis of acute acalculous cholecystitis with CT requires that 2 major diagnostic criteria be met or, alternatively, that 1 major criterion and 2 minor criteria be met. These criteria are as follows: Major criteria Gallbladder wall thickening greater than 3 mm Subserosal halo (i.e., gallbladder wall edema) Pericholecystic fatty inflammation Pericholecystic fluid (without ascites or hypoalbuminemia) Mucosal sloughing Intramural gas Minor criteria Gallbladder distention (>5 cm transverse) High-attenuation bile (sludge)Reported sensitivity and specificity 0f CT scan in diagnosis of acalculous cholecystitis vary but generally have been greater than 90-95% (24). Tc-99m iminodiacetic acid cholescintigraphy is a highly reliable test and is easily performed even in acutely ill patients and should be the test of choice in all patients predisposed to and suspected of acute acalculous cholecystitis (25). In general, diagnostic quality studies with augmentation yield a sensitivity of 80-90% and a specificity of 90-100%. False positives may occur reducing the specificity of the test. With morphine augmentation, the false-positive rate is decreased and the specificity is improved (26). Cholescintigraphy is a useful tool for early diagnosis of acalculous cholecystitis in critically ill patients, in whom ultrasonography alone does not provide enough information to permit a sufficiently early decision regarding indications for surgery. Many authors suggest that the combination of ultrasonography and cholescintigraphy improves diagnostic accuracy and reduces false-positive and false-negative rates (27, 28). The role of the various imaging modalities in acute acalculous cholecystitis is still somewhat controversial. In general, no single imaging study is ideal. The 3 primary imaging modalities often are complementary, with ultrasound (US) or CT providing anatomic information and evaluation of adjacent structures and cholescintigraphy providing functional information (29, 30). The importance of early diagnosis and immediate treatment is reflected in the fact that without immediate treatment the condition rapidly progresses to perforation or gangrenous cholecystitis, with a mortality as high as 65 %. With early diagnosis and intervention, the mortality drops to 7 % (31). Radiological changes associated with acalculous cholecystitis are not specific and can occur with many other non-biliary conditions. Thickening of the gallbladder wall may result from a large spectrum of pathological conditions and may have different appearances. Accurate diagnosis is usually established after a correlation of imaging findings, laboratory data and clinical history (32). Wegener et al. performed a comprehensive prospective ultrasonographic study in 93 patients to investigate gallbladder wall thickness and gallbladder volumes in various non-biliary disease states. They found that without changes in gallbladder volume, the mean gallbladder wall thickness was significantly increased in patients with liver cirrhosis, viral hepatitis, chronic congestive heart failure, hypoalbuminemia, and chronic renal failure but not in patients with diabetes mellitus as compared to a control group. They concluded that a variety of non-biliary disorders are associated with significant thickening of the gallbladder wall (33). Congestive right heart failure can cause thickening of gallbladder wall associated with pericholecystic fluid that mimics acalculus cholecystitis (34, 35), but additional findings of extravascular volume overload, such as pleural or pericardial effusions, ascites, dependent subcutaneous oedema, distended IVC and pulmonary congestion in the lung bases seen in patients with congestive heart failure, help in differentiation between the two conditions. Hypoalbuminaemia in patients on intensive care units may cause gallbladder wall thickening and can cause confusion with acute acalculous cholecystitis, which occurs most commonly in these patients. CT findings are helpful for distinguishing these conditions. Most of the diagnostic difficulties arise from lack of clinical correlation and proper interpretation of the radiological findings due to decreased mental awareness secondary to trauma or/and diminished patient responses due to sedation and ventilation. Overcautiously, acalculous cholecystitis should be considered in every patient who is critically ill or injured and who has clinical findings of sepsis with no obvious source (36). In presence of these diagnostic difficulties we believe that over-diagnosis of acalculous cholecystitis is permissible and may be safer in critically ill patients. We also recommend maintaining a low threshold for instituting empiric, minimally invasive therapy in the form of percutaneous cholecystostomy. Although acute acalculous cholecystitis is a disease traditionally observed in the critically ill, it has also been reported in outpatients without typical predisposing critical illness (37, 38). Savoca et al. reported a recent increase in the de novo presentation of outpatients with this disease, especially in elderly male outpatients with vascular disease (39). Similarly, Shridhar et al. observed de novo presentation of acalculous cholecystitis in several outpatients, young and middle-aged healthy individuals, in the absence of critical illness or predisposing factors (40). In spite of the reported increased incidence of acalculous cholecystitis in outpatients without typical predisposing critical illness, we believe that over-diagnosis of the condition in the outpatient set-up is dangerous as it may distract the attention of the treating physician (especially junior medical staff) from more serious medical issues that endanger the patient’s life and need immediate attention. We feel that it is safer to consider those patients as inappropriate patients for acalculous cholecystitis and the diagnosis should only be established in presence of strong clinical, labarotary and imaging evidence of the disease. We would also like to point to another area of concern regarding training of our junior medical staff which was well expressed by Professor Herbert L. Fred in his interesting topic “hyposkillia”. We totally agree with him that we should teach them high- touch medicine based on a carefully constructed medical history coupled with a pertinent physical examination and critical assessment of the information thus obtained. One then determines which studies, if any, are indicated. And if studies are deemed necessary, the simpler ones are ordered first; not high- tech medicine essentially bypasses the medical history and physical examination, and, primarily on the basis of the patient's chief complaint, goes directly to a slew of tests that typically include magnetic resonance imaging or computed tomography, or both (41). Summary Acute acalculous cholecystitis is a rare variety of gallbladder inflammation. It is a potentially fatal form of acute cholecystitis that usually occurs in critically ill patients. Recently acalculous cholecystitis was reported to have increasing incidence in outpatients without typical predisposing critical illness or trauma. Without immediate treatment, the condition rapidly progresses to perforation or gangrenous cholecystitis, with a mortality as high as 65%. Diagnosis of acalculous cholecystitis may depend mainly on radiological findings due to decreased patient mental awareness secondary to trauma or/and diminished patient responses due to sedation and ventilation which makes eliciting of the clinical signs difficult and sometimes impossible. The pitfalls of radiological diagnosis result in over- or under-estimation of the condition. We believe that over-diagnosis of acalculous cholecystitis is permissible and may be safer in critically ill patients and recommend maintaining a low threshold for instituting empiric, minimally invasive therapy in the form of percutaneous cholecystostomy. On the other hand, over-estimation of the condition in outpatients without typical predisposing critical illness may be dangerous as it may distract the attention of the treating physician from more serious medical issues that need urgent attention and immediate management. References1. Owen CC, Jain R: Acute Acalculous Cholecystitis. Curr Treat Options Gastroenterol; 2005; 8 (2): 99-104. 2. Kiss L, Nagy L, Juhász F, Nagy Z, Soós A: Acute acalculous cholecystitis. Acta Chir Hung; 1991; 32 (4): 337-40. 3. Howard R: Acute acalculous cholecystitis. Am J Surg; 1981; 141: 194-198. 4. Jacobs JE, Birnbaum BA: Abdominal computed tomography in intensive care unit patients. Semin Roentgenol; 1997; 32: 128-41. 5. Wang AJ, Wang TE, Lin CC, Lin SC, Shih SC: Clinical predictors of severe gallbladder complications in acute acalculous cholecystitis. World J Gastroenterol; 2003; 9 (12): 2821-3. 6. Saito A, Shirai Y, Ohzeki H, Hoyashi J, Eguchi S: Acute acalculous cholecystitis after cardiovascular surgery. Surg Today; 1997; 27: 907-909. 7. Hagino RT, Valentine RJ, Clagett GP: Acalculous cholecystitis after aortic reconstruction. J Am Coll Surg; 1997; 184: 245-248. 8. Hatada T, Kobayashi H, Tanigawa A, Fujiwara Y, Hanada Y, Yamamura T: Acute acalculous cholecystitis in a patient on total parenteral nutrition: case report and review of the Japanese literature. Hepato-Gastroenterology; 1999; 46: 2208-2211. 9. Kamimura T, Mimori A, Takeda A, Masuyama J, Yoshio T,Okazaki H, Kano S, Minota S: Acute acalculous cholecystitis in systemic lupus erythematous: a case report and review of the literature. Lupus; 1998; 7: 361-363. 10. Date K, Shirai Y, Hatakeyama K: Antiphospholipid antibody syndrome presenting as acute acalculous cholecystitis. Am J Gastroenterol 1997; 92: 2127-2128. 11. Parangi S, Oz MC, Blume RS, Bixon R, Laffey KJ, Perzin KH, Buda JA, Markowitz AM, Nowygrod R: Hepatobiliary complications of polyarteritis nodosa. Arch Surg; 1991; 126: 909-912. 12. Imai H, Nakamoto Y, Nakajima Y, Miura AB: Allergic granulomatosis and angiitis (Churg-Strauss syndrome) presenting as acalculous cholecystitis. J Rheumatol; 1990; 17: 247-249. 13. Jannuzzi C, Belghiti J, Erlinger S, Menu Y, Fekete F: Cholangitis associated with cholecystitis in patients with acquired immunodeficiency syndrome. Arch Surg; 1990; 125: 1211-1213. 14. Katsinelos P, Pilpilidis I, Papaziogas B, Chatzimavroudis G, Paroutoglou G, Mimidis K, Dimiropoulos S, Kamperis E: Fatal acute acalculous cholecystitis as an early complication after radiation therapy. Chirurgia (Bucur); 2008; 103 (2): 223-6. 15. Babb RR: Acute acalculous cholecystitis. A review. J Clin Gastroenterol; 1992; 15 (3): 238-41. 16. Barie PS, Fischer E: Acute acalculous cholecystitis. J Am Coll Surg; 1995; 180: 232-244. 17. Savoca PE, Longo WE, Pasternak B, Gusberg RJ: Does visceral ischemia have a role in the pathogenesis of acute acalculous cholecystitis. J Clin Gastroenterol; 1990; 12 (1): 33-36, 18. Huffman JL, Schenker S: Acute acalculous cholecystitis: a review. Clin Gastroenterol Hepatol; 2010; 8 (1): 15-22. 19. Boland G, Lee MJ, Mueller PR: Acute cholecystitis in the intensive care unit. New Horiz; 1993; 1 (2): 246-60. 20. Indar A, Beckingham I: Acute cholecystitis. BMJ; 2002; 325: 639-43. 21. Cornwell EE 3rd, Rodriguez A, Mirvis SE, Shorr RM: Acute acalculous cholecystitis in critically injured patients. Preoperative diagnostic imaging. Ann Surg; 1989; 210 (1): 52-5. 22. Am J Surg; 1981; 142: 290-292. 23. Becker CD, Burckhardt B, Terrier F: Ultrasound in postoperative acalculous cholecystitis. Gastrointest Radiol; 1986; 11: 47-50. 24. Mirvis SE, Whitley NN, Miller JW: CT diagnosis of acalculous cholecystitis. J Comput Assist Tomogr; 1987; 11: 83-87. 25. Ramanna L: Cholescintigraphy in acute acalculous cholecystitis. AJG; 2008; 650 – 53. 26. Jamart J: Cholescintigraphy in the diagnosis of acute acalculous cholecystitis. Eur J Nucl Med; 2000; 27 (4): 459-61. 27. Mariat G, Mahul P, Prévôt N, De Filippis JP, Cuilleron M, Dubois F, Auboyer C: Contribution of ultrasonography and cholescintigraphy to the diagnosis of acute acalculous cholecystitis in intensive care unit patients. Intensive Care Med 2000; 26 (11): 1658-63. 28. Kalliafas S, Ziegler DW, Flancbaum L, Choban PS. Acute acalculous cholecystitis: incidence, risk factors, diagnosis, and outcome. Am Surg; 1998; 64: 471-5. 29. D'Agostino HB, van Sonnenberg E, Sanchez RB, et al. : Imaging of the percutaneous cholecystostomy tract: observations and utility. Radiology; 1991; 181 (3): 675-8. 30. Flancbaum L, Choban PS: Use of morphine cholescintigraphy in the diagnosis of acute cholecystitis in critically ill patients. Intensive Care Med; 1995; 21 (2): 120-4. 31. Adam A, Roddie ME: Acute cholecystitis: radiological management. Baillieres Clin Gastroenterol; 1991; 5: 787-816. 32. Zins M, Boulay-Coletta I, Molinié V, Mercier-Pageyral B, Jullès MC, Rodallec M, Petit E, Berrod JL. Imaging of a thickened-wall gallbladder. J Radiol; 2006; 87 (4 Pt 2): 479-93. 33. Wegener M, Börsch G, Schneider J, Wedmann B, Winter R, Zacharias J: Gallbladder wall thickening: a frequent finding in various non-biliary disorders -- a prospective ultrasonographic study. J Clin Ultrasound; 1987; 15 (5): 307-12. 34. Herbener TE. The gallbladder and biliary tract. In: Haaga JR, Lanzieri CF, Sartoris DJ, Zerhouni EA, editors. Computed Tomography and Magnetic Resonance Imaging of Whole Body, Ed. 3, Vol. 2. St Louis, MO: Mosby, 1994:978-1036. 35. Paulson EK. Acute cholecystitis: CT findings. Seminars in US, CT, and MRI; 2000; 21: 56-63. 36. Fabian TC, Hickerson WL, Mangiante EC: Post-traumatic and postoperative acute cholecystitis. Am Surg; 1986; 52: 188-192. 37. Ryu JK, Ryu KH, Kim KH: Clinical features of acute acalculous cholecystitis. J Clin Gastroenterol; 2003; 36 (2): 166-9. 38. Valdivia-Gómez GG, Suárez R, Chavelas-Lluck MA, Caneda-Mejía M, Zaga-Minian I: [Acute non-calculous cholecystitis in non-hospitalized patients]. Gac Med Mex 1995; 131 (4): 405-8. 39. Savoca PE, Longo WE, Zucker KA, Mc Millen MM, Modlin IM: The increasing prevalence of acalculous cholecystitis in outpatients (results of a 7-year study). Ann Surg; 1990; 211 (4): 433-7. 40. Shridhar Ganpathi I, Diddapur RK, Eugene H, Karim M: Acute acalculous cholecystitis: challenging the myths. HPB (Oxford); 2007; 9 (2): 131-4. 41. Fred HL: Hyposkillia: deficiency of clinical skills. Tex Heart Inst J; 2005; 32 (3): 255 -256.


what is average roi for advertising

As a result from their efforts on Facebook, the team saw an average ROI of 450%, with campaigns ranging from 300% to 600% ROI. The team has also been contacted by Facebook to film a case study video to feature Gravity Defyer on the Facebook company testimonials page.

"February 05, 2015Case Study Inbound Marketing: 450% average ROI from Facebook advertising and organic content effort RSS Free Newsletters SUMMARY: Taking advantage of social media's ability to reach broader audiences is a staple in inbound strategies. However, simply posting content is not enough to capitalize on some social platforms. Gravity Defyer, a shoe retailer, turned to Facebook to help increase brand awareness and connect with customers on a more personal basis. However, it wasn’t until the marketing team began to utilize Facebook's features that it truly reaped the benefits of the platform. Learn how using Facebook as a customer service portal, posting organic content and leveraging paid services, the company was able to secure an average 450% ROI. Tweetby Erin Hogg, Reporter Gravity Defyer prides itself on being a wellness shoe company, offering advanced patented footwear technology in every product sold. Its mission is to help every person achieve new levels of performance, protect their bodies and live pain free. THE CUSTOMERCurrently, Gravity Defyer's audience demographic is adults 45 to over 50, but the marketing team is looking to target a broader demographic. The team understands how important foot health is for a person's overall well-being and strives to teach an audience from 20 to 40 years old about prevention of health issues that come later in life, some due to poor physical activity. In more mature customers, the company aims to help in alleviating discomfort and pain and to help them find a more comfortable shoe that fits their everyday activities. CHALLENGEWith a goal to target broader audiences, the marketing team at Gravity Defyer turned to social media to gain more brand awareness. The team has found Facebook to be an effective channel to focus on brand identity, customer service and targeting customers for remarketing. It uses Facebook to directly talk to customers and make sure any customer service issues are addressed through the channel. Gravity Defyer’s team leverages promoted and boosted posts to reach more people with the ultimate goal to drive up revenue. The Facebook effort at Gravity Defyer began in 2012, but leveraging its features, including advertising, did not begin until 2013. Megan Light, Social Media Marketing Manager, Gravity Defyer, was brought onboard to help create more content for the brand and to further leverage the platform's capabilities to advertise via promoted and boosted posts. CAMPAIGNAs Light and Sarah Olea, Public Relations Manager, Gravity Defyer, explained, the company was leveraging direct response marketing for a large part of its business life. ""We wanted to create a social presence. Gravity Defyer has been a direct response company for a long time, so creating content that will be engaging to help customers engage with us and help us to answer some of the questions that they might not want to just pick up the phone or do research,"" Olea said. However, the team also wanted to use the same direct response method to add advertising and remarketing to the Facebook account. The goal was to start a presence on Facebook, target the current customer base and start to widen the demographics by reaching younger audiences as well. Step #1. Create Facebook ads Light creates ads for Facebook with the help of Gravity Defyer's creative department. Ads appear in the brand's targeted audiences' newsfeeds and will change based on their performance. ""We'll use an ad, and if we notice the impressions aren't doing well or they're going down, then we know to change them,"" Light said. Light bases ad campaigns on Facebook according to what new products Gravity Defyer is launching and the most popular shoes with consumers. Ads typically contain an image of a shoe with background information on the technology in the product. Light and Olea bounce ideas for Facebook ads daily and work with another team member who also works in paid advertising for the company. They will research what's happening in the news and what's happening in the company, including insights into top sellers and which shoes have the highest stock. Events the company is involved in provide another aspect in strategizing Facebook ad campaigns. For example, the team participated in a diabetes walk and posted ads and content around that event. For campaigns that do not perform well in terms of engagement and number of conversations in each ad, those ads will be paused. For successful campaigns, the team will refine and improve those for future postings. The team runs four campaigns at a time on Facebook, and they are changed out once a month to keep the offers fresh to audiences. ""We want people to be excited about what they see, and if people see the same thing over and over again, they are going to be like, 'I already saw this. I don't want to go to this website,'"" Light explained. Targeted ads To target ads to Gravity Defyer's audience, the team leverages features in Facebook advertising to get the most ROI from campaigns. The platform will take the current demographics of people that are liking the Gravity Defyer Facebook page and will target other users with similar characteristics. These characteristics would include age, household income, marital status and geographic location. Step #2. Develop organic content Organic content is created to share on the Gravity Defyer Facebook page to engage with audiences. Light looks back at successful organic content posts from the beginning of the brand's Facebook presence to model new posts on those that resonated well with users. Light strives to make organic content posts on Facebook visually appealing with related captions. She also bases organic content on causes the brand is involved with, including diabetes and arthritis awareness. To stay organized and plan out content, the team utilized an editorial and PR calendar that highlights certain events the company is involved in. The social team will be aware of an event Gravity Defyer participates in, such as the American Diabetes Walk, and will post content inviting their audience to donate to the cause or join the team at the event. Also, as November was Diabetes Awareness Month, the team gave away a pair of shoes on behalf of the cause. News releases are utilized to drive more engagement with the brand. Releases will focus on Gravity Defyer's medical research studies or new products that will be featured in magazines in an editorial space. Light also runs affiliate programs with bloggers, who will receive a pair of Gravity Defyers and write reviews of them. ""So when the review comes out, we'll send it out to all the employees, and then we'll schedule different Facebook posts to make sure that we share that same post on all the social media platform,"" Olea said. Click here to see the full version of this creative sample Using an affiliate program, Light finds bloggers for the brand based on fitness, lifestyle and wellness writers, ""people that our customers can relate to,"" she explained. ""Our shoes retail between a $150 and $300, so we definitely want to make sure that when we're sending out shoes to bloggers that we’re going to have an impact on their fans, their followers that we're going to be able to reach a certain number,"" Olea said. Even if a blogger only has 500 followers, but the content is well-written and fits in the Gravity Defyer's brand, the team will engage with them versus a blog that has 100,000 followers but includes unrelated content. To further locate appropriate bloggers, Light will search the Web and contact bloggers directly to help create a personal connection with them. Once a blog post featuring a product review is complete, the team will review the post to ensure it matches the brand's look and feel before it is shared on Gravity Defyer's social media audience. Step #3. Test posts to evaluate effectiveness Light explained that to achieve the most effective ads on Facebook, the team deploys A/B testing to discover what resonates with the Facebook audience the most. ""We'll use the same picture and then have different captions and see which ones perform better. Then, based on that, we'll use the ad that performs better,"" Light said. In organic content that is created for Gravity Defyer, Light researches trends in engagement to analyze what content performs best. She has discovered that content that includes more exclamation marks and emoticons receives more likes on Facebook when compared to other content. Boosted posts are also tested to discover what resonates best with customers, allowing the team to allocate funding more effectively to those posts. Click here to see the full version of this creative sample Boosted posts allow marketers to allocate a certain dollar amount to a post, widening the reach of that post. Step #4. Use Facebook for customer service Facebook serves as a customer service channel in which fans of Gravity Defyer often post questions about products. Light tracks all comments on the Facebook page each day and ensures that commenters receive a personal reply as quickly as possible. If the customer is looking for a product, Light will include links to whatever shoe they are looking for to ensure they are directed back to the brand's ecommerce site. ""As much as we want to interact with them, we also want them going to our website,"" Light said. When complaints arise, Light will direct the comment to customer service when she does not have the solution for them. Light trained with customer service for a week upon first starting at Gravity Defyer to learn basic best practices for handling customer comments and complaints. She has supplemented that training by reading up on blogs about how to best interact with customers and performed research on what other companies do and how they interact online. Light advised other marketers charged with handling customer service online to always be patient and polite when handling difficult situations. ""I feel like Facebook made it easier for the customer to have a voice and have power, and so now big companies don't really have the right to do whatever they want. They have to own up to what the customers need, and I think that's kind of overall a good thing for everyone,"" Light said. Step #5. Achieve internal alignment In better leveraging Facebook for customer service, the marketing team is striving to achieve effective communication with the customer service department. ""Sometimes even Customer Service may find out if [a post] is working before we review the report, because they'll call and say, 'Hey, a lot of people are calling about this post or about this ad,'"" Olea said. Customer service also receives notifications from customers if a particular coupon code presented in an ad or email isn't working correctly. In being proactive about prepping customer service for calls, Light or Olea will monitor posts that are doing well on Facebook and let the customer service reps know ahead of time they might receive calls on those posts so they are fully aware of what that promotion entails. ""Some of the promotions we run on Facebook may be exclusive to social media, and so some people may see that and pick up the phone to place the same order. So, Customer Service has to be aware of how to redirect the customer to either go back online or they will walk them through the process,"" Olea said. RESULTSSince fully implementing Facebook into its marketing efforts in 2013, Gravity Defyer has doubled its revenue attribution from Facebook in the past 10 months. The team is also seeing one-fourth of its overall website traffic are customers coming directly from Facebook.

As for advice for other marketers looking to up their Facebook game, Olea recommended marketers remember that Facebook can be, and should be, used for many reasons including direct response and customer interaction, ""which builds loyal, return customers and consistent revenue."" ""Our efforts have definitely proven the value in being a company with an active social media presence, and we will definitely continue to test and improve our campaigns to help drive growth and revenue for our company,"" Olea said. Light added her favorite part about using Facebook for marketing is talking directly to customers and building a loyal base along with brand awareness. ""There is just no reason not to be on Facebook right now,"" Light said. Olea explained that while it may be more challenging to prove ROI from brand awareness, it is worth the investment to use ads and boosted posts because it improves reach and helps to bring in new customers. ""That's what ultimately helps to prove that you are generating an ROI from social media,"" Olea said. Coming up in 2015, Gravity Defyer will be launching new styles and its new slip-resistant shoes, as well as a new pain relief study conducted in a partnership with UCLA and Olive View Medical Center that will be promoted via social media. The team will also be organizing new contests and giveaways for its Facebook audiences. ""Now that we can see the ROI and the money that we've investing, we’re definitely going to be able to have a larger budget to allocate to Facebook. And that's definitely going to help us out as well,"" Olea said. Creative Samples Product review blog post Facebook ad Source Gravity Defyer Related Resources Facebook Ads: How Zappos.com manages a $10 million strategy Social Media Marketing: How a pharmaceutical company gained 107,000 Facebook likes in one month PPC Advertising: How to track Ad Words and Facebook ads in 5 steps B2B Retargeting: 5 tactics from burn pixels to Facebook "


how many calories do you burn by dancing?

You can burn 105-620 calories dancing for 30 minutes. It depends on how much you weigh, how hard you work, the type of dance, and the number of breaks you take. Below is a general estimate of how many calories you can burn during 30 minutes of various types of dance.

How many calories do I burn dancing?

How many calories do I burn dancing?

Slow paced ballroom dance Waltz, foxtrot, samba, tango, mambo, chacha, etc. If you weigh 150 lbs, you can burn approximately 105 calories in 30 minutes. If you weigh 200 lbs, you can burn approximately 145 calories in 30 minutes. If you weigh 250 lbs, you can burn approximately 180 calories in 30 minutes. If you weigh 300 lbs, you can burn approximately 215 calories in 30 minutes. If you weigh 350 lbs, you can burn approximately 250 calories in 30 minutes. If you weigh 400 lbs, you can burn approximately 285 calories in 30 minutes. Fast paced ballroom Line dancing, irish step, disco, folk, square dancing, polka, hula, swing, etc. If you weigh 150 lbs, you can burn approximately 160 calories in 30 minutes. If you weigh 200 lbs, you can burn approximately 215 calories in 30 minutes. If you weigh 250 lbs, you can burn approximately 270 calories in 30 minutes. If you weigh 300 lbs, you can burn approximately 320 calories in 30 minutes. If you weigh 350 lbs, you can burn approximately 375 calories in 30 minutes. If you weigh 400 lbs, you can burn approximately 430 calories in 30 minutes. Modern dance Jazz, twist, jazz, tap, jitterbug, etc. If you weigh 150 lbs, you can burn approximately 170 calories in 30 minutes. If you weigh 200 lbs, you can burn approximately 230 calories in 30 minutes. If you weigh 250 lbs, you can burn approximately 285 calories in 30 minutes. If you weigh 300 lbs, you can burn approximately 345 calories in 30 minutes. If you weigh 350 lbs, you can burn approximately 400 calories in 30 minutes. If you weigh 400 lbs, you can burn approximately 460 calories in 30 minutes. Aerobic dance If you weigh 150 lbs, you can burn approximately 230 calories in 30 minutes. If you weigh 200 lbs, you can burn approximately 310 calories in 30 minutes. If you weigh 250 lbs, you can burn approximately 385 calories in 30 minutes. If you weigh 300 lbs, you can burn approximately 465 calories in 30 minutes. If you weigh 350 lbs, you can burn approximately 540 calories in 30 minutes. If you weigh 400 lbs, you can burn approximately 620 calories in 30 minutes. You’ll burn fewer calories in a low-impact aerobic dance class and more calories in a high-impact aerobic dance class. Calories burned doing aerobics. Sources: Ainsworth BE, Haskell WL, Whitt MC, et al. Compendium of physical activities: an update of activity codes and MET intensities. Med. Sci. Sports Exerc., Vol. 32, No. 9, Suppl., pp. S498–S516, 2000. Calorie calculations from equation: (METs x 3.5 x body weight in kg)/200 = calories/minute You might also enjoy: How many calories do I burn playing basketball? How many calories do I burn playing golf? How many calories do I burn in a hatha (gentle) yoga class? How many calories do I burn playing hockey? How many calories do I burn lifting weights/strength training?


does bloated stomach hurt

Health General Health Care Pain & Pain Management My stomach REALLY hurts and im bloated. Why?

Whats going on? ( I ate a couple minutes ago)1 following 5 answers Answers Relevance Rating Newest Oldest Best Answer: You probably need to clear out your digestive system. Confused Girly · 8 years ago0 1 Comment1Source (s): Secrets To Cure Bloating : http://Bloating Cure.ohfos.com/?cz EClare · 1 year ago0 0 Comment Yeah I know the pain! Ha ha. Usually the bloating appears with women during menstruation or stress on the organs such as the stomach or bladder. It may have been due to whatever you ate or you might be feeling stressed (this often creates gas within the lower abdomen. Usually some relieving pills take care of the pain for you after a while. you should sit and relax and after a while the bloating should tone down. good luck!Source (s):health class Air · 8 years ago2 0 Comment This Site Might Help You. RE: My stomach REALLY hurts and im bloated. Why? Like i said in my title, my stomach hurts pretty bad, and im bloated. It also keeps on popping and when it pops i feel a moments relief. Whats going on? ( I ate a couple minutes ago)Source (s):stomach hurts im bloated why: https://bitly.im/a BLFg Lonnie · 3 years ago0 0 Comment Anything that inflames the stomach lining can spark gastritis, a sometimes sharp but often dull, gnawing upper abdominal pain that can be accompanied by belching, bloating, and nausea. Heartburn may cause similar symptoms, but that pain typically is a burning sensation in the center of the chest, behind the breastbone. The three most common causes of stomach-lining inflammation are: Increased secretion of stomach acid, stimulated by coffee, tea, alcohol, or cigarettes. Direct irritation by a food such as hot peppers or by a medication, particularly a nonsteroidal anti-inflammatory drug (NSAID) such as aspirin, ibuprofen (Advil), or naproxen (Aleve). Erosion of the stomach's mucus barrier, most often caused by prolonged use of NSAIDs. You may be able to pacify the pain by avoiding those provoking substances and taking nonprescription heartburn drugs such as famotidine (Pepcid AC) or ranitidine (Zantac 75). If those measures fail, your doctor may prescribe a more potent acid-reducer such as lansoprazole (Prevacid) or omerprazole (Prilosec). I hope this helps you. And good luck, and happy holidays.imsety · 8 years ago3 0 Commentsounds like gas. gas can be extremely painful i would get some medicine for gas relief Anonymous · 8 years ago0 0 Commentget gas-x also known as simethicone at walgreens, its cheap Source (s):nurse Anonymous · 8 years ago0 1 Comment Maybe you would like to learn more about one of these? Look For Franchises For Sale Need migraine treatment? Find Moving Container Services Get an MBA while working


continental congress meaning

What is Continental Congress? Legal Definition The Continental Congress, also known as the Philadelphia Congress, was a convention of delegates called together from the Thirteen Colonies which became the governing body of the United States during the American Revolution. The Congress met from 1774 to 1789 in three incarnations.

What is Continental Congress?

The first call for a convention was made over issues of the blockade and the Intolerable Acts penalizing the Province of Massachusetts, which in 1774 enabled Benjamin Franklin to convince the colonies to form a representative body. Much of what we know today comes from the yearly log books printed by the Continental Congress called ""Resolutions, Acts and Orders of Congress"" which gives a day to day description of the debates and issues. Although the delegates were divided early on as to whether to break from Crown rule, the second Continental Congress on July 2, 1776, passed a resolution asserting independence, with no opposing vote recorded. The Declaration of Independence was issued two days later declaring themselves a new nation: the United States of America. It established a Continental Army, giving command to one of its members, George Washington of Virginia. It waged war with Great Britain, made a military treaty with France, and funded the war effort with loans and paper money. The third Continental Congress was the Congress of the Confederation, under the Articles of Confederation.-- Wikipedia Legal Definition The first national legislative assembly m the United Slates, which met in 1774, in pursuance of a recommendation made by Massachusetts and adopted by the other colonies. In this congress all the colonies were represented except Georgia. The delegates were in some cases chosen by the legislative assemblies in the states; in others by the people directly. The powers of the congress were undefined, but it proceeded to take measures and pass resolutions which concerned the general welfare and had regard to the inauguration and prosecution of the war for independence. Black, Const. Law (3d Ed.) 40; 1 Story, Const. §§ 198-2l7.-- Black's Law Dictionary Related Legal Terms Continental Currency, Continental, Congress, Outer Continental Shelf Transboundary Hydrocarbon Agreements Authorization Act, Bill Of Credit, Enabling Act Of 1802, Ohio Constitutional Convention, Tariff Of 1789, Natural And Legal Rights, Articles Of Confederation Link To This Legal Definition Did you want to cite the CONTINENTAL CONGRESS definition? Copy and paste the below to your blog or Web page or create a forum post. Blog / HTML Link Copy Forum / UBBCode Link Copy Reddit / Markup Link Copy "


who was george w kirk

George W. Kirk, Union army officer in the mountains and leader of the state militia against the Ku Klux Klan, was born and raised in Greene County, Tenn. He received a liberal education, and in 1860 married Marie L. Jones.

Kirk, George W.

Kirk, George W.by Allen W. Trelease, 198825 June 1837–17 Feb. 1905See also: Kirk-Holden War

Early in the Civil War, Kirk may have joined or been conscripted into the Confederate Army. His sentiments were outspokenly Unionist, however, and by 1862 he left the state to join the Federal army. He received several promotions, emerging from the war as a colonel. In 1864 and 1865, after raising a cavalry regiment among the mountain Unionists of North Carolina and Tennessee, he developed a reputation as leader of a series of daring and destructive raids into western North Carolina. In June and July 1864 he took 130 men from Morristown, Tenn., to Camp Vance, near Morganton, captured its garrison, and destroyed considerable military and railroad equipment before slipping back through the mountains. He led later forays into Caldwell, Mc Dowell, Haywood, Watauga, and Macon counties before hostilities ended in May 1865. In many of these operations Kirk and his men lived off the land, seizing and destroying the property of Confederate supporters and thereby winning their undying enmity. After the war, in 1866, Kirk settled briefly in Asheville and in Rutherfordton, where he opened a small store. But he soon returned to Tennessee and engaged principally in farming in Washington County. In 1867 he was commissioned in the Tennessee militia, and two years later commanded a regiment that occupied Jackson and Overton counties and arrested several Ku Klux Klansmen. In June 1870, while visiting Washington, D. C., as a war claims agent, he was commissioned by Governor W. W. Holden to raise a regiment of North Carolina militia in the mountains for the purpose of quelling Ku Klux terrorism in Alamance and Caswell counties. He enlisted over 600 men, some of them wartime comrades-in-arms and perhaps a third of them fellow Tennesseans. In July he took 200 of the recruits to Alamance and Caswell, where they proceeded to arrest about 100 men charged with murder and other serious crimes. Opponents charged the militia with atrocities, but with a few exceptions not under his immediate surveillance, Kirk's prisoners testified to fair treatment. Although the so-called Kirk-Holden war succeeded in breaking up Klan organization and activity in the two counties, the prisoners were never punished owing to the collusion of local officials and the governor's inability to try them by special tribunal. Moreover the campaign triggered an adverse political reaction, helping Democrats to win the August legislative elections and providing grounds for their later impeachment of Governor Holden. Kirk was immediately subjected to legal retaliation by his recent prisoners. When the militiamen were disbursed in September, he went to Raleigh under an arranged Federal arrest in order to evade sheriffs and process servers. In December, cleared of Federal charges and threatened with mob violence, he returned secretly and by a circuitous route to his home in Tennessee. Not long afterwards Kirk moved to Washington, D. C., and served as an officer of the police force guarding the government buildings. For several years he was employed in the Patent Office. He then returned to the mountains, took up mining, and reportedly made and lost several fortunes. In 1898, suffering from heart and kidney ailments, he went to California where he moved about, chiefly in the mining districts. By 1900 he was living in Oakland. He died at Gilroy, Calif., survived by his wife and two sons, John A., an architect and highway construction official at Gilroy, and W. T. S., a mining engineer in Alameda.


what is medical term for neck fusion?

A Patient's Guide to Anterior Cervical Fusion Introduction Most neck pain is due to degenerative changes that occur in the intervertebral discs of the cervical spine and the joints between each vertebra.

The vast majority of patients who have neck pain will not require any type of operation. However, if the non-operative treatments fail to control your pain, your surgeon may suggest an anterior cervical fusion to try to reduce your neck pain. The purpose of this information is to help you understand: The anatomy of the cervical spine The rationale for performing an anterior cervical fusion What you can expect from this procedure, including possible complications Anatomy In order to understand your symptoms and treatment options, you should start with some understanding of the general anatomy of your neck. This includes becoming familiar with the various parts that make up the neck and how these parts work together. Please review the document, entitled: Cervical Spine Anatomy Rationale Surgery is not necessary in every case. No one type of surgery works for every neck pain problem. Numerous surgical procedures have been designed to treat each type of neck pain. An anterior cervical fusion is done for two reasons: To remove pressure from the nerve roots caused by bone spurs or herniated disc material To stop the motion between two vertebrae - a spinal segment The Operation Discectomy One of the most common surgical procedures for problems in the cervical spine is an anterior cervical discectomy. The term ""discectomy"" means ""remove the disc"". A discectomy relieves the pressure on a nerve root by removing the herniated disc causing the pressure on the nerve root. In the cervical spine, the disc is usually removed from the front. An incision is made in the front of your neck right beside your trachea (windpipe). The muscles are moved to the side. The arteries and nerves in the neck are protected as well. Once the spine is reached from the front, each disc and vertebra are identified using an X-ray to make sure that the right disc is being removed. Once this is determined, the disc is removed all the way back to the spinal cord. Any bone spurs that are found sticking off the back of the vertebra are removed as well. Great care is taken to not damage the spinal cord and nerve roots. In the cervical spine, a discectomy is usually combined with a spine fusion where the two vertebrae on either side of the disc that has been removed, are allowed to heal together, or fuse. The cervical fusion is described in detail below. Anterior Cervical Fusion Once the disc has been removed between the vertebrae, a cervical fusion is performed. This procedure allows the surgeon to fill the space left by removing the disc with a block of bone taken from the pelvis. Placing a bone graft between two or more vertebrae causes the vertebrae to grow together, or fuse. The bone graft is usually taken from the pelvis at the time of surgery, but some surgeons prefer to use bone graft obtained from a bone bank. Bone graft from a bone bank is taken from organ donors and stored under sterile conditions until needed for operations such as spinal fusion. The bone goes through a rigorous testing procedure, similar to a blood transfusion. This is in order to reduce the risk of passing on diseases, such as AIDS or hepatitis, to the recipient. For more information to help you understand bone graft please refer to the separate document, entitled: Understanding Bone Graft There are two basic types of spinal fusion: Anterior Interbody Fusion This type of fusion is much more common in the neck. This type of fusion is described above. In the interbody fusion, a bone graft is placed between two vertebrae and replaces the removed disc. During the healing process, the vertebrae grow together, creating a solid piece of bone out of the two vertebrae. Posterior Fusion You may hear the term posterior fusion as well. In the posterior fusion, the bone graft is placed on the back side of the vertebrae. During the healing process, the vertebrae grow together, creating a solid piece of bone out of the two vertebrae. This type of fusion is only rarely used in the cervical spine, generally only for fractures of the spine. If surgery is necessary, the anterior interbody cervical fusion is used to treat most problems in the neck caused by degenerative disc disease. These include unrelieved neck pain and pressure on the nerve roots caused by bone spurs or a herniated disc. The goal of spinal fusion is to stop the motion caused by segmental instability. This reduces the mechanical neck pain caused from excess motion in the spinal segment. The anterior cervical fusion may also be done in a way that spreads the vertebrae apart a bit, trying to restore the space between them. Increasing the distance between the vertebrae also makes the foramen larger in the back part of the spinal column. This may reduce the pinching and irritation of the nerve roots by bone spurs around the foramen. Instrumented Cervical Fusion When doing a cervical fusion, the bone graft may simply be wedged in between the vertebra. It is held there simply because it is wedged in tight. In recent years, there has been an increase in the use of metal plates, screws, and rods to try to increase the success of helping the spine to fuse. Many different types of metal implants are used; all try to hold the vertebrae in position while the fusion heals. Bone heals best when it is held still, without motion between the pieces trying to heal together. The healing of a fusion is no different than healing a fractured bone, such as a broken arm. However, the neck is a difficult part of the body to hold still. In the past, casts and braces were used in an attempt to reduce the motion in the neck and to increase the success rates of a spinal fusion. In most cases, these braces and casts were simply too cumbersome to wear for three months, and did a poor job of actually holding the neck still enough to allow the fusion to heal. In the cervical spine, the most common form of internal fixation is using a metal plate and screws. The plate sits on the front of the vertebrae and the screws go backwards into the vertebral body to help hold the plate in place and to help keep the bone graft from slipping out of place. By using metal plates and screws, the vertebra can be held rigidly in place while the fusion heals. Braces and casts are not needed. Rehabilitation For a more complete discussion of the rehabilitation programs for neck problems review the document, entitled: Neck Rehabilitation Complications With any surgery, there is a risk of complications. When surgery is done near the spine and spinal cord these complications (if they occur) can be very serious. Complications could involve subsequent pain and impairment and the need for additional surgery. You should discuss the complications associated with surgery with your doctor before surgery. The list of complications provided here is not intended to be a complete list of complications and is not a substitute for discussing the risks of surgery with your doctor. Only your doctor can evaluate your condition and inform you of the risks of any medical treatment he or she may recommend. To understand more about the potential complications of spinal surgery, please review the document entitled: Complications of Spine Surgery Copyright © 2003 De Puy Acromed.« Back to Patient Guides "


where do morel mushrooms grow?

They love rich soils with a lot of humus and rotting fallen trees and stumps. You won't find morels growing on the crest of a wind-swept prairie hill. Both the time and habitat for morel hunting coincides with that for ticks. Lyme disease is serious; remember to take proper precautions.

Morel Mushrooms

Morel Mushrooms When and where do I pick morel mushrooms? This is a question with a lot of answers grounded in years of folklore and anecdotal evidence.

A few things, however, can be discerned for the mushroom hunter. In Nebraska, morels (Genus Morchella) can be found starting in mid-April in the southeast part of the state, the beginning of May in central Nebraska, and later as you head north and west. Morels don't all emerge at once, so there's a morel season that can last several weeks.

It's also good to remember that morels can emerge at different times over the years depending on local conditions pertaining to soil moisture and temperature, or if it's an early or late spring. Prime morel habitat is more common in the eastern part of the state than the west, but you can find morels throughout Nebraska. They require loose soil, high humidity, and decaying vegetation. With that in mind, it is clear that morels like riparian habitats, but they will grow in ravines or deciduous woodlands that are not close to streams.

For more information: The Elusive Morel - Nebraska Game & Parks Commission The Great Morel